Some upheld, recommendations

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.

Summary

After Ms C's business moved into new premises in September 2009, Business Stream wrote asking her to confirm that the premises were occupied and to set up a water account. Ms C said that she completed and returned the forms, but heard nothing more. Business Stream said they did not receive the documents, and so it was not until an inspector visited her premises in December 2012 that an account was set up for her business and her first invoice issued. Ms C complained that the delay to her first invoice being issued was unreasonable. She also complained that it was not until it was issued that she realised her water consumption was unexpectedly high. Subsequent investigation found two leaks. She complained that Business Stream should have done more to help her identify and repair the leaks.

We found that it was Ms C's responsibility to tell Business Stream (or another provider) that she had moved into the premises. That said, we accepted that she had tried to do so when she received Business Stream's forms. We found that Business Stream had experienced problems with forms going missing around that time. Ultimately, we considered that this contributed around 12 months to the delay in the first invoice being issued. We did not consider it Business Stream's responsibility to identify or repair internal leaking pipes. However, we felt that they should recognise that Ms C incurred additional expense as a result of her first invoice being delayed, as it was not until she received it that she realised there was a problem with her water supply.

Recommendations

We recommended that Business Stream:

• offer Ms C an ex-gratia payment equivalent to ten percent of her water bills for the period in question, in recognition of the delay to her initial bill and its impact on her ability to identify problems with her pipework.

Summary

Mrs C, who owns a holiday cottage, complained after Business Stream contacted her by phone about an outstanding bill for the premises. At the time she was not aware that she was obliged to pay Business Stream, as she believed she paid through her council tax for the water at the cottage. After Mrs C’'s MSP wrote to Business Stream on her behalf, it was established that the account had been set up with the wrong start date, and Mrs C was issued with a corrected invoice. She was then sent an invoice showing that the balance on her account had been cleared, which lead her to close her account with Business Stream, and transfer to another water company. She was then sent a further invoice showing a large outstanding balance. She complained to the chief executive, who offered her a goodwill payment.

Mrs C was still unhappy and complained to us that Business Stream had unreasonably pursued her for the amount due and that they had not dealt with her in a professional way.

Our investigation found that Business Stream is legally the default supplier. This applies in all cases, including those where a business does not realise it is liable for water charges, or is operating under the belief that water charges are paid to the local authority. Mrs C had acted in good faith, but unfortunately had received inaccurate advice about water charges from her local authority, so we did not uphold this complaint. We also found, however, that the goodwill payment had not been processed. Although Business Stream did do this after we became involved, they did not apologise to Mrs C for the failure, they repeatedly issued invoices without any explanatory correspondence, and the order in which these were issued was confusing. We also found that Business Stream failed to acknowledge or apologise for the time and trouble they had caused Mrs C, and so we upheld her complaint about the way in which they dealt with her.

Recommendations

We recommended that Business Stream:

• apologise for the failings identified in our investigation;
• make a time and trouble payment; and
• ensure that, when corrections are made to customer accounts, invoices are issued with explanatory correspondence.

Summary

Mr C complained that Business Stream unreasonably refused to award a burst allowance following a leak at a property he managed. He also complained that their handling of the complaint was inadequate, and that this had caused him an unreasonable amount of additional work and inconvenience.

We did not uphold the first part of the complaint. We found that, in fact, it was Scottish Water who decided to reject the allowance (as in their view too little excess water was used to merit awarding it), which was a decision that they were entitled to make under their procedures for dealing with burst water pipes.

Our investigation did, however, find that Business Stream had not investigated Mr C’s complaint for some eleven months and so we upheld his concerns about their complaints handling. Although there were a number of complex issues being investigated on the site, we found that it was unreasonable for Business Stream not to have taken any action in respect of the complaint.

Recommendations

We recommended that Business Stream:

• apologise in writing for the failings identified in our report; and
• cancel the recovery charges that were applied to Mr C's account while he was awaiting a response to his complaint.

Summary

Mr C, who is a prisoner, complained that the Scottish Prison Service (SPS) failed to enable him to have outdoor exercise. Our investigation found, however, that the reason for this was that the outdoor exercise time for his residential area conflicted with another optional activity he took part in. We also found that the SPS had offered other arrangements for him since he made his complaint, so that he could do both. We did not uphold this complaint as we considered that the SPS had acted reasonably.

