Some upheld, recommendations

Summary

C’s parent (A) lived in a nursing home and had been shielding during the COVD-19 pandemic. A was later admitted to hospital and was placed in a green pathway (a ward for COVID-negative patients) ward in preparation for emergency surgery. Following surgery and a few days in the High Dependency Unit, A was transferred to another ward which C was advised was a red pathway ward (a ward for COVID-positive patients). A was discharged over a week later.

C complained to the board about A’s transfer to a red pathway ward and had not been satisfied with the explanation the board provided. C also complained about the standard of nursing care, the decision to discharge A, and that the board failed to arrange follow-up care for A following their discharge.

We took independent advice from a nurse and a consultant geriatrician (specialist in medicine of the elderly). We found that, while the decision to transfer A to a red pathway ward had been reasonable and appropriate in the specific circumstances, the board had not reasonably explained the decision to C. Therefore, we upheld this part of C’s complaint.

We also found that the standard of nursing care and decision to discharge A was reasonable. The board also made the relevant referrals to the appropriate community services after A’s discharge. Therefore, we did not uphold these aspects of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not explaining the rationale behind the transfer of A to a red pathway ward. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that social work failed to reasonably assess A’s needs following a hospital admission, in relation to whether they required 24-hour care, and C’s concerns that social work ignored clinical opinions.

We took independent advice from a social worker. We considered that it was reasonable for social work to have concluded initially that A did not technically meet the criteria for residential care and was functionally fit to be discharged home with a support package. While we noted that the opinions of others were taken into account in arriving at this conclusion, we considered that there was a failure to fully examine the emotional impact on A of potentially being discharged. The council had already acknowledged that there could have been more detailed discussion with A’s GP and further exploration of the views of a specialist nurse from the psychiatry team, which we agreed with. We also considered that some wording used in the social work assessment to describe A’s reactions could have been perceived to lack empathy and compassion. We upheld this complaint.

A suffered a stroke three days after the initial social work assessment was concluded. They were in temporary accommodation at the time, awaiting further assessment. It was subsequently agreed that A required 24-hour care. They remained in the temporary facility until their transfer to a care home, but died a month later. C complained that a delay in social work re-assessing A delayed their transfer to a care home, which meant the transfer took place during lockdown when the family were unable to support A with the move. The council advised that A was re-assessed in a timely manner once a care home vacancy became available. We considered that it was reasonable for the assessment to be updated once a vacancy arose and were satisfied that the delay was due to a lack of available places and not due to a failing on the part of social work. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to give enough weight to the emotional impact on A of potentially being discharged and for the wording used to describe A’s reactions. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Appropriate weight should be given to the emotional impact of discharge on clients. Social workers should be aware of the impact of language used and where it may be perceived to lack empathy and compassion.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the council’s handling of a planning application. Planning consent was approved for a development that was contrary to the Local Development Plan. Whilst C acknowledged that the Planning Committee were entitled to approve the development, they considered that, in doing so, the Committee failed to explain what material considerations had contributed to the decision to go against the Local Development Plan and approve the application. C also complained that a pre-determination hearing should have been held, but was not.

C raised their concerns in a complaint to the council. They said that it took many months of repeated attempts to obtain a response from the council and, when the council did respond, C did not consider that their concerns had been addressed.

We took independent advice from a planning specialist. There was no question that the Planning Committee had the authority to approve developments that were contrary to the Local Development Plan, as long as there were relevant material considerations, or justifiable reasons for doing so. We acknowledged the council’s position that the report of handling for the application set out the material considerations that had to be taken into account when determining the application and that this information was available to the Planning Committee when reaching their decision. However, the report of handling presented the material considerations with reference to the Local Development Plan and explained in detail why the Planning Officer considered the proposed development went against the Local Development Plan and why they recommended the application be refused. We found that there was a clear unexplained “leap” from the Planning Officer’s recommendation to refuse, to the Committee’s decision to approve. We considered that there should have been a clear record of the reasons for approving the planning application in the minutes of the Committee meeting and in the decision notice. We were critical of the council for failing to record the reasoning behind the Planning Committee’s decision. Therefore, we upheld this aspect of C's complaint.

We were satisfied that the decision on whether to hold a pre-determination hearing was a discretionary decision for the council to make. We found no evidence to suggest that their decision not to hold a pre-determination hearing was unreasonable. Therefore, we did not uphold this aspect of C's complaint.

