Some upheld, recommendations

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.

Summary

Mrs C complained about the care given to her husband (Mr C) during two admissions to St John's Hospital. In particular, she was unhappy with the content of the discharge letters and complained that the content of these had adversely influenced her husband's treatment. She was also unhappy with the board's handling of her complaints about this.

As part of our investigation, we obtained independent advice from one of our advisers, who is a consultant physician in acute internal medicine. After taking this advice we found no evidence that Mr C had not received appropriate care during the admissions and that there was no evidence that his treatment was in any way influenced by the discharge letters. Our adviser said that the discharge letters were medically appropriate, and that Mr C had been thoroughly examined, investigated and diagnosed before each discharge. The decisions to discharge him were also reasonable and appropriate.

The board accepted that, while they had responded to Mrs C's initial complaint in line with their complaints procedure, they had not met their time standards in responding to her second complaint, and they apologised for this. We also found that although, in response to Mrs C's continuing concerns, they had obtained a second opinion about Mr C's clinical care, they had failed to address all the issues she raised in her complaint.

Recommendations

We recommended that the board:

• remind staff of the need to adhere to the timescale for responding under the NHS complaints procedure; and
• ensure that complaint responses address the issues raised in a complaint.
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Summary

Mrs C complained about the treatment she received from her dentist when she attended with a broken tooth. She complained that the dentist removed a remaining part of her tooth without her consent, that he used a local anaesthetic, which she had asked not be used, and that he performed root canal treatment and inserted a crown poorly. She also complained that her complaint about this was inadequately handled.

After taking independent advice from our dental adviser we found that the remaining part of Mrs C's tooth could not be saved and it was reasonable for the dentist to remove it. No formal written consent was required for this, but we noted that the dentist did not seek verbal consent, which would have been good practice. We were satisfied with the choice of local anaesthetics he used and found that an alternative was used because Mrs C said she had had an adverse reaction to the standard anaesthetic. However, we were critical that the dentist did not properly document his use of this, and of the work he carried out to prepare Mrs C's tooth for a crown. The root canal filling did not fill the entire root, leaving space for infection. Furthermore, the dentist perforated the filling material with the post that was inserted to hold the new crown. We upheld Mrs C's complaints about these aspects.

We also found that Mrs C's complaint was not handled in line with the complaints procedure in place in the dentist's practice at the time. However, that procedure was not fit for purpose and Mrs C's complaint was actually handled in line with the level of service that we would expect patients to receive. As such, we found the complaints handling to be reasonable.

Recommendations

We recommended that the dentist:

• apologise to Mrs C for the issues highlighted in our decision letter;
• reimburse Mrs C any charges for her dental treatment on the dates in question;
• take note of our adviser's comments about Mrs C's root canal treatment, post preparation, and the recording of the use of local anaesthetics with a view to identifying any points of learning for future treatment; and
• ensure that his current procedure for handling complaints is in line with NHS Scotland guidance.

Summary

Mr C complained on behalf of his wife (Mrs C) and his son (Mr A) that the mental health care and treatment the board provided was inadequate. In particular, he said that after being placed on the waiting list, the board delayed in providing his wife with a mental health assessment, cancelled this meeting without explanation and that the replacement meeting (and others) were not specific to her needs. He also said that they did not provide Mr A with the psychiatric support he needed and that, despite a number of appointments, they failed to get to the root of his problems and provide a proper diagnosis. The board, however, said that Mr A did not have a mental illness. Mr C also said that the board had released confidential information about the complaint to Mr A, and failed to deal properly with all of his complaints.

In investigating this complaint, we carefully considered all the complaints correspondence and relevant medical records. We obtained independent advice from a consultant forensic psychiatrist, which we also took into account.

Our investigation found that there was a delay in providing Mrs C with psychological treatment. The eventual appointment was then cancelled without explanation, and replaced by a form of treatment about which Mrs C had no input. Our adviser said that the way the treatment was carried out was not patient focused and did not appear to have any benefit.

During the same period of time, Mr A was provided with reasonable care and treatment. A thorough assessment was completed and an appropriate treatment plan was established. However, Mr A was given information about correspondence from Mr C without Mr C's permission. When Mr C complained about this, the board delayed in dealing with his complaint, contrary to their stated complaints handling process.

Recommendations

We recommended that the board:

• make a further apology to Mrs C for the failures our investigation identified;
• emphasise to relevant staff that the treatments they offer to patients should be patient centred and take the patient's (and carer's) views into account in providing this care and treatment;
• emphasise to relevant staff that psychological interventions should follow an established model to ensure focus;
• emphasise to staff concerned the importance of seeking appropriate permission before releasing 'third party' information;
• apologise to Mr C for their shortcomings; and
• emphasise to staff the importance of following their complaints procedure.

Summary

Mrs C complained about the care and treatment that her mother (Mrs A) received in the Glasgow Western Infirmary. Mrs A was admitted to hospital after a fall at home. She was treated for a chest infection, but tests found that she also had a cancerous tumour on her lung which had spread to her liver. Clinical staff decided that active treatment for this was not appropriate and that palliative care (care provided solely to prevent or relieve suffering) should be provided. Although discussions took place around potential discharge options for Mrs A, her condition deteriorated and she died in the hospital within two weeks of her admission. Mrs C complained about the nursing care that Mrs A received, discharge planning, nutrition and hydration and communication from staff.

