Some upheld, recommendations

Summary

Mr C complained that the council did not address or adequately handle his complaints about antisocial behaviour and noise pollution involving neighbours who were council tenants.

At the start of our investigation the council explained that although they had investigated Mr C's complaint, he had not made a formal complaint through their complaints handling procedure. We considered, however, that the council should have applied their complaints handling procedure in the first instance.

In investigating Mr C's complaint about noise pollution, we found that the council had followed the relevant procedures and had dealt with this reasonably, and we did not uphold his complaint. The council's investigation found that the building predated the relevant building regulation and that there was an issue with sound insulation. Although there was no requirement to bring the sound insulation up to modern-day standards, the council agreed to do so, and to share the costs with Mr C. Various options were still being considered when Mr C brought his complaints to us.

In relation to other antisocial behaviour that Mr C complained about, however, which included graffiti on his property, alleged illegal activity and accumulation of rubbish in the garden, we found that the council had not taken reasonable steps to address his concerns. We upheld his complaint, as we were not satisfied that the process for dealing with rubbish had been followed as, although a verbal warning had been given to his neighbour, there was no written warning as detailed in the council procedure. We also did not consider that they had explained their procedure on graffiti to Mr C or advised him to contact the police in relation to alleged criminal behaviour, although we did find that they had recommended he contact the police in relation to any breach of the peace that took place.

Recommendations

We recommended that the council:

• consider taking further action to address the noise transference issue if the agreed works are judged to be unsuccessful;
• take steps to raise awareness of their complaints handling procedure, particularly the definition of a complaint, with the relevant service area staff;
• record Mr C's complaint and provide an apology for failing to use the proper complaints handling procedure in the first instance; and
• apologise to Mr C for their failure to fully address all his concerns about antisocial behaviour and provide him with an assurance that their estates management framework, which includes their procedures for addressing antisocial behaviour, will be followed as appropriate in future.

Summary

Mr A was a tenant of the association. Mrs C, who is a support worker, complained on his behalf that the association did not deal competently with his complaints about gas safety concerns. From the evidence we saw, however, we were satisfied that the association acted appropriately to deal with these.

Mrs C also complained that the association did not provide adequate and appropriate assistance to Mr A when there was no heating or hot water in his home over a weekend in October. They had offered Mr A a small amount in recognition of the inconvenience caused to him, which he had not accepted. Our investigation found that Mr A had undergone surgery, which required him to be careful about his personal hygiene, and he also had temporary care of his young son. The association were aware of his personal circumstances and Mrs C had raised concerns with them about the lack of heating or hot water in Mr A’s property that weekend. The association’s response was to suggest that Mr A should contact family or friends to see if he could stay with them and/or use their washing facilities or use the local swimming pool over the weekend. They also supplied him with two temporary heaters.

Given the time of year, Mr A’s state of health and the fact that he had his son in his care, we considered Mr A’s situation to be an emergency. We found that the association had failed to properly appreciate the adverse effects the problem had on him and his son and had not taken all reasonable action to help him, and the recommendations we made reflect this.

Mr A also claimed reimbursement for additional gas usage, which the association refused based on the evidence he gave them. We were satisfied that this decision was reasonable, although we made a recommendation as we thought that the association should have been more proactive in communicating the findings to Mr A or Mrs C.

Recommendations

We recommended that the association:

• review how they communicated with Mr A and ensure any improvements identified are taken forward when dealing with tenancy repairs;
• issue Mr A with an apology for the failings identified; and
• pay Mr A the the maximum amount payable under their policy for unreasonable delay in completing an emergency repair.
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Summary

Ms C complained that the association had not reasonably investigated her complaint or offered her support during a neighbour dispute about noise disturbance. During our investigation we found that the association had not thoroughly investigated Ms C's complaint as they had not spoken to all the parties involved. We, therefore, upheld this part of Ms C’s complaint.

We found, however, that the association had followed their policy in supporting Ms C by offering her mediation and suggesting a practical solution, and we did not uphold this part of her complaint.

Recommendations

We recommended that the association:

• take steps to ensure that in future they keep better records to justify their decisions; and
• apologise to Ms C for the failings we identified.