Mr C also complained about various aspects of the handling of his complaint. We upheld some of this, as we found that the SPS had not acted in accordance with prison rules. These say that, at the first stage of the complaint, a prisoner must be offered the chance to discuss it verbally, and that the final stage of the complaint should take no more than 20 days. Neither of these things happened. In terms of the opportunity for discussion, as the SPS have already introduced a revised form as a result of a previous complaint to us we did not need to make a recommendation.

Recommendations

We recommended that the SPS:

• apologise to Mr C for the two complaints handling issues identified; and
• remind staff of the requirement to meet the 20-day timescale of Prison Rule 123(9).

Summary

Mr C, who is a prisoner, complained after the prison took the decision to place him under restraint, using a body belt. He said that the decision was unnecessary and that he was held under restraint for more than 12 hours without approval from Scottish Ministers. He also complained that prison staff failed to appropriately observe him whilst he was under restraint, and that he was unreasonably denied access to toilet and water breaks.

Our investigation found that the prison were authorised by prison rules to place Mr C under restraint. The prison explained that they decided to do that because he was continuously harming himself and refusing medical treatment. We cannot question a decision that the prison were entitled to take, unless there is evidence to show us they failed to do something properly in reaching that decision. Mr C did not agree with the decision, but that was not a reason for us to uphold this complaint.

In looking at the period of time Mr C was held under restraint, the prison rules say a prisoner cannot be placed under restraint for more than 12 hours without Scottish Ministers’ authority. The prison held Mr C under restraint for more than 12 hours without seeking that permission. They identified this error before Mr C complained, and took steps to review the process and ensure staff were aware of it. In addition, the prison rules confirm that an officer must monitor a prisoner continuously while they are held under restraint. The prison said that this happened in Mr C’s case, but he disputed this. There was no closed-circuit television evidence available for us to see, but documented evidence in the form of log sheets confirmed that staff generally recorded information about Mr C’s behaviour at least once every 15 minutes. However, the prison were unable to provide evidence that he was checked between 19:30 and 22:00. Without that, we could not reach a fully formed decision as to whether Mr C was continuously monitored, but it meant that the evidence did not show that he was. Mr C also said he was denied toilet and water breaks whilst wearing the restraint. The documented evidence indicated that he was provided with a drink and access to the toilet only once and in our view, that was unacceptable. In light of our findings, we upheld all of these complaints.

Recommendations

We recommended that the Scottish Prison Service:

• apologise to Mr C for inappropriately failing to seek the required permission to hold him in the restraint for more than 12 hours;
• ensure written records are maintained for the entire time period that a prisoner is kept in restraints; and
• ask the prison to advise staff that when a prisoner is being held in a restraint, they should be offered access to water and the toilet regularly, and this should be appropriately documented.

Summary

Mr C complained about the council’s handling of three planning applications. He said that the applicant had originally claimed that a number of people, including Mr C, supported all three applications. Mr C, however, said that he had supported only one (smaller) application. The police were still conducting an investigation into this when the council granted planning permission. Mr C questioned the transparency of the council’s decision.

Our investigation found that the information about the level of support for the applications came to light after the planning reports were prepared and they had to be amended. However, the copies on the council’s website were not updated properly and so Mr C questioned whether or not the committee, when they decided to grant permission, had considered the accurate reports. The council acknowledged that their website was out of date and said that this was an administrative error. They said that this did not mean that the committee had considered out of date information and explained that the matter was specifically brought to the chair’s attention at the start of the meeting. They also explained that they had taken legal advice and were told that, on the basis of 'innocent until proven guilty', the applications should be decided despite the ongoing police investigation.

Although the council provided the original and updated paperwork, there was no documentary evidence that could confirm exactly what papers the committee had considered. In addition, the legal advice had been given verbally, so there was no documentary record of what had been said. Although we upheld Mr C’s complaint that incorrect information was made available online, we did not find that the council had unreasonably determined the applications. They had taken legal advice and, from an administrative perspective, took a decision that they were entitled to take (although we did recommend that they keep records of such advice in future).

Recommendations

We recommended that the council:

• consider making contemporaneous records of verbal legal advice to ensure a clear audit trail; and
• update their website to reflect the accurate reports considered by the committee (in both the planning and committee sections).