With regard to the council’s handling of C’s complaint, we found that there were excessive delays to the council’s response, despite C chasing them on a number of occasions. We were critical of the council’s delays and their failure to consider C’s correspondence through their complaints procedure. We were also critical of the fact that, when the council issued their response, they failed to address the main points of C’s complaint. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the poor handling of their complaint and provide a full response to their initial enquiry as to the Planning Committee’s reasons for approving the application contrary to the Planning Officer’s recommendation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• That the council consider how they may take steps to clarify complaints to ensure that they are progressed through the correct channel.
• That the council share this decision with members of the Planning Committee and remind them of the need to properly document the reasons for their decisions.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C, a representative of an organisation that provides support to planning application objectors, complained on behalf of an objecting neighbour (A). C raised a number of concerns about the council’s handling of a retrospective planning application. An unauthorised development had been reported to the council’s planning enforcement team. The retrospective planning application was approved, subject to conditions. C complained that the council failed to reasonably assess the risk of flooding at the site, that they failed to follow correct procedure for the scale of the development and failed to take into account an objection submitted by the Scottish Environment Protection Agency (SEPA).

We reviewed the relevant planning documents and sought independent advice from a planning adviser. We found that there was a failure to seek a flood risk assessment, particularly in light of the concerns raised by SEPA, the fact the development was on a listed flood plain and the Planning Officer had identified a risk of flooding as a reason for recommending refusal of the application. As such, we upheld complaint C’s complaint about the failure to request a flood risk assessment.

In respect of C’s concerns about the council’s consideration of SEPA’s consultation response, we found that the content of SEPA’s response was accurately summarised in the Planning Officer’s report to the Planning Committee. We did not uphold this aspect of C’s complaint.

Our final consideration was whether the council failed to refer the planning application to Scottish Ministers. We concluded that the council should have treated SEPA’s response as an objection to the planning application and that this should have led to the application being referred to Scottish Ministers. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the issues highlighted in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• That the council offer to meet with A to discuss ways of establishing to what extent the development may have contributed to an increase in flooding on their property and what action the council can take to mitigate this.

What we said should change to put things right in future:

• The council should review their standard working practice of not requiring technical assessments in cases where they anticipate refusing an application due to the cost that would be incurred by the applicant.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment that they received in relation to their mental health from the board over the course of just over a year. C was also concerned about the treatment that they received from a psychiatric consultant including consideration of referring C to a different health board and dealing with complexities in the case, such as C’s parent being employed by the board. We took advice from an independent psychiatric nursing adviser. We found that the overall standard of treatment provided to C was reasonable and did not uphold this complaint.

C was also concerned that the board unreasonably delayed the organisation of community mental health care to them due to concerns over safety and risk. Although C was ultimately referred to the specific community mental health team outwith the area that they had requested from early in the process, we found that the board’s regard for the potential risks of such an arrangement were reasonable and that, overall, there was no unreasonable delay due to the board’s action and that the standard of care provided was reasonable. We did not uphold this complaint.

C was further concerned that the psychiatric consultant did not reasonably record their assessment and reasoning of decisions to hospitalise C, to prescribe medicine to C or to refer C to a psychologist. We found that record keeping over the relevant period had been reasonable and that, taking all of the available evidence, the psychiatric consultant had reasonably recorded their assessments and reasoning regarding C’s treatment. We did not uphold this complaint.

C was concerned about delays in the board responding to complaints about their care and treatment, the board’s inability to explain the reasons for those delays and the board’s failure to provide a copy of a response to an elected representative as C had requested. While the board had accepted some of these failures during their consideration of the complaints submitted or while responding to our enquiries we also concluded that, contrary to the board’s views, the reason for these delays were confusion within the board and a lack of clear responsibility for responding to the complaints. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Re-iterate their apologies to C for the unreasonable delays in responding to the complaints and their unreasonable failure to provide a copy of their response to their MSP as they had requested. Apologise to C that they did not provide reasonable explanations for the delays in responding to the complaints. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Establish a clear hierarchy of responsibility for complaint responses and a system of escalation to senior management for circumstances where complaints have not been responded to within three times the length of a timescale in the Complaints Handling Procedure, or Complaints and Feedback Team follow up messages do not result in action to progress matters.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C’s adult child (A) had spent time in hospital due to abdominal pain, following which complaints had been raised and promises made that action would be taken to prevent any recurrence. A few years later, A spent time in hospital again as a result of abdominal pain and swelling, bruising to the legs and breathing issues. During the admission, A required cardiopulmonary resuscitation (where the heart and/or breathing is re-started if it stops) and died in hospital. A post-mortem examination established that A had rheumatoid arthritis-related constrictive pericarditis (a condition that causes the flexible sac that surrounds the heart to become stiff, preventing the heart from functioning properly).

