Some upheld, recommendations

Summary

Mrs C's late mother (Mrs A) was admitted to Hairmyres Hospital on numerous occasions during 2012 due to heart problems. She was admitted from mid September to early October with unstable angina and, following admission to another ward a week later, she was under the care of a cardiologist (heart specialist) who thought she might have a chest infection and said that antibiotics should be prescribed. Mrs C said that while on this ward Mrs A was unable to eat and was prescribed large amounts of medication for heartburn and acid reflux. On the day of her discharge, Mrs A was seen by a dietician who noted that her food intake was poor and that Mrs A disliked hospital food. Antibiotics were not prescribed. Shortly after discharge, Mrs A's GP diagnosed her with a chest infection, and prescribed antibiotics. Mrs A was re-admitted to hospital by emergency ambulance three days after being discharged and died six days later. The death certificate stated the cause of death as infection of unknown origin, acute kidney injury (abrupt loss of kidney function), chronic renal impairment (gradual loss of kidney function), recent myocardial infarction (heart attack) and ischaemic heart disease (when the arteries narrow).

Mrs C complained that when Mrs A was discharged, she was already suffering from the infection that contributed to her death, and that communication by staff was inadequate. She was also concerned about what she described as the appalling meals being served to vulnerable people and said that it was unacceptable that families had to feed their relatives in hospital.

We found the board unreasonably failed to carry out a test and to prescribe antibiotic treatment, so we upheld this complaint. However, we noted the independent advice of our medical adviser who said that, although not prescribing antibiotics was a significant medical failure, even if they had been prescribed earlier they would not have had a significant effect on the outcome. Nonetheless, this caused a great deal of distress to Mrs C who was left with uncertainty about its impact on Mrs A's death. Problems with communication also meant that it appeared Mrs C and her family were unaware of how unwell Mrs A was during her second last admission to hospital.

In relation to the complaint about dietary requirements, we found no evidence of any shortcomings in respect of food and nutrition. Our investigation found that Mrs A was referred to a dietician at the right time, was seen within a reasonable time and that food and fluids charts were started when appropriate.

Recommendations

We recommended that the board:

• carry out a significant event analysis to address why a c-reactive protein test was not carried out, why antibiotics were not commenced and the communication failure; and
• apologise to Mrs C for the failures identified.

Summary

Mr C, who is a Member of Parliament, complained on behalf of his constituent (Mrs B) about the care and treatment that her father (Mr A) received at Kilsyth Victoria Cottage Hospital. The hospital is a rehabilitation facility, and medical cover is provided by GPs from a local medical practice. Mr A was admitted to the hospital because of general weakness and after having fallen at home. He remained there for approximately six weeks before being discharged to a nursing home. Mrs B was dissatisfied that her father was given dihydrocodeine (strong pain relief) for a chest infection, which she felt made him unwell. Mrs B also felt that her father was discharged from hospital too early.

In responding to the complaint, the board explained that the dihydrocodeine had been prescribed for pain relief and not for a chest infection. They also said that Mr A's discharge was appropriate as his observations (including his temperature, blood pressure, pulse and oxygen levels) were satisfactory.

We took independent advice on Mr A's case from our GP medical advisers. Our investigation found that the records made by medical staff about why dihydrocodeine had been prescribed were poor. The drug prescribing sheet recorded that it was prescribed for pain, but there was no record showing where the pain was located or how bad it was. However, the board provided further evidence that Mr A had sustained a fracture after falling several months earlier and was prescribed dihydrocodeine four times a day for this, indefinitely. We concluded that it was reasonable to prescribe dihydrocodeine and that the dosage was appropriately changed to an 'as required' basis, and so we did not uphold this complaint.

In terms of Mr A's discharge from hospital, we found a lack of detailed entries by the GPs to show that they assessed Mr A's condition properly during his admission, and that he was not reviewed by a GP on the day he was discharged, despite having had a high temperature for three days. We were critical of this, and also noted that although the board told us that Mr A's observations were satisfactory they also said that they were not within his usual range. We, therefore, upheld this complaint as we could not conclude from the evidence that Mr A's discharge was reasonable.