Summary

Mr C complained about the care and treatment provided to his late mother (Mrs A) by her medical practice over a three-year period before she died in 2012. Mrs A had a complex medical history with many severe and debilitating conditions, which had been present for a number of years. Mr C raised a number of issues about the care and treatment provided for his late mother's conditions, including the treatment she received for leg ulcers, chronic kidney disease (CKD) and epilepsy, dietary issues, and nursing infection control methods. Mr C also complained that the GP had not communicated adequately with him and/or Mrs A.

Our investigation, which included taking independent advice from one of our medical advisers, found that the care and treatment provided to Mrs A was reasonable, appropriate and timely. The adviser reviewed Mrs A's medical records and found no evidence (other than one lapse in monitoring kidney function) that her care and treatment was deficient. National guidance on the management of CKD says that kidney function should be monitored at least every three months, and there was at one point a gap of six rather than three months in testing Mrs A's kidney function. There was no explanation for this gap but the adviser said that it had no detrimental effect on Mrs A's overall condition.

We did, however, identify failings in communication and upheld Mr C's complaint about that. We found that some of the written communications from the GP to other healthcare professionals contained subjective comments about Mrs A and her lifestyle. After Mr C complained to the practice, the GP acknowledged that the comments were not appropriate and apologised to Mr C for the distress this had caused him. The adviser agreed that the comments were not appropriate and said that they had detracted from the GP's otherwise professional approach to Mrs A's care. The adviser was also concerned that at times the GP appeared to make unilateral decisions about Mrs A's care without discussing them with her and/or Mr C.

Recommendations

We recommended that the practice:

• ensure that the GP reflects on their practice in relation to communication and discusses any learning points at their next appraisal.

Summary

Ms C complained that a consultation that her late husband (Mr A) had at his medical practice was unreasonable, and was unhappy with their handling of her subsequent complaint. Mr A had been suffering from a cough and loss of appetite, and was due to see his GP but as his condition had worsened he arranged an earlier emergency appointment. The GP examined him and diagnosed pneumonia. He prescribed an antibiotic (a drug used to fight bacterial infections), took blood samples for testing, completed a referral form for Mr A to take to his local hospital for a chest x-ray later that day and planned to review Mr A again in one week, or earlier if his condition deteriorated. Mr A returned home, and, sadly, his teenage son found him dead there some three hours later. Ms C complained to the practice in July and September 2013 and the GP responded in July and October 2013. Ms C was dissatisfied with the responses and asked us to look at her complaint.

Our investigation, which included taking independent advice from one of our medical advisers, found that there were some failings in the GP's actions and his recording of the consultation and we upheld this part of Ms C's complaint. The adviser said that although the GP had noted some observations, other key observations (such as blood pressure, temperature, and respiratory rate) were not recorded. The adviser said that, although there was no indication that Mr A needed to be immediately admitted to hospital, the lack of these recordings were of concern where a patient had been diagnosed with pneumonia.

The adviser also noted that guidance on the management of lower respiratory tract infections (SIGN 59), issued by the Scottish Intercollegiate Guidance Network (SIGN) recommended that two different, but complementary, types of antibiotic should be prescribed for patients with suspected pneumonia. SIGN 59 also recommended review in 48 hours rather than the one week planned by the GP. Overall, the adviser was of the view that immediate hospitalisation might not have changed the outcome for Mr A. He said that bronchopneumonia (acute inflammation of the lungs) - which was identified as the cause of Mr A's death - can progress rapidly and aggressively. Because of the failings in the records of the consultation, however, it was impossible to say this for certain. We noted that the practice had conducted a significant events analysis (a process of examining what happened and identifying what, if anything, went wrong and what, if any, remedial action is needed). The adviser said that this had picked up some, but not all, of the learning points from this complaint.

Our investigation found that the practice acknowledged and responded to Ms C's complaint within the timescales in their complaints process, which mirrored the national guidance on complaints handling. The first acknowledgement was incorrectly dated but the practice manager had apologised for this in a later letter. Although we appreciated that Ms C was not happy with the practice's handling of her complaint, we considered that the timescales had been met and all the issues she raised were addressed - albeit not to her satisfaction. Because of this we did not uphold this part of her complaint.

Recommendations

We recommended that the practice:

• ensure that the GP reflects on his practice in relation to these events, in particular in relation to SIGN 59 and clinical note-taking, and discusses any learning points at his next appraisal;
• review their procedure for conducting a significant event analysis to ensure that all learning points are recorded and addressed; and
• issue a written apology for the failings our investigation identified.