C raised a number of concerns regarding the clinical investigations carried out into A’s symptoms, the time taken to reach a diagnosis and the quality of clinical nursing care provided. C complained about the standard of communication from the board’s staff and expressed their concern that the improvements that had been promised previously had not been implemented by the board.

We took advice from an independent nursing adviser. We found that multiple, relevant, investigations were carried out to establish the cause of A’s symptoms, appropriate specialist advice was sought, a reasonable treatment plan was followed and that the true nature of A’s heart condition was not detectable, despite the appropriate investigations having been carried out. Given this, we found that the medical care and treatment provided to A had been of a reasonable standard. We did not uphold this aspect of the complaint.

We found that the board’s monitoring and management of A’s fluid balance and wound care was not of a reasonable standard, and that there were apparent issues in terms of the nursing staff’s engagement with A and their family. We found that the board had failed to provide A with a reasonable standard of nursing care. We upheld this aspect of the complaint.

While we found the board’s communication with C following A’s death was generally reasonable, we found that the board unreasonably failed to apologise to C for not contacting them when A became unresponsive. Given this, and that there were communication failings that the board had accepted, we found that the board had failed to communicate with A’s family appropriately during their admission and following their death. We upheld this aspect of the complaint.

We did not find any evidence that the actions and service improvements promised following C’s earlier complaint were implemented by the board. We also found that if actions were taken, they were not effective, as the board accepted that similar issues had recurred. We found that the evidence the board provided regarding actions taken as a result of their later commitments were from too small a sample of patients and taken over too short a period to adequately demonstrate that issues identified had been addressed. Given this, we found that the board had failed to implement the actions and service improvements promised following C’s earlier complaint. We upheld this aspect of the complaint.

We found that C’s complaint was taken seriously and investigated thoroughly. However, there were delays to starting an investigation into the most recent issues raised by C and to arranging a meeting regarding these. We also found that the board’s communication with regard to the Chief Executive’s attendance at any meeting and how the most recent issues would be taken forward were poor. Given all of the above we found the board failed to handle C’s complaint reasonably. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the issues highlighted. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A’s family for failing to contact them when A became unresponsive. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A’s family for failing to effectively implement the actions and service improvements promised following C’s original complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The board should conduct an audit of the relevant ward's current compliance with their obligations to monitor fluid balance and wound condition to ensure that the improvements that have reportedly been made since C’s complaint are reflected in the nursing care currently provided on the ward.
• The board should conduct two audits of the general quality of nursing care in the relevant ward to demonstrate an improvement in standards over the next six months.
• The board should effectively implement the actions and service improvements promised following C’s original complaint and take action to effectively address issues regarding nursing care, communication, attitude and behaviour.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Ms C provided her express consent for her pronouns to be used for this publication.

Ms C complained about matters relating to the SPS failing to give Ms C advice and failing to put in place an appropriate procedure for Ms C to obtain certain items. Ms C also complained about the SPS refusing to allow Ms C to wear her own clothing and having the use of certain electrical items. We took independent advice from an adviser who specialises in equal opportunities and diversity.

We found that there were delays in the SPS giving Ms C advice and in putting in place a process to order certain items. We upheld these aspects of Ms C's complaint.

We found it was reasonable that the SPS refused Ms C's request to wear her own clothes and have access to the electrical items. Therefore, we did not uphold these aspects of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the delays in providing her with advice and putting in place a process for her to order items to support her gender identity. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• All relevant SPS staff should be clear about their obligations to transgender prisoners and their policy on accessing, or facilitating access, to items to support their gender identity.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the council's handling of a planning application.

C's neighbour was granted planning consent for an outbuilding in their garden. C noted that this space was to be used for commercial activities and complained that the council failed to comply with their own adopted and emerging Local Development Plan policies when reaching the decision to approve the application. C did not consider that their concerns in this regard had been addressed in the report of handling.

C raised further concerns as to how the approved development would impact the neighbouring properties and the local area. C contended that the council failed to appropriately notify all of the affected neighbours.

When objecting to the development, and in their subsequent complaint to the council, C noted that approving the application would allow the developer, or future owners of the residential property, to conduct other activities that could be disruptive. C did not consider that the council had taken adequate steps to consider this eventuality, or to limit the activities to those listed by the applicant. C raised a complaint with the council, but did not feel that all of their concerns were addressed.

