Some upheld, recommendations

Summary

Mrs C complained on behalf of her late brother-in-law (Mr A) that the medical practice delayed twice in referring him to hospital. Mr A visited his GP nine times between September 2011 and November 2012, with various symptoms, including a sore throat. He was finally referred to the ear, nose and throat (ENT) department in November 2012, and was diagnosed with throat cancer, for which he had surgery and radiotherapy.

When he then reported ear pain to the ENT surgeons he was told that this was likely nerve damage following his treatment. He continued to experience pain and in May 2013 went to his GP. The GP found evidence of inflammation, prescribed various drops, and told Mr A to come back if the pain did not resolve. Mr A went back to the practice the next week and saw a locum (temporary) GP who diagnosed nerve damage and prescribed a drug for nerve pain. He also advised Mr A to come back if the pain did not stop. Mr A contacted the practice by phone a week later and told another GP that he was still in pain. The GP made an urgent referral to ENT that day, and Mr A was seen by an ENT consultant some four days later. After further investigations he was diagnosed with inoperable throat cancer in July 2013 and he died in January 2014.

Our investigation included taking independent advice from one of our medical advisers, who is a GP. We did not uphold the first complaint as the adviser said that there was no unavoidable delay in making the first referral to ENT. The clinical records showed that although Mr A reported throat pain on some occasions, this was not a constant feature and there was evidence that at times certain treatments resolved or improved this. When, however, Mr A reported a 'red flag' symptom (a symptom especially likely to indicate a particular serious illness) in November 2012, the GP had spoken to an ENT specialist and urgently referred Mr A that day.

On the second complaint, the adviser found that there was a delay of one week between Mr A being seen by the locum GP, who appeared to have considered making an urgent referral, and the referral actually being made after Mr A's phone call. The adviser said that in view of Mr A's recent medical history, the locum should have referred him immediately. It was not clear from the records whether the locum prepared the referral but it was not sent, or if the referral was not made until later. Either way, there was an avoidable delay of one week on the part of the practice and we upheld this complaint.

Recommendations

We recommended that the practice:

• take steps to ensure that such delays in urgent referrals do not occur again.

Summary

Mr C, who is a prisoner, complained that he was issued with mail on a Sunday, when it should have been issued on a Saturday. He also complained that the prison failed to ensure that staff adhered to the procedures regarding cell searches, as well as those for handling and responding to his complaints.

We asked the prison about mail deliveries, and it was clear that mail should not be delivered on a Sunday, unless there are exceptional circumstances. As Mr C had clearly received mail on some Sundays, which was evidenced by more than one complaint to the prison about this and by the prison's responses, we upheld this complaint.

On the matter of the cell search, our investigation found that the Prisons and Young Offenders Institutions (Scotland) Rules 2011 give the SPS the right to search a prisoner's cell, and any items of property in their possession, at any time. Although the SPS has this right, it is moderated by the requirement to carry out a search quickly and decently and with proper regard for a prisoner's dignity. There were, however, no records of the search that Mr C complained about and in the absence of such evidence, we could not uphold this complaint.

The prison staff dealing with Mr C's initial complaints did not offer to speak to him within 48 hours of receiving the complaints, as required. In dealing with his complaint about mail delivery, the prison also did not provide an explanation for the delay at any stage of the complaints process. As we would expect this to be provided, and the complaints process to be followed, we upheld this complaint.

Recommendations

We recommended that Scottish Prison Service:

• provide the Ombudsman with evidence that mail delivery is now part of the weekend duty manager's checks;
• provide the Ombudsman with records to demonstrate that mail delivery has taken place on Saturdays; and
• remind residential first line managers of the need to provide a summary of their investigation and the evidence to support their decision, as stated on the prisoner complaints form.

Summary

Mr C's property was included in the council's housing improvement programme, which involved comprehensive works. Mr C became unhappy after work started on his home, and following a Freedom of Information request about the programme, he complained that the contract was being undertaken in-house, without going out to tender. As part of his complaint, he asked that his concerns about this were brought to the attention of council members. Mr C also complained that he had not been consulted in advance about the proposed work in accordance with the council's Tenant Handbook.

Our investigation found that the requirement for the council to go out to compulsory competitive tendering had ended in 2003, and the decision became a delegated matter. The programme had been approved by the full council and the decision that the refurbishment works would not be put out to tender was made by the Head of Service under delegated powers. We did not find anything to suggest that the council's advice about this to Mr C in response to his complaint was incorrect, nor that there was a requirement to bring his concerns to the attention of council members. However, we saw no evidence that his request for this to be done had been responded to, and we made a relevant recommendation.

