Some upheld, recommendations

Summary

Mrs A had a brain tumour. Two years after she was diagnosed with this, and after three epileptic seizures and a possible stroke, she was admitted to hospital. Mrs A's family were unhappy with her care and treatment while she was there and discharged her home early the next month. Mrs A died just under three weeks later. Mrs A's son (Mr C) complained about her care and treatment and the level of communication with her family while she was in hospital. He also complained about the way the board dealt with his subsequent complaint.

During our investigation, we gave careful consideration to all the relevant information, including all correspondence, meeting notes, Mrs A's clinical records and the board's complaints policy. We obtained independent advice from our nursing adviser and this too was taken into account.

Our investigation found that Mrs A's fluid and food intake was poor, but that the nursing notes showed that she was offered food and drinks. Our adviser said that while staff had clearly tried to improve her intake, it was often the case that very unwell patients were reluctant to eat or drink. Mrs A also had a thrush infection in her mouth, and this must have been difficult for her. We found that Mrs A's medication and pain relief were appropriate for her condition and she had been referred to the palliative care (care to prevent or relieve suffering) team. We also found that before Mrs A was discharged, a plan was put in place to support her at home. The records showed that staff had tried to keep the family regularly updated, but it was accepted that their efforts had not perhaps met the family's expectations and could be improved. Overall, we found that Mrs A's care and treatment was acceptable. However, we upheld Mr C's complaint about complaints handling, as after he complained there was clear evidence of delay.

Recommendations

We recommended that the board:

• offer a formal apology for the delay in dealing with the complaint.

Summary

Mr C complained that his wife (Mrs C) was not provided with reasonable care and treatment after an operation to remove her womb, ovaries and fallopian tubes at Glasgow Royal Infirmary. He said that Mrs C had received an incorrect amount of morphine (pain relief) after surgery and as a result she stopped breathing and nearly died. Mr C and his son witnessed this and it had caused them both considerable upset. Mr C also said that the board unreasonably handled his complaint about this.

We took independent advice on this complaint from one of our medical advisers, who is a consultant anaesthetist. Our investigation found that Mrs C did not receive excessive morphine. Our adviser said that Mrs C exhibited a recognised but rare complication of a standard analgesic (pain relief) technique, which resulted in her breathing being impaired. We found that hospital staff and clinicians provided the correct care and treatment to Mrs C throughout her stay in hospital and so we did not uphold this complaint. However, we found that staff communication at the time of the incident could have been better, and made a recommendation to improve this.

During our examination of the complaints handling we found a period where the board delayed in contacting Mr C, which they had acknowledged. For this reason we upheld that complaint and made a recommendation.

Recommendations

We recommended that the board:

• advise the Ombudsman on the steps taken to ensure that the communication failures (after the incident, and a misleading entry on the discharge letter) do not recur;
• issue Mr C with a full and sincere apology for the failings identified; and
• advise the Ombudsman of the steps they take to ensure that the complaints handling failures identified in this complaint do not recur.

Summary

Mr C complained about the care and treatment that a medical practice provided to his late mother (Mrs A) before her death. He said that GPs had not taken reasonable steps to assess and monitor Mrs A's pain when making changes to her medication. He also said that they had unreasonably put Mrs A on the Liverpool Care Pathway (a framework used by healthcare professionals in the last hours or days of life when a death is expected).

We obtained independent advice on this complaint from our GP adviser. We found that in general, the practice had taken reasonable steps to assess and monitor Mrs A's pain when making changes to her medication. However, we upheld this complaint as they should have ensured that arrangements were in place to review Mrs A and that this was noted in the medical records, after her medication was increased on one occasion and it was identified that she had a chest infection. At the very least, they should have phoned to find out if the medication was effective or was causing problems. There was no evidence that they did so.

Our investigation also found that the practice had considered admitting Mrs A to hospital or to a hospice when her condition deteriorated. They discussed this with the family and with the nursing staff caring for Mrs A. They decided that she should not be admitted and that they would start the Liverpool Care Pathway. We did not uphold this complaint as, although we considered that the GP should have recorded more detail about the decision we found that, based on the information available at the time, the decisions not to admit Mrs A to hospital and to start the Liverpool Care Pathway were, on balance, reasonable. That said, we found that the practice's responses to Mr C about the matter had not been satisfactory and that they had failed to respond in detail and we made a recommendation to address this.