Recommendations

We recommended that the board:

• emphasise to GPs at the hospital the necessity of clearly recording the reasons for prescribing medication in the clinical records, and that the nursing staff accurately record a patient's level of pain;
• apologise to Mr C for the failings identified in our investigation;
• draw to the attention of medical staff at the hospital the importance of ensuring discharge paperwork has been checked and signed by medical staff; and
• carry out an audit of clinical records at the hospital to ensure the medical staff are recording sufficient information regarding a patient's medical history, general condition and examinations carried out.

Summary

After an accident, Mr C was admitted to the emergency department at University Hospital Ayr with a suspected broken collarbone. He was in severe pain and had been given pain relief by ambulance paramedics. The medical records showed that he was placed in an 'urgent' triage category, with a target time of having a medical assessment within one hour of admission. (Triage is the process of deciding which patients should be treated first based on how sick or seriously injured they are.) However, Mr C was not assessed by an orthopaedic doctor (dealing with conditions involving the musculoskeletal system) until several hours later. The doctor ordered an x-ray and while at the radiology department, a healthcare professional adjusted Mr C's position and he felt a shooting pain. After the x-ray was taken, Mr C said the doctor told him that he had no broken bones, and that the arm might have been dislocated, but popped back into place. Mr C was told to take pain relief and soak in a hot bath, and was discharged with pain relief medicine an hour later. Nine days later, he returned to work. The next day, while involved in manual labour, he suffered a further injury and went back to the emergency department. Tests showed that he had a fracture of the neck of the shoulder blade.

Mr C complained about the time it took before he saw a doctor on his first visit, and said that the doctor did not make him aware of the severity of his injury. Mr C also said that although the board said in their response to his complaint that the use of a sling had been discussed with him and that he had a full range of movement when he left hospital, he did not agree with this. He said that he had felt relief when he returned from x-ray, but this was due to the medication. Mr C also complained about the board's complaints handling.

After taking independent advice from one of our medical advisers, we found that Mr C's wait was well within the national target timescale (four hours from admission to completion of management), particularly as dislocation of the shoulder was not initially suspected and there was no evidence to support that it had been dislocated. We also noted that, while Mr C was waiting, the emergency department had to deal with three emergencies that required more immediate medical attention than he did. Our adviser said that the care and treatment and discharge advice Mr C received was reasonable. An x-ray was performed (the results of which the adviser said were normal), and an assessment of the range of movement in the shoulder was carried out and noted. The advice Mr C received when he was discharged was, therefore, reasonable in light of the evidence of his injury, as was the doctor's decision not to provide a sling. In view of all of this, we did not uphold Mr C's complaints about his care and treatment.

We did, however, uphold the complaint about the board's complaints handling. We found that there were delays and that they did not respond all the elements of Mr C's complaint. We were also concerned that Mr C was not told that he could approach us (as he should have been) when the board contacted him about the delay in responding to his complaint.

Recommendations

We recommended that the board:

• review their complaints handling process in the light of our findings, and raise the shortcomings identified with relevant staff; and
• apologise to Mr C for their failure to fully address the complaint he raised.

Summary

Mr C complained that Business Stream delayed issuing their invoice to him and was unhappy with their charges. Business Stream originally billed Mr C for water, waste water and drainage. However, when his landlord told them that Mr C paid water charges to him they amended their invoice to drainage charges only. Mr C was unhappy that the drainage charges were based on his property’s rateable value rather than his actual usage.

In terms of the time taken to issue their invoice, Business Stream confirmed that their wholesaler, Scottish Water, had given them Mr C’s details in December 2010. However, Business Stream did not take the necessary steps on receipt of this information and Mr C’s account was not opened until November 2012, when they sent him an invoice backdated to December 2010.

Our investigation found that although Mr C might not have known that Business Stream were the default provider of water services, that did not in itself make their charges invalid. However, we saw no evidence that Business Stream took any significant action when they were given Mr C’s details in December 2010 and on balance we upheld his complaint about the delay in issuing the invoice. In terms of charges, Business Stream showed us that they had acted in accordance with their policy by invoicing Mr C on the basis of his rateable value, and we did not uphold his second complaint.

Recommendations

We recommended that Business Stream:

• apologise to Mr C for the delay in issuing their initial invoice.