With regard to Mr C's complaint about lack of consultation, the council acknowledged that their Tenant Handbook did say that individual tenants would be consulted about the programme. However, this was not done because it was not considered appropriate. The council provided evidence that confirmed that a range of methods had been used to provide tenants with advice about what would happen and when. However, because it was unclear how the decision not to carry out individual consultation was arrived at, we were unable to conclude that it had been taken appropriately.

Recommendations

We recommended that the council:

• reply to Mr C about his request that council members were made aware of his concerns about tendering for the housing improvement programme; and
• consider Mr C's comments about consultation as part of a procedural review.

Summary

In 2002, Mr and Mrs C purchased a flat in Edinburgh. The flat was the subject of a statutory repairs notice the following year, but Mr and Mrs C said that they were unaware of this as the council had not served the notice on them, but on the previous owner. They told us that they had seen scaffolding go up on part of the property, but the first they knew about repairs being undertaken under a statutory notice was when they received a bill for their share of the costs in 2013. Mr and Mrs C questioned the delay in issuing the invoice, and the costs. They complained that the council had failed to conduct conservation works on their property in such a way that they could evidence that their invoice was justified, and that the council did not handle their complaint in accordance with the complaints procedure.

Our investigation found that, although there was a long delay between the work starting and the issue of the invoice, there was evidence that the council sent notices about this to Mr and Mrs C's property. These were addressed to the owner or occupier, even if they were not then passed to Mr and Mrs C. Although this was unfortunate, we took into account that Mr and Mrs C were aware that there was scaffolding on the building, and we considered that it would have been reasonable for them to have asked neighbours and/or the council about this. Although Mr and Mrs C thought the documentation was inadequate, the council had provided them with the final account, detailing the works. We did not uphold their complaint, as we concluded that, whilst the documentation was sparse, Mr and Mrs C's complaint came down to a dispute about their liability for their share of the costs, and we were not able to adjudicate on this. Where we had found fault was not with the contract, but with the delay in issuing the account. The council had apologised to Mr and Mrs C for this, and we decided that it would not be reasonable to ask for a reduction in the invoice, as Mr and Mrs C's liability had not increased as a result of the delay.

We upheld the complaint that the council did not handle Mr and Mrs C's complaint in accordance with the council's procedure. We found that it was not dealt with appropriately in terms of timescale, agreement of the complaint or what was being sought as an outcome. We also found that there was a lack of updates and Mr and Mrs C were not asked to agree the timescale for investigation of the matter being extended.

Recommendations

We recommended that the council:

• issue a formal apology to Mr and Mrs C for the council's failure in their service standards for complaints handling.

Summary

Mr C told us that he had received a bill from the council for repair work on his tenement, carried out under an emergency statutory notice that the council had issued. He said that this was the first communication he had received about this, and that there was a four and a half year gap between the work being undertaken and when he and other owners were told about the cost. He said that neither he nor his neighbours were notified by statutory notice that work was to be carried out. He also said that when he first raised concerns about this and queried his share of the costs, the council told him that this would be investigated and that they would put the demand for payment on hold until this was done. However, during their investigations he was sent letters demanding payment. Mr C was also dissatisfied with the way in which the council investigated his complaint.

When we investigated this, the council acknowledged that there was no evidence that they had issued a statutory notice to Mr C. They also explained why the invoice for the completed work was not issued earlier, and we noted that they had already apologised to Mr C for this. We upheld Mr C's complaints about the failure to issue the statutory notice and about the demand for payment, and made a recommendation. As, however, we found that the council's investigation into the costs had been appropriate, we did not uphold that complaint.

Recommendations

We recommended that the council:

• consider whether, given the failure identified, they should rebate part of the fee levied against Mr C for his share of the costs of the council's administration on the contract.

Summary

Mr C, who is a landlord, said that he told the council in March 2012 that his tenant, who was in receipt of housing benefit, had not paid his rent and asked them to intervene in this. He complained that the council failed to take action, and did not deal properly with his correspondence and complaints.

We did not uphold his complaint that the council failed to act in March 2012, as Mr C was unable to provide us with any evidence that he had been in touch with them about this then. The first evidence of contact was in June 2012, when he sent them an email about it. The council said that this was when he first brought the issue to their attention. Despite extensive enquiries, we did not find any documentary evidence that Mr C contacted the council earlier than this, so we were unable to conclude that they failed to take appropriate action.