Summary

Mr C was referred to Dumfries and Galloway Royal Infirmary. After tests and surgery, it was confirmed that he had prostate cancer, and he was started on hormone therapy. Mr C later had a scan of his abdomen and pelvis, and it was thought that the cancer was spreading and that he might also have Crohn's disease (a long-term condition that causes inflammation of the lining of the digestive system). In the meantime, Mr C was required to have a bone scan.

Mr C complained that in carrying out his surgery, the board did not follow his wishes about the use of anaesthetic, and did not tell him about the use of hormone therapy, that he might have Crohn's disease or that he needed a bone scan. He also complained about the delay in arranging a colonoscopy (examination of the bowel with a camera on a flexible tube) and in receiving radiotherapy.

We obtained independent advice on the complaint from one of our medical advisers, who is a consultant urological surgeon (a specialist in problems of the urinary and male reproductive systems). We took all relevant information into account, including the complaints correspondence and Mr C's medical records.

Our investigation found that, in accordance with his wishes, Mr C had a spinal anaesthetic when he had surgery. However, in association with this, he had been given some sedation to relieve anxiety. Although Mr C said that he had been explicit about the use of sedation, there was nothing in his notes to confirm this and we did not uphold this complaint. Mr C also said that there was a delay in providing him with a colonoscopy and the evidence showed that after a scan (made as a result of an urgent referral and which suggested possible Crohn's disease) it was ten weeks before a request for a colonoscopy was made. It took a further month for this to be carried out and it was only then, when a diagnosis was confirmed, that radiotherapy could be considered. Mr C's complaint about delay was, therefore, upheld. Furthermore, we found nothing to show that hormone therapy had been discussed with him, or that he had been told that he could have Crohn's disease. We upheld his complaints about this as well as about general communication during his treatment. We also found that the board did not deal with his complaints within a reasonable timescale.

Recommendations

We recommended that the Board:

• apologise to Mr C for their failure to discuss his medication with him properly;
• ensure that relevant staff are made aware of the findings of this complaint and if necessary undertake relevant training;
• emphasise to relevant staff the importance of completing timely and appropriately detailed medical records;
• specifically apologise for their failure to discuss the possibility of Crohn's disease;
• ensure that relevant staff are reminded of their responsibility to keep patients appropriately informed of their medical condition;
• apologise for the delay in sending a response to the complaint.
• share my comments with the clinicians involved, including those involved in multi-disciplinary team meetings, to ensure that CT scan results are considered and acted upon promptly; and
• provide a written explanation about the two different decisions taken in relation to radiotherapy treatment.

Summary

Mr C raised a number of issues with the university relating to practical matters and supervision in the first year of his post-graduate research. He then submitted more complaints about matters he was unhappy about, including a complaint about alleged bullying and harassment.

Mr C complained to us that the university had not dealt with the various issues he had raised with them and had not followed their complaints handling procedures. Our investigation found that the university did not progress all the issues Mr C raised as complaints and had not followed their procedures in dealing with all the complaints he had made, and so we upheld this aspect of his complaint.

He also complained that the university did not adequately investigate and respond to his complaints. We did not uphold this complaint, as we found that the university carried out thorough investigations, responded in detail to the issues they considered, and made several informal attempts to resolve the issues Mr C raised.

Recommendations

We recommended that the university:

• apologise to Mr C for not following their procedures in dealing with all his complaints; and
• consider how best to ensure consistent recording of frontline resolution complaints.

Summary

Mr C, who was a student, appealed against the results of an exam that he had not passed. The university did not uphold his appeal, and because this was his fourth unsuccessful attempt at the exam, Mr C had to withdraw from the course. Mr C was unhappy with the handling of his appeal, and complained to us. We were not able to consider his complaint at that stage, as he had not been through the second stage of the university's academic appeals process. After corresponding with us, Mr C wrote to the university to ask them to consider his appeal at the second stage, although it was over a year beyond the normal deadline for this. The university agreed to do so, and upheld his appeal, but offered him an alternative course to complete a different degree, rather than a further attempt at the exam.

Mr C was not happy with the university's handling of his appeal, and complained again to us. He claimed that the university had not reasonably considered it, and had not taken his support needs into account when putting him through the second appeal.

After considering the information provided, we found that the university had not followed its own policies and procedures in considering Mr C's second appeal. The appeal was considered by a single person, rather than an independent panel, and Mr C had not had an opportunity to hear and respond to the issues and evidence being considered. However, we found that the university had made reasonable adjustments to support Mr C in completing the appeals process.

