Some upheld, recommendations

Summary

Mr C complained about the way the council dealt with his complaint about their education services. He also complained that they unreasonably told him that they would no longer correspond with him by email.

Having reviewed the evidence, our investigation found that the council had responded to his complaints in line with their procedures. We noted, however, that they had given an incorrect reason for restricting his email contact, and had failed to ask him to reduce the level of email correspondence he was providing before restricting his contact with them. For this reason, we upheld this aspect of the complaint.

Recommendations

We recommended that the council:

• write to Mr C to apologise for giving inaccurate reasons for restricting his email contact.

Summary

Mr C corresponded with and complained to the council about their maintenance of a park. He was dissatisfied at the end of the complaints procedure and raised his complaints with us, including that they had not responded appropriately to his complaints.

We found that there was evidence that the council had reasonably maintained the park during the period concerned. However, we also found that the council had not responded reasonably to Mr C's complaints because they did not provide full responses to the issues he raised, and on one occasion provided inaccurate information.

Recommendations

We recommended that the council:

• apologise to Mr C for the complaints handling issues identified; and
• ensure all staff are reminded of the need to provide full responses to complaints.

Summary

Mr C lives with his partner (Ms B), who has a disability. He complained about the council’s handling of the couple's request for a mutual exchange of council properties. He said the council unreasonably refused permission for this on the basis that the property that Mr C and Ms B were hoping to move into could not be fully adapted to Ms B’s potential future requirements. Mr C said the council told him that if he wished to go against their decision and proceed with the exchange he would have to sign a disclaimer saying that he accepted that the council would not be responsible for any future adaptations, and that he would have to fund these himself. Mr C said the council later changed their policy and agreed the exchange, but he also complained that they then failed to carry out a property condition check before the exchange took place.

Our investigation found that the council’s written policy on mutual exchanges at the time did not say that properties had to be fully adaptable. When we asked them for information, they explained they had based their decision on an unwritten policy about this, which they said meant that the mutual exchange could not be granted. We upheld Mr C's complaint, as we found that it was not appropriate for the council to rely on an unapproved, unwritten policy when determining whether a mutual exchange could be granted. As there was nothing in their procedure on mutual exchanges to indicate that the exchange should not be approved, we considered that they unreasonably refused permission. It was also clear that the council’s policy did not require tenants to sign disclaimers in situations such as this. Again, it appeared that the council were operating an unwritten policy on completion of disclaimers in respect of future adaptations. We did not uphold the complaint about the property check, as the council provided us with evidence that they inspected the property before the mutual exchange.

We noted that the council had apologised for some of their failings and had taken some remedial action, but we made recommendations as we considered that further remedial action was required.

Recommendations

We recommended that the council:

• provide Mr C and Ms B with a written apology for unreasonably refusing permission for their mutual exchange;
• feed back to the staff involved our decision about their refusal of the mutual exchange;
• revise their mutual exchange policy to include information on the adaptability of properties; and
• provide the Ombudsman with documentary evidence of the feedback previously given to staff about this complaint and the refresher training they received.

Summary

After his circumstances changed, Mr C felt that he could no longer remain in his privately rented accommodation. He was finding his situation very stressful due to mental health problems. He approached the council for assistance but he complained that the way they processed his housing application was unreasonable. He also said that they failed to follow proper processes, delayed in allowing him access to their web-based portal service and wrongly said that he had failed to obtain permission to tape a meeting. He said that the council's handling of his complaint to them about this was inadequate.

When investigating the complaint, we considered the complaints correspondence, details of Mr C's housing application, copies of the council's internal records and the council's housing allocations policy. We also contacted Mr C's community psychiatric nurse. Our investigation found that the council followed their procedures when dealing with Mr C's application and that taking his health problems into account they had, with his agreement, made arrangements for him to stay longer in his privately rented accommodation. Although Mr C was clear that he had requested the council's permission to tape a meeting he had with their officer, we found no written evidence of this. We did not uphold either of these complaints, but we did uphold the other three. There was clear evidence that the council's communication with Mr C was poor. The council acknowledged this and had apologised. There was also evidence that there was delay in allowing Mr C access to their portal helpline service, and in responding to his complaint.

Recommendations

We recommended that the council:

• apologise for their failure in this matter; and
• emphasise to helpline staff the importance of a timely reply.

Summary

Mr C, who is a solicitor, complained on behalf of a client (Mr A) that the council acted unreasonably when they included a note on planning permission issued in response to Mr A's planning application. The note said that the building referred to in the application was not a dwelling house. Our investigation found that, in stating an opinion on a legal interpretation, the note went further than normal informative notes. Although this was a view that the council were entitled to hold, we found that it was not appropriate to communicate it in such a note, and we found that they had acted unreasonably in doing so.