We did, however, uphold his complaint about correspondence and complaints handling. The evidence showed that Mr C contacted the council on numerous occasions over an 11-month period with his concerns about his tenant and communicated with various teams in the revenue and benefits department. In general, the council did respond to his communications. However, we were critical of them for failing to confirm their understanding of his concerns with him at an early stage and for failing to explain the services the different parts of the council could provide. They also did not advise Mr C of the outcome of their initial investigation when he asked that they start to make housing benefit payments directly to him, as landlord, and of any right of appeal against this decision. Mr C's first formal complaint was not considered appropriately under the council's complaints procedure and he was not advised how to escalate his complaint. There was also an unreasonable delay of two months in responding to a letter from Mr C's MSP and the council did not send updates or explain the delay.

Recommendations

We recommended that the council:

• ensure that they advise a landlord requesting a review of a housing benefit decision of the outcome of the review and of any statutory right of appeal;
• ensure that staff deal with formal complaints under the council's complaints procedure appropriately and advise complainants how to escalate their complaint, should they remain dissatisfied;
• consider making a payment to Mr C of an amount equivalent to the June 2012 housing benefit payment; and
• provide Mr C with a written apology for the failings identified in this case.

Summary

Mr C is a landlord of a property classed as a house of multiple occupancy. When he asked the council to uplift bulk waste he says he was told that he had to pay for the service, as his premises were commercial. Mr C disputed this and said that he paid council tax and if his premises were being classed as commercial he should have been paying business rates. He told us that it took the council three months to respond to his enquiries and complaints about the matter, and he still did not have a satisfactory explanation. He complained to us about the classification of his property and about the council's complaints handling.

We found that the council had not in fact classified Mr C's property as commercial, and we did not uphold that complaint. We did find, however, that he had been given misleading information that caused him to believe this.

We upheld Mr C's complaint about the council's complaints handling. We noted that they had written to him apologising for the delay in providing their written response, and that the information he had been given about a charge was inaccurate. They confirmed that there would be no charges involved in arranging a bulk uplift. They also arranged for the correct procedural information to be given to senior management at the call centre he had contacted, which was to be communicated to all staff dealing with the public to ensure that customers are accurately advised in future.

Recommendations

We recommended that the council:

• ensure that call centre staff are reminded of how to deal appropriately with complaints; and
• apologise to Mr C for the poor service he received from the call centre.

Summary

Mr C complained on behalf of a local action group about the council's handling of a planning application to build on a site occupied by a commercial property. Mr C said the council unreasonably failed to implement a planning clause requiring replacement of a tree; failed to respond appropriately to concerns about the protection of another tree; and unreasonably failed to obtain information on the appearance of proposed garage doors. He also said the council wrongly claimed that, at a Scottish Government Reporter's meeting, the roads department representative did not support a proposal for planters along the pavement at the front of the new building; and that the council unreasonably delayed in responding to letters about the development.

We took independent advice from one of our planning advisers. He explained that the council could not have used the planning condition to require the replacement of the tree as it was not located in the application site, so we did not uphold this complaint. However, he said that the council could have used different provisions to require another company (that owned the land where the tree was located) to replace it. We were not satisfied that the council took appropriate steps to secure the replacement of the tree, or that they took all appropriate steps to safeguard the other tree. In both cases, we were also critical of the council's failure to provide this office with actual evidence of their actions, and we made recommendations to address all these failings.

Our adviser explained that no public consultation was required about the detail of the garage doors and the council's planning officer was entitled to deal with this under delegated powers. On the matter of what was said at the Scottish Government Reporter's meeting, there was insufficient objective evidence of what the roads department representative actually said. We did not uphold these complaints.

We upheld the complaint that the council delayed in providing information to the action group and local councillors on the health of the second tree, and in responding to Mr C's complaint, and we also criticised the standard of their response.

Recommendations

We recommended that the council:

• make relevant staff aware of our findings on the complaints about the trees;
• ensure that, as a consequence of this complaint, staff in future keep full records of their actions as detailed by our adviser;
• confirm to the Ombudsman when replacement trees will be planted; and
• issue Mr C with a written apology for failing to respond to a letter within a reasonable time and for failing to address the new issues raised.