Recommendations

We recommended that the practice:

• make the staff involved in Mrs A's care and treatment aware of our findings;
• issue a written apology to Mr C for the failure to satisfactorily respond to his complaints;
• take steps to ensure that in the future complaints are investigated and responded to appropriately; and
• remind the GPs of the need to maintain clear and thorough medical notes.

Summary

Mrs C complained that nursing staff failed to provide support to her daughter (Ms A) after she was discharged from hospital. She said that they had failed to act appropriately in relation to two visits made to the local housing office to try to secure accommodation for Ms A. Mrs C also complained about the handling of her complaints.

To investigate the complaint, we took all relevant documentation into account, including Ms A's clinical notes and the complaints correspondence. We also obtained independent advice from two of our medical advisers.

The investigation showed that there were differing accounts of what happened after the first visit to the housing office, which we could not reconcile. Based on the available evidence and our advisers' comments, we found that Ms A's discharge was planned and that the support provided by the nursing staff was reasonable. We were, however, concerned about a lack of detail in the nursing notes, and made a recommendation about this. We also found that, while the board had provided a reasonable response to the issues Mrs C raised, they failed to respond within the timescale set out in the NHS complaints procedure.

Recommendations

We recommended that the board:

• ensure that, when nursing staff on the ward record clinical events, they do so in sufficient detail that it is clear to colleagues precisely what occurred, what risks there were (if any), and how matters were dealt with and by whom; and
• apologise to Mrs C for the delay in responding to her complaint.

Summary

Mr and Mrs C complained to Scottish Water about a blocked drain, but were told that the problem was theirs to resolve as the blockage was on their property. Mr and Mrs C instructed contractors, who established that the problem lay under the public footpath and was for Scottish Water to address. Scottish Water later confirmed this as correct. Mr and Mrs C requested that Scottish Water reimburse their costs, and complained about delay in completing the work. Scottish Water refused, however, to refund the costs on the grounds that they had no legal liability. They did, however, apologise for and explain the delay. Mr and Mrs C continued to pursue their complaint both with us and Scottish Water, who reviewed the circumstances and offered Mr and Mrs C 50 percent of their costs.

During our investigation we took into account all the relevant documentation and made further enquiries of Scottish Water. Our investigation found that the blockage causing problems was indeed under the public footpath and was for Scottish Water to resolve. However, accessibility to the drain from Mr and Mrs C's' side was complicated by an existing shaft. In the circumstances, Scottish Water said that they had no alternative but to ask Mr and Mrs C to address this, at their own cost, to allow access. However, we found that Scottish Water could have asked to do this work themselves or installed an access chamber from the public side of the blockage which, while it would have increased the time taken, would have been at Scottish Water's cost. While Scottish Water ultimately offered to reimburse 50 percent of costs, they were entirely responsible for the blockage under the public footpath. We upheld Mr and Mrs C's complaints about the costs and the handling of the complaint, but not about delay, for which we found the explanation reasonable.

Recommendations

We recommended that Scottish Water:

• repay the costs incurred;
• make a formal apology for the way in which the complaint was handled; and
• consider formulating a policy to cover circumstances where an ex-gratia payment may be required.

Summary

Mrs C's business occupies small premises next door to her domestic property. Her business does not have running water, sink or toilet and the water she uses for her business is obtained from her domestic property. Business Stream told Mrs C that because her business had access to water and waste water facilities in her property she was liable to pay for water services for business use. Mrs C questioned whether she was liable for charges as she did not have a direct water supply and only used a small amount of water for her business. She also said that she was previously told that in her circumstances she would not be charged.

During our investigation, Business Stream told us that they had no record of Mrs C previously being told that in the circumstances there would be no charge for the water she used for her business. They said they had reviewed her situation as a result of the complaint, but that her business did have access to water services in her domestic property. Although she was paying for the domestic element of these services, she was not paying for the services she used in connection with her business. We noted that her liability to pay for water for business use had been confirmed and did not uphold this complaint.

Mrs C also complained about the delay in an invoice being sent to her and said that, as a result, she received an invoice in 2013 backdated to 2010. We found that there had been a delay in the SPID (unique supply identification number) being created and her premises being set up on Business Stream's account. We also saw evidence that from 2011 Business Stream had sent Mrs C letters at her business premises, asking her to contact them. We could not, therefore, conclude that Business Stream were wholly responsible for the delay in the invoice but, on balance, we upheld the complaint as we were concerned that there was a delay of almost a year before the property was set up on Business Stream's billing system.

Recommendations

We recommended that Business Stream:

• apologise for the initial delay in setting up Mrs C's business property on their billing system; and
• contact Mrs C to discuss the repayment options available.