Recommendations

We recommended that the university:

• issue Mr C with a written apology for the failings our investigation identified;
• reconsider Mr C's stage two appeal, in line with the academic appeals regulations; and
• review the academic appeals regulations to ensure that the powers of the deputy principal in relation to stage two appeals are clearly stated.

Summary

Miss C, who was a student, complained that she was unfairly and hastily withdrawn from her placement (time spent in a workplace to get work experience). She said that when she complained to the college they did not follow their complaints handling procedure. The decision to remove Miss C from the placement was one that the college were entitled to make, and so our investigation focused on the administrative and procedural actions leading up to that decision, especially the handling of a meeting between Ms C and the college.

Our investigation found that the college had, in considering Miss C's complaint, accepted that they should have explained why she was being called to the meeting, and that she should have been made aware of any concerns about her performance before it. As a result of the original complaint, the college had reviewed their procedures. Students will in future be advised in advance about the purpose of a meeting, and a log book has been introduced to record student progress.

Miss C was concerned that two members of staff had attended the meeting, but we were satisfied that the college explained the reasons for this. We were, however, concerned that action was not taken earlier when the placement brought concerns about Miss C's progress to the college's attention, and that a number of days passed before calling Miss C to the meeting.

We were satisfied that the college had considered and responded to the issues Miss C raised and had followed their procedures in handling her complaint. We did find that the question of who should attend an appeal hearing was open to misunderstanding, but we did not comment on this as the college have since introduced a two stage complaints procedure with no referral to an appeal hearing.

Recommendations

We recommended that the college:

• follow up in writing, when meeting with a student to discuss concerns regarding their placement;
• provide a student in advance of a meeting with all documents to which the college are going to refer; and
• ensure that relevant staff are aware of the need to advise complainants of the next step in the complaints procedure if they remain dissatisfied.

Summary

Mrs C took a lease on a property in 2006, as she planned to open a small business. Although this had not happened, she kept the lease, hoping she would be able to start trading. Mrs C believed she had an agreement with Scottish Water that she would not pay water charges until she opened her business. She said that in early 2012, Business Stream phoned and said the agreement would be honoured but she then received an invoice backdated to 2008. Mrs C said she called them repeatedly about this and was told they would investigate and call back, but this never happened. After several months of calls, Business Stream wrote to say that as she used the property for storage she was liable for fixed water charges, whether she used water or not.

Mrs C complained that because of the agreement it was unreasonable for Business Stream to backdate charges, and that she was unhappy because they said they would honour it, then went back on the agreement. She also said they did not tell her that the council might exempt her property from rates (which has now happened) and because of this exemption, she said Business Stream should also waive their charges. Finally, she said they refused to acknowledge her complaint until she put it in writing, and when she did they did not respond to all her questions.

Business Stream said they were entitled to backdate the account as, under their policy, a customer using the property for storage is liable for fixed water charges. They had no record of any agreement with Scottish Water, or of Business Stream agreeing that she was not liable for water charges.

We did not uphold all of Mrs C's complaints. There was no written evidence of the agreement, and we found Business Stream were generally entitled to do what they had done although they had not given Mrs C any information when setting up her account. We did, however, uphold her complaints about an additional charge on the account, and about how they handled her concerns. We found that the additional charge was the cost of a disconnection survey. However, as they should have told her about this beforehand, they should not have added the charge to her account. We also found that for six months they delayed treating Mrs C's concerns as a complaint, although she repeatedly contacted them about this. As they had not dealt with this properly and their customer service records were incomplete and inaccurate, we said they should not have levied a recovery charge. We made a number of recommendations to improve service in future.

Recommendations

We recommended that Business Stream:

• review their procedures to ensure that a copy of their standard terms and conditions are supplied to all new customers at the point their account is opened;
• remove the survey charge from Mrs C's account;
• remove the recovery charge from Mrs C's account;
• credit a payment to Mrs C's account to reflect the distress, delay and inconvenience caused by their failure to treat the matter appropriately as a complaint;
• review their policy 'Leaving a property or Ending an Agreement' to ensure it defines clearly what actions they will take to verify a property is empty;
• visit the site to ascertain if the property is now empty; and
• apologise in writing for the failings our investigation identified.