Summary

Mrs C complained to us about the care and treatment of her late mother (Mrs A) while she was in the care of St Michael's Hospital. She raised concerns about her mother's oral health care, and her enteral tube feeding (she was fed by a percutaneous endoscopic gastrostomy (PEG) tube into her stomach, also known as 'enteral tube feeding').

We took independent advice from one of our advisers, who is an experienced nurse. We found that Mrs A was an in-patient for 13 months. A care plan was put in place when she was admitted, which identified her oral health care needs, and we found that this was followed. However, it was not reviewed and updated on a monthly basis, and did not take into account Mrs A's increased risk of mouth problems due to the enteral tube feeding. Mrs A was also given a mouth wash on an ongoing basis, as she had a painful mouth due to gum disease. Our adviser pointed out that the guidelines for the use of the mouthwash indicate that it should only be used for seven days, after which its use should be reviewed. This did not happen.

In relation to Mrs A's enteral tube feeding, Mrs C raised concerns that the care and management of her mother's tube was insufficient, and that on occasion she was fed while lying flat. This then led to her aspirating (breathing in foreign material) her food, and contracting aspirational pneumonia (inflammation of the lungs and airways from breathing in foreign material). Mrs A died of aspirational pneumonia. Our investigation found that Mrs A's enteral tube feeding was in line with her care plan. However, the documentation of this care was on an 'exceptional' basis, in that staff only recorded events that were outside the normal care provision. The evidence indicated that Mrs A had not been laid flat to feed, and that when she was found flat, appropriate action was taken to remedy the situation. We found that the board's actions in relation to Mrs A's tube feeding were reasonable, but that their care in relation to her oral health was inappropriate.

Recommendations

We recommended that the board:

• ensure that staff are aware of the need for monthly reviews of oral care plans and the level of detail that should be recorded; and
• provide a written apology for the failure to provide appropriate oral health care for Mrs A.

Summary

Mrs C complained about the care and treatment that the Royal Infirmary of Edinburgh provided to her late mother (Mrs A) who passed away 12 days after being admitted there after having had a stroke. Mrs C was also concerned about poor staff communication about Mrs A's deteriorating condition, and the way in which the board dealt with her complaint.

After taking independent advice on Mrs C's complaints from one of our medical advisers, we did not uphold her complaint about her mother's care and treatment. The adviser said that although Mrs A’s condition was complex, the care and treatment she received was in line with national guidance recommended by the Scottish Intercollegiate Guidelines Network on the management of stroke patients. We found evidence that accident and emergency (A&E) staff assessed Mrs A and arranged a brain scan in a timely manner. Furthermore, A&E staff sought prompt advice from specialist staff. Although aspirin could have been given to Mrs A sooner, it was administered within the 48 hour guideline recommended by NHS Quality Improvement Scotland, and the adviser thought it unlikely that Mrs A's outcome would have been any different even had it been given sooner. We also concluded that Mrs A was promptly assessed by both physiotherapy staff and speech and language therapy staff after she was transferred to the stroke ward. In addition, frequent medical reviews were carried out and appropriate monitoring and treatment of her heart rate to help keep it under control.

We did, however, uphold Mrs C's other complaints about communication and complaints handling. When the board met with Mrs C to discuss her complaint, they apologised for the lack of information about Mrs A's deteriorating condition on the day of her admission to A&E and accepted that there were significant communication problems when Mrs A was transferred to the combined assessment unit and then to the stroke ward. They said that they were taking steps to address this.

The board accepted that there were mistakes in their written response to Mrs C's complaint. They apologised for these, issued an amended version of the correspondence, and reimbursed Mrs C for the money she had to pay to receive their letter, which had insufficient postage on it. We also found that, although Mrs C told the board that they had written to her at the wrong address, there was a delay of three months before she received a further letter from them responding to her complaint as they had used the incorrect address again. We also established that: they had not responded within the 20 working day target set out in the Scottish Government's complaints procedure guidance; contrary to that guidance, the board's internal complaints policy permitted them to suspend the 20 working day response target when the person complaining accepted the offer of a meeting, and they had not kept Mrs C updated about when their response would be issued.

Recommendations

We recommended that the board:

• provide evidence to support the action they have taken to improve communication between staff and relatives regarding patients who have suffered a stroke;
• feed back to relevant staff the importance of ensuring timely and accurate responses to complaints, and of providing updates when the 20 working day timescale cannot be met, in accordance with the Scottish Government's complaints guidance; and
• review their internal complaints policy to ensure that it is in line with the Scottish Government's complaints guidance.