Mr A's representatives subsequently discussed the note with the council. Mr C said that they were told that the note could not be removed. Mr C then wrote to the council and said that he had been instructed to raise proceedings for judicial review. The council obtained legal advice from their solicitors. After considering the legal advice, the council removed the note. However, Mr C complained to us that the council had failed to engage with Mr A's representatives properly, which meant that they had to raise proceedings for judicial review before the council agreed to remove the note. Mr C said that they had incurred costs of over £8,000 and wanted the council to reimburse them. We did not, however, uphold this complaint. We found that under the planning regulations there were remedies available to remove the note, of which Mr A's professional advisers would have been aware. They could have pursued these rather than applying for judicial review. We also considered that the council had not been given a proper opportunity to consider the matter before the judicial review proceedings were started.

Recommendations

We recommended that the council:

• issue a written apology to Mr A for inappropriately including the note in the planning permission; and
• confirm to the Ombudsman that they have learned lessons from this case and will ensure that in the future, notes of this nature will not be included in planning permission.

Summary

Ms C gave up her council tenancy in August 2012. Before she left, the council's clerk of works visited and pointed out damage to several doors which he said would need replacing. He advised it would be cheaper for her to arrange the work herself, which she did. After she left the property, she was told the work was not up to standard and was issued with a bill for the work. She queried this but got no reply. The bill was issued again, some seven or eight months later. She contacted the council again and then complained that she had been charged for these items and about the delay in contacting her about the bill.

At the initial inspection of the property, Ms C had signed a declaration that she would repair the items identified, that the list was not exhaustive (ie that further repairs might be identified at the change of tenancy inspection) and that failure to undertake the repairs would result in the council carrying them out and billing her (this is known as recharging). The change of tenancy inspection that took place after she left the property identified a number of repairs, including to the work that Ms C had arranged and paid to have done. The council said that the work was not an acceptable standard and had required repair/replacement. They provided us with photographic evidence in support of this. They wrote to Ms C after the inspection setting out the rechargeable repairs, but it appeared that Ms C did not respond to this.

It is not for us to question the council's decision about whether the work was done to an acceptable standard. That is a decision that they were entitled to take and we found no evidence of administrative error in the way they reached it. Ms C had signed the declaration and the council had written to her after the final inspection with a list of rechargeable repairs, which Ms C did not appear to have questioned at that time. We did not uphold this aspect of her complaint but we did make a recommendation, as we considered that the council could have made it clearer that if the work was not done to a standard they considered acceptable, they would then carry it out and issue an account for the cost. We upheld her complaint about the delay in contacting her because, in the absence of an explanation, the delay was unreasonable. However, as the council had already apologised for the distress caused, acknowledged that they could have provided her with better support and advice and reduced the bill, we decided that no further recommendations were required.

Recommendations

We recommended that the council:

• consider altering the pre-termination inspection paperwork to make it clearer to tenants that failure to have the work done to a standard acceptable to the council would result in the council carrying out the work and issuing an account for the cost.

Summary

Ms C was a voluntary patient at the board's eating disorders unit. Some four months after she first attended there, the clinician responsible for her overall care told her that he intended to apply for a Compulsory Treatment Order (CTO - an order that allows professionals to treat a person's mental illness). A CTO can, however, only be implemented with the support of a Mental Health Officer (MHO), and they did not agree. A GP who knew Ms C agreed with the MHO and the application was dropped. Ms C was discharged from the unit and continued her treatment in the community.

Ms C complained that the period leading up to the application for the CTO was not managed responsibly, in that she was not provided with a proper explanation for the application. She said that she had been complying with her treatment programme and that there was no need for compulsory measures. Ms C also said that she was not provided with appropriate levels of support, that her family and other health professionals were not effectively communicated with and that her right to confidentiality was not respected.

Our investigation found that there was a failure to communicate effectively with staff as well as inappropriate wording in an anticipatory care plan, which meant that Ms C was effectively detained on the unit, despite being a voluntary patient, so we upheld that part of her complaint. We did not, however, find that Ms C was not provided with appropriate emotional or psychological support or that her confidentiality was breached.

Recommendations

We recommended that the board:

• issue Ms C with an apology for the failings identified in this investigation;
• develop a policy to reflect the Mental Welfare Commission’s guidance in relation to short term detention, for staff use and guidance and ensure this is distributed to all staff;
• remind medical staff of the need to ensure anticipatory care plans have sufficient flexibility to allow practitioners to exercise their clinical judgement; and
• ensure all staff are aware that communication with patients about a CTO application must comply with Mental Welfare Commission guidance.

Summary

A Member of Parliament (Mr C) complained to us on behalf of Mr and Mrs A whose daughter (Ms A) died from skin cancer. Mr and Mrs A felt that their daughter's diagnosis and treatment was unreasonably delayed because a mole was not properly removed from her scalp four years previously, and that there was a failure to make appropriate follow-up arrangements. They also said that the board refused Ms A’s requests for surgery when she developed a breast lump and unreasonably insisted that she attend an appointment at a time when bad weather made travelling to hospital very difficult.