Summary

Mr C complained on behalf of a school about Business Stream's handling of the school's water account. He said that there was unreasonable confusion about metering and billing and unreasonable delay in resolving this. Mr C also complained that Business Stream failed to identify potential cost savings or to deal with a complaint about the issues he had raised. He was also concerned that the water meter was too large for the school's needs, and that although the meter was changed after the school applied for a downsize, the reduction in charges was not appropriately backdated.

During our investigation, Business Stream accepted that there had been confusion about billing and metering since the account was opened, that there had been an error in processing the application for a meter downsize and because of this the wrong meter had been installed. Because of these failings, we upheld this part of Mr C’s complaint. As a result of their error, Business Stream offered the school redress. Based on the evidence provided, we were satisfied that Business Stream had responded to this part of the complaint and had taken action. We found no evidence that they had not followed their policy in relation to the backdating of the reduced charges.

Recommendations

We recommended that Business Stream:

• issue an apology to the school for their handling of these matters; and
• as a matter of urgency, make the necessary amendments to the school's account and provide in writing a full breakdown of all charges.

Summary

Ms C complained about the Care Inspectorate's handling of an investigation into a complaint made about her nursery, which had been upheld. In particular, she said that they failed to deal with the investigation within the timescales allowed, failed to deal with the complaint in a reasonable manner and did not conduct the investigation according to their guidelines. She also said that they published their decision on their website following the investigation, although she had submitted a complaint about their handling of the complaint.

During our investigation we found that, in line with their procedures, the Inspectorate had communicated with the parent who had made the complaint about the timescale for completion of the investigation. However, they accepted that they should have told Ms C that the investigation was not going to be completed within the timescales detailed in their procedures and should have apologised for this. We were satisfied that the Inspectorate had considered and responded to Ms C's concerns about how they had dealt with the complaint about her nursery. In addition, we noted that, as a result of Ms C's concerns, they had agreed to reopen the parent's complaint for a further full investigation to allow further information to be sought, and had decided to set aside the regrading that had been applied following the complaint. However, we were concerned that there had been a delay in removing the regrading information from their website.

Recommendations

We recommended that the Care Inspectorate:

• apologise to Ms C for the delay in removing the downgrading from the website.

Summary

Ms C complained that the council failed to respond to her complaint that council staff refused to provide receipts when she hand delivered letters to the reception desk at council offices. She told us that she had explained to the council that she did not use email and found it impractical to use registered post, but had experienced situations where council officials had denied receiving correspondence, or important documents had gone astray. She said that she had been told by council staff that the council do not provide receipts.

Our investigation found that the council do not have a policy or process for providing receipts where mail has been hand delivered, but were considering this as part of an ongoing internal review of their practices, which we considered helpful. We said we would ask the council to let us know the outcome of this. However, they were unable to explain why Ms C’s complaint about the matter was not dealt with under their complaints procedure, so we upheld that element of the complaint and made recommendations.

Recommendations

We recommended that the council:

• review internal arrangements for the receipt, logging and acknowledging of complaints correspondence to provide assurance that the council fully comply with the requirements of the model complaints handling procedure;
• apologise to Ms C for the failure to deal with her complaints; and
• ensure that the issues Ms C raised in her letters of complaint are dealt with, in line with the council's complaints procedure.

Summary

Mr C is the non-resident owner of a flat in a block where the council also owned a flat. When Mr C bought his flat in 2006, he was aware that the council wanted to carry out repairs to the building. While Mr C agreed, the other private owners did not, and only an emergency repair was undertaken. When the council tenant then found dampness in their flat, the council inspected the block and, given the lack of previous consensus on the subject of repairs, issued a statutory repairs notice. The database they used for notifying owners was not, however, updated and so Mr C and another non-resident flat owner did not receive letters about this, either from the council or from their contract administrators. Mr C eventually became aware of the notice some two years after it was issued, and paid his share of the costs. More recently, however, after media reports alerted Mr C to concerns about the administration of statutory notice contracts, he complained. Mr C received a final reply from a senior official some months later.

We did not uphold Mr C's complaints about his requests for information about why the block of flats was selected for a statutory notice and the choice of contractor or about additional works undertaken, as we did not find that anything had gone wrong in this. We did, however, find that the council did not fully consider his complaint and review his case, as they had linked it to a similar complaint from another owner, and had not considered all the issues Mr C had raised.

Recommendations

We recommended that the council:

• consider whether they should rebate the fee levied on Mr C for his share of the costs of the council’s administration of the contract.