Summary

Mrs C complained that Business Stream delayed in issuing their first bill to her. Mrs C had been in her property for nearly five years before she received her first water bill. During this time she thought that her water charges were covered by business rates, for which she had a small business exemption. Mrs C did not have a water meter and Business Stream calculated her bill for the five-year period based on the rateable value of her property. When she received the bill, Mrs C applied for a meter and this reduced her charges. She considered that her bill for the initial period would have been lower if she had been billed earlier, as she would have applied for a water meter earlier.

It was clear from the evidence that Business Stream had not been aware that Mrs C had moved into the property, and only identified that it was no longer vacant when they carried out an audit. We found that they should have had a better process in place during this period for them to identify premises that were no longer vacant. Although we consider that there is at least some onus on the customer to notify Business Stream that they have moved into or occupy a property and that they have a duty to ensure that bills are paid, on balance, we upheld the complaint. Business Stream had apologised for the delay in contacting Mrs C and had confirmed that they now have a process in place to identify occupied properties that were previously vacant.

Mrs C also complained that Business Stream refused to use average meter readings to calculate her charges for the backdated period. We were satisfied that Business Stream assessed her charges in line with their policy on this. They also told Mrs C that she could pay the arrears back over 48 months. Having carefully considered the matter, we did not uphold this aspect of the complaint, although we made a related recommendation.

Recommendations

We recommended that Business Stream:

• review the outstanding arrears when the new policy on backdating arrears is published.

Summary

Mr C, who is a prisoner, complained that the built-in DVD player on his in-cell TV set did not work. He did not feel it was fair to pay the full TV service charge when his set was defective. However, the prison confirmed that Mr C was paying for access to TV channels, which he still had, and not the DVD facility. They explained to us that, due to budgetary restrictions, they were not always able to provide new sets and their focus was on ensuring that every cell had access to TV channels. We considered this reasonable and did not uphold this aspect of the complaint.

Mr C also complained about the way in which the prison handled his complaint. He said that the manager who first considered his complaint was also a member of the prison's internal complaints committee (ICC) who considered his complaint at the next stage, and that his complaint form was not signed by the three committee members. In responding to this, the prison had pointed out that the manager gave what the prison considered to be a standard reply for that type of complaint. They said he had not offered an opinion on it that could later affect the outcome of the hearing. They acknowledged that the ICC members had omitted to sign the complaint form and an administrator had signed it on their behalf.

The prison rules do not advise against ICC members being involved at an earlier stage of the complaint. However, we pointed out that it is good practice for staff involved in complaints to be impartial, independent and accountable. While we were satisfied that the outcome of this complaint was not negatively influenced by the manager’s presence on the ICC, we took the view that a potential conflict of interest could have arisen, and that his appointment to the ICC would have best been avoided. We also noted that the ICC members should have signed the complaint form, and in the circumstances, we upheld this aspect of the complaint.

Recommendations

We recommended that the Scottish Prison Service:

• take steps to ensure that members of the ICC have not previously been involved in the handling of the complaint being considered; and
• remind staff that, when they participate in an ICC hearing, they appropriately sign part 5 of the PCF1 form.

Summary

Organisation C complained to the Commissioner about the actions of a councillor who chaired a public design competition initiated by the council. Two members of the organisation were council employees at the time of the competition, and the organisation said that there had been attempts to coerce them to inappropriately influence the competition process. The organisation also alleged the councillor had acted inappropriately in relation to the competition. The Commissioner investigated and made a finding that there had been no breach of the code of conduct for councillors (the code).

Organisation C complained to us that the decision was wrong because the Commissioner's view that there was a gap in the evidence for the first allegation and that the second allegation was out of jurisdiction did not justify the conclusions made. They were also concerned about how the evidence of whistleblowers was treated.

We did not uphold the first complaint, as the decisions outlined in the Commissioner’s letter were sufficient to justify his view that there had been no breach of the code. However, we were concerned that the note of the decision contained significant additional comments that seemed to make judgements on the actions of the councillor, and on the actions of the council itself. It was not clear what standards the Commissioner was using to judge this, as the actions of the council were clearly not covered by the code and, in the case of the actions of the councillor, the Commissioner had said they were not. We explained that this was confusing and made a recommendation on this point.

On the complaint about the way whistleblowing evidence had been handled, we found no evidence that the Commissioner had made errors in his assessment of what weight to put on the evidence or fact-finding. However, we were concerned that staff were named in a public report. This appeared to have been out of line with the Commissioner's standard practice and we were not persuaded by the explanations he gave us about this. The naming of witnesses in such an unusual way led to a perception that the witnesses had not been dealt with appropriately and, on this basis, we upheld this complaint and made a further recommendation.