We took independent advice from a planning specialist. We found that the council were largely able to demonstrate that the planning application had been handled reasonably. Therefore, we did not uphold this complaint. However, the report of handling failed to address C's concerns about the potential for other activities taking place at the site in the future. Whilst we were satisfied that the council were entitled to reach the decision that they had, we were critical of them for failing to demonstrate that this issue had been considered prior to consent being granted and we made a recommendation in this regard. We also found that the council failed to address this, and another issue, in their responses to C's complaint. This was particularly concerning given how central these two issues were to C's complaints about their handling of the planning application. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to handle their complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• That the council share this decision with their planning staff.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained to the council about various aspects of Social Work Services (SWS) involvement with their children. C complained that SWS failed to invite C to a 72-hour Looked After Child (a looked after child is a child under the care of the council) review. C further complained that at the review, SWS had not given appropriate consideration to the children's care planning, and had failed to correctly follow the Section 25 Children (Scotland) Act 1995 in placing their children with a family member.

We took independent advice from a social work adviser. We found that SWS had made reasonable attempts to contact C to advise them of the review meeting. Therefore, we did not uphold this aspect of the complaint. We found that information presented at the meeting was lacking in respect of the children's own views, and SWS had failed to fully document their discussions with one of C's children. However, we considered that appropriate consideration had been given to care planning for the children. Therefore on balance, we did not uphold this aspect of the complaint but provided feedback to the council about the importance of ensuring accurate recording of social work activities, including seeking views, to inform care planning.

We also found that although C was in disagreement with the placement, and the views of the children themselves had been lacking, C's estranged partner had authority under section 25 of the Children (Scotland) Act 1995 to agree to the voluntary arrangement. We found SWS had followed best practice in ensuring C's estranged partner was appropriately supported in their decision-making regarding the children's care planning, and although there had been a delay in signing the section 25 paperwork, the placement had been valid. Therefore on balance, we did not uphold this aspect of the complaint.

C further complained that SWS had unreasonably presented at their home during COVID-19 restrictions. We found that SWS had failed to follow their own COVID-19 guidance relating to home visits by not exploring the option of a remote meeting with C. We also found SWS had not provided C with a copy of the relevant guidance; had not made enquiries as to the status of C's health; and had not confirmed what PPE would be required to support the visit in advance. We upheld this aspect of C's complaint to the extent that SWS had failed to follow its own guidance, but not to the extent there had been a breach of public health guidance for which this office has no jurisdiction.

C also disagreed with the council's responses to their complaints and the manner in which these had been handled. We did not find any concerns with the manner in which the council had handled C's complaints, all of which were responded to in line with the Model Complaint Handling Procedure and good complaint handling principles.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Feedback the findings of this investigation to relevant staff for reflection and learning, and to inform future practice.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C and B complained about the board's handling of reports of alleged elder abuse in relation to a family member (A). They also complained that the board had failed to handle appropriately a referral made to the District Care Panel (DCP) for residential care for A, and had failed to give sufficient consideration to A's circumstances and that they were at risk of harm when rejecting the request. They also complained that following concerns for A's welfare, A had been removed from their place of residence, but the board had failed to properly assess A's care needs or to provide A with a reasonable level of support. In pursuing these matters, C and B said that the board's communication with them had fallen below a reasonable standard.

We took independent advice from a social worker. We found that although the Adult Support and Protection (ASP) investigation was procedurally sound, it had been lacking in quality. The board's analysis of A's circumstances and the Personal Outcome Plans were lacking, and were not persuasive in assessing a care need. As such, we found that the board had failed to safeguard A. We upheld this aspect of the complaint.

We also found that although the DCP handled A's referral for residential care appropriately, the information provided to the DCP was lacking in terms of the quality of the ASP investigation and the robustness of the case presented regarding A's situation. As such there was a failure by the board to prioritise securing urgent short-term accommodation that took account of A's circumstances. We upheld this aspect of the complaint.

We found that following A's removal from their place of residency, the board had followed up with A reasonably. We did not identify any further shortcomings in the board's assessments of A's care or living needs. We did not uphold this aspect of the complaint.

Finally, we found that the board had, at times, failed to respond to C and B's questions and requests for information regarding their concerns about A. We also found that there had been occasions where the board's correspondence with C and B had been unreasonably slow. We therefore upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and B for the poor handling of their correspondence. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C, B and A for the issues identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The board should (i) share this decision notice with the staff involved in A's case with a view to reflecting on how the ASP investigation could have better identified the nature and extent of their situation and pushed for an outcome that would have better protected A; and (ii) use this case as a reflective exercise to consider the effect of undue pressure and trauma on decision-making in ASP cases.
• The board should review how they track and respond to general correspondence to ensure all points are responded to fully and within a reasonable timescale.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.