As part of our investigation, we took independent advice from two medical advisers, a skin specialist and a cancer specialist. Our investigation found that Ms A’s mole was at first only partially removed because of where it was on her scalp. A biopsy (tissue sample) was taken and analysed, and it was reported that the results did not show that the mole was malignant. Based on this, it was reasonable that there was no formal follow-up after the mole was removed. However, our investigation found that histopathology reporting (the study of changes in tissues caused by disease) was unsatisfactory, as the biopsy was reported incorrectly and the sample taken did show signs of malignancy. One of the advisers also said that it would have been good practice to remove the mole fully, as it was clearly possible to have done so. Ms A then developed lumps on her neck and, later, a lump on her breast. Although we found that the board carried out appropriate investigations into these lumps and provided relevant treatment, we found that there had been some avoidable delays because Ms A was not prioritised as a suspected cancer patient. We upheld Mr C's complaints about removal of the mole and about diagnosis.

We did not uphold the complaints about the appointment, or about refusal to offer surgery earlier. We found that three separate tests had found that Ms A’s breast lump was benign and skin cancer in the breast of a woman of her age would be very rare. As such, we were satisfied that the board’s initial advice that surgery was not necessary was reasonable. Surgery was arranged appropriately when the lump persisted and began to irritate Ms A. We were also satisfied that the board did not insist that Ms A attend her appointment during the difficult weather conditions. They did give appropriate advice about how long it might take to reschedule the appointment, should she decide not to attend.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs A for their failure to remove all of Ms A's mole and for the incorrectly reported biopsy;
• review their systems for clinical pathological correlation with a view to avoiding a similar misdiagnosis in the future;
• apologise to Mr and Mrs A for the delay to Ms A's diagnosis; and
• conduct a review within their breast, radiology and pathology departments of their sampling techniques and histopathology reporting quality.

Summary

Mrs C complained about the care and treatment that the board provided to her late mother (Mrs A) before she committed suicide. Mrs A had been admitted to hospital with low mood and worsening anxiety. She had a diagnosis of recurrent depressive disorder and a history of drug overdoses dating back a number of years. When it was initially proposed that Mrs A would be discharged from hospital, both she and Mrs C had concerns that she was being discharged too early. After taking independent advice from one of our medical advisers, we found that that staff had taken these concerns on board and had postponed the discharge by five days, which we found showed evidence of reasonable patient and carer involvement. We found that Mrs A's subsequent discharge was appropriately planned and phased. Risk assessments had been carried out and she had three successful overnight passes before her discharge. In view of all of this, we considered that it had been reasonable for the board to discharge Mrs A.

Mrs C also complained that staff had failed to ensure that there was an adequate support package in place when Mrs A was discharged. It had been agreed that she would be followed up by a community psychiatric nurse (CPN) and would attend an out-patient psychiatric clinic. We found that the planned follow-up care at the time of Mrs A's discharge was reasonable, in that it was adequate to meet her needs and her level of assessed risk. However, Mrs A's consultant in hospital had recorded that she would receive CPN input for as long as was indicated after she was discharged, and in the weeks after her first appointment with a CPN, Mrs A's anxiety levels had increased. Mrs C, Mrs A and her GP had all contacted the board to say that she was struggling with increased anxiety. Despite this, after a second CPN visit, it was decided that the visits would stop. Although it was decided that she would be referred to a mental health day service, Mrs A had concerns about this. The CPN also told Mrs A that she was moving to another job. We found that, on balance, in view of Mrs A's increased anxiety it was unreasonable to discontinue the CPN follow-up after only two visits and so we upheld this complaint. We did, however, consider that it was appropriate for the CPN to tell Mrs A that she was moving to another job. Mrs A took her own life just two days after the second appointment. Had the CPN input been continued, the next visit would probably not have been for another few weeks. We took the view that it would, therefore, be unreasonable to say that the withdrawal of CPN support was a significant factor in Mrs A's decision to take her own life.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the premature decision that Mrs A no longer needed to see a CPN; and
• make the relevant staff aware of our finding on this complaint.

Summary

Mr C complained about a delay in Business Stream issuing his first invoice. He was also unhappy that water charges were based on his property’s rateable value, as he did not have a water meter.

Our investigation found that Mr C’s property had been a ‘gap site’ (a site that has never been billed for water). As a result, Scottish Water (Business Stream’s wholesaler) had told Business Stream in August 2010 that the property was receiving water without being charged. Mr C had moved into the property in March 2011, but Business Stream did not invoice him until after they visited the site in January 2013. Although Mr C may not have known that Business Stream were the default water provider, that did not automatically mean that their charges were invalid and so, in deciding his complaint, we considered the responsibilities of both parties. We found no evidence to indicate that Business Stream took any significant steps with regard to the property before the site visit. We considered that, when viewed as a whole, Business Stream took an unreasonable length of time to issue the first invoice and we upheld Mr C’s first complaint.

Business Stream explained that their charges were originally based on his property’s rateable value, but said that after Mr C submitted a reassessment application, a meter had been installed and his charges were now based on that. We found no evidence that Business Stream calculated the charges inappropriately before the meter was installed. However, there was some confusion about the reassessment process which may – at least in part - have contributed to a slight delay in the meter being installed. Although we did not uphold this complaint we made a recommendation.

Recommendations

We recommended that Business Stream:

• consider whether an adjustment to the unmetered balance would be appropriate, in light of the confusion over the reassessment process.