Recommendations

We recommended that the Commissioner:

• reflects on the note on the Commissioner's decision, and the difficulties that the confusion and lack of clarity about the status of statements within it has caused; and
• develops a policy for the naming of individuals in future cases, to ensure consistency, which should take particular account of the position of individuals being asked to give evidence about their employers.

Summary

Mr C complained about the way in which the council handled a complaint he made about social work involvement with him and his family. He was unhappy that the council asked him to restrict the information he wanted to present to a social work complaints review committee (CRC) and said that the council allowed the CRC to take place knowing that it would be unable to address the details of his complaint. He also complained that the council had referred him to the SPSO inappropriately and that a council manager involved in investigating his stage two complaint had also been involved in the social work decision-making.

We took the view that the council did not request this to try to prevent Mr C from putting forward his detailed arguments. It was intended as helpful advice, given their knowledge of CRCs and how they operate. The request was, however, worded in such a way that they asked (rather than advised) him to restrict the amount of information he presented to the CRC. The council were able to give him advice, but our view was that only the members of the CRC itself could ask him to restrict his submission and so we upheld this element of his complaint. We did not uphold his other complaints. We found that Mr C was given the opportunity to speak about this in full at the CRC and that CRC members had access to his full submission. There was, therefore, no evidence that they were unable to consider his complaints sufficiently and robustly. We also took the view that the council acted correctly by referring Mr C to the SPSO, in line with their obligations under the SPSO Act, and the evidence we saw did not support his view that the manager was involved in investigating the complaint.

Recommendations

We recommended that the council:

• feed back to the relevant committee services staff that, while the council can advise a complainant, only the CRC themselves can request that a complainant restricts their submission.

Summary

Mr C was concerned about the development of a piece of land near his home. The council had given planning permission for development of the site, with certain conditions attached. Just before the time limit on this consent expired, some work was carried out on the site, after which the council confirmed that the developer had discharged their responsibilities under the planning conditions. Mr C complained to the council that this decision was unreasonable, and that they had not made relevant documents available to the public as required by legislation. The council responded to Mr C's complaints, but he remained dissatisfied and complained to us.

Our investigation found that the council had acted in line with legislation and procedure in deciding whether the conditions had been discharged. They had not, however, made all relevant documents available as they should have done so we upheld that element of the complaint. Mr C also complained about the council's handling of his complaints, but we decided this had been reasonable.

Recommendations

We recommended that the council:

• remind their staff that they must ensure that all relevant parts of the planning register are available to the public as required in legislation.

Summary

Ms C had council tax arrears, and had made arrangements (with sheriff officers acting for the council) to clear these. She told us that she had not disputed the arrears but when she was interested in buying her home and asked the council to issue her with a right to buy certificate, they had unreasonably declined to do so because she had uncollected council tax arrears. However, she had an invoice from the sheriff officers saying that her account for the period in dispute was clear. She told us that the information from the council about her council tax account was inconsistent and inaccurate; and that the council unreasonably expected her to keep payment receipts for 20 years.

We were provided with only limited evidence from both Ms C and the council, but the council confirmed that in 2010 a request from solicitors acting for Ms C for a right to buy certificate was declined on that basis. We did not uphold Ms C’s complaint about this because the council’s records showed that her account was in arrears in 2013. However, our investigation found a disparity in the information that sheriff officers acting for the council had given Ms C, and that provided by the council. The council have a duty in law to collect council tax, and we found nothing restricting them from taking steps to collect old debts. However, as it was unclear what arrears were outstanding in recent years, we upheld this point of complaint and made recommendations. It was too late for us to investigate actions taken 20 years ago, and we explained to Ms C that we could not consider events from that time.

Recommendations

We recommended that the council:

• review their procedures to include an enquiry to their debt management partners about the balance of arrears on a customer's council tax account before responding to an enquiry or complaint related to such an account;
• put Ms C's account on hold while further investigation is undertaken into the transactions undertaken on her council tax accounts through sheriff officers, and provide both her and the Ombudsman with documentation which confirms how their findings about the balance on her accounts was arrived at;
• waive any statutory penalties that have not been levied correctly; and
• formally apologise to Ms C.