We took independent advice on this case from a medical adviser and a nursing adviser. The clinical records indicated that Mrs A had varying levels of confusion throughout her admission, which made it difficult for staff to assess the extent to which she could consent to treatment or take part in discussions about her care. Generally we were satisfied that Mrs A's formal consent was not needed for the tests that she underwent, and we found that staff clearly recorded information about her preferences in terms of discharge arrangements and what she wanted to know about her diagnosis. We found that Mrs A's wishes about this were ultimately respected, and that all of the clinical treatment she received was appropriate. However, we were critical of some aspects of her nursing care. We found that staff failed to properly assess what additional support Mrs A might have needed during her admission. Mrs A had experienced problems early in her admission and we found that staff later kept drinks and snacks out of her reach to avoid spillages, rather than providing suitable utensils to help her eat and drink when she wished. We took the view that help with this might have made her time in hospital more comfortable, and that failure to provide this was poor practice. Overall, we found that the board failed to take adequate account of Mrs A's specific personal needs and upheld this complaint. We also upheld Mrs C's complaint that the board's responses to her formal complaints were unreasonably delayed.

We did not, however, uphold Mrs C's complaint about communication. Although we recognised that she was unhappy with the level and quality of communication from staff, we generally found this to have been reasonable. That said, we were critical of the board for failing to provide a private room for discussions about Mrs A's diagnosis.

Recommendations

We recommended that the board:

• apologise to Mrs C for the issues highlighted in our investigation;
• provide us with up-to-date details of the action they have taken to improve nursing staff's compliance with completion of patient admission and assessment documentation, including the provision of suitable utensils for patients with special needs;
• remind relevant staff of their responsibilities in obtaining patient consent to discuss care and treatment with family members;
• apologise to Mrs C for their poor handling of her complaint; and
• take steps to ensure their investigations and responses are not unreasonably delayed.

Summary

Mrs C complained about the care and treatment her late mother (Mrs A) received at the Western Infirmary, Gartnavel General Hospital and Victoria Infirmary. Mrs A was initially admitted to the Western when she fell and fractured her hip. She had a hip replacement operation and was transferred to Gartnavel. Mrs C said that as Mrs A had developed pressure ulcers on her foot she was discharged home too soon, only to be admitted to the Victoria two days later, having fallen again. Mrs C had further concerns about the care of the pressure ulcers and a lack of physiotherapy, and said that her mother was again discharged too soon because she then had several more falls and had to go back to hospital.

We took independent advice on this case from three of our advisers (specialising in nursing, physiotherapy and acute medicine for older people). Mrs A had been assessed as being at high risk of developing pressure ulcers, but we found no evidence that nursing staff at Gartnavel and Victoria hospitals monitored her for this. Although a special pressure relieving boot was provided after the pressure ulcer was identified, staff did not start a wound chart to monitor and assess the ulcer as they should have done. We concluded that the nursing care in both these hospitals fell below a reasonable standard, and was not in accordance with guidance issued by NHS Quality Improvement Scotland. The board also acknowledged a delay of around 12 days in Mrs A starting physiotherapy in the Victoria after she had a short period of illness. We said that this was unreasonable, and prolonged her stay there.

In relation to Mrs A's discharge from Gartnavel, our adviser said that in itself a fall shortly after discharge would not mean the discharge was inappropriate. Although we were highly critical of the board for having lost some of Mrs A's medical records, we decided that evidence from the physiotherapy, occupational therapy and nursing records showed that Mrs A's mobility was reasonably assessed, and no significant changes were noted before she was discharged. In addition, there was evidence showing that the second discharge from the Victoria was appropriate and referrals had been made for Mrs A to continue to have her needs assessed at home.

Recommendations

We recommended that the board:

• audit a sample of patient records at Gartnavel General Hospital and the Victoria Infirmary to ensure skin risk assessments are being conducted, and appropriate care plans are in place in accordance with NHS Quality Improvement Scotland guidance;
• ensure patients in the Victoria Infirmary are promptly reviewed by physiotherapy after a period of sickness;
• apologise to Mrs C for losing Mrs A's medical records and for failing to identify that they were missing when responding to the complaint;
• review their practice on the storage of patients' medical records to prevent a recurrence of failing to store medical records securely; and
• ensure patients are referred in good time to the appropriate community rehabilitation team in preparation for discharge from Gartnavel General Hospital.

Summary

Ms C, a former student, said that the university had not made reasonable attempts to resolve issues she raised about resources. She complained to them about this, and about their decision not to accept future applications from her on the grounds of inappropriate conduct. The university did not uphold her complaints and she complained to us.

Our investigation found that the university had tried to informally resolve the issues she raised and had carried out a thorough investigation. However, they had not given her the opportunity to respond to the allegations about her conduct, and had not followed their disciplinary procedure. We, therefore, found it unreasonable that the university decided to refuse her applications without giving her the opportunity to respond to these allegations.

Recommendations

We recommended that the university:

• consider either extending the scope of the existing student disciplinary policy to include a broader range of unreasonable actions, or implement a specific unreasonable actions policy to assist staff in managing communications with students where necessary; and
• apologise for refusing to accept future applications on the basis of behaviour when they had not followed their own procedures for managing student behaviour.