Some upheld, recommendations

Summary

Mrs C complained about the care given to her late husband (Mr C) while he was in hospital. She said that he was moved three times but only on the last occasion was it suitable for his condition. She alleged that he was not comfortable or properly looked after and that his clinical care was poor. In particular, she said that he endured terrible pain when his chest drains were being replaced. Overall, Mrs C believed that the lack of proper care hastened Mr C's death. She further complained that she was not kept informed by staff about his condition.

In investigating this complaint, we obtained independent advice from medical and nursing advisers. We also took into account all the information provided by Mrs C and by the board (including the relevant correspondence and clinical records). The board had said that the clinical care and treatment given to Mr C were appropriate. However, our medical adviser said that Mr C should have been referred earlier to a thoracic surgeon and should not have undergone four attempts to insert chest drains, particularly without appropriate sedation. There were also failings in Mr C's nursing care, in that his dignity and privacy were not always protected. We, therefore, upheld Mrs C's complaints about her husband's care and treatment, although we did not uphold the complaint that she was not kept informed, as the evidence showed that good attempts were made to let her know what was happening.

Recommendations

We recommended that the board:

• make a formal apology to Mrs C for the shortcomings in the clinical care given to her husband;
• train doctors, as insertion care appears to be less than adequate, to ensure that drains are properly inserted and secured properly;
• review their protocol for Intercostal Chest Drain to ensure that it is sufficiently comprehensive and includes how to deal with recurrent pneumothoraces;
• make a formal apology to Mrs C for failings in the nursing care given to her husband; and
• provide the Ombudsman with evidence confirming that systems are in place (and regularly monitored) to address the failures identified.

Summary

Mrs C complained about an examination she was given by a doctor before undergoing an emergency caesarean section (c-section - an operation to deliver a baby). She felt the examination was unnecessary, that she was not given information on what it entailed and that the doctor had not obtained her consent for it. Mrs C was also unhappy with the length of time it took the board to reply to her complaint and said that some of the information in their letter was inconsistent with previous information she had been given.

The hospital had identified two days before the c-section was carried out that Mrs C's baby was in the breech position (ie in a bottom down position instead of the more common head down position). We established that on the day of the c-section, it was necessary for the doctor to examine Mrs C to confirm whether her waters had broken and that she was in labour. After taking independent advice from one of our medial advisers, we found that the examination was carried out in accordance with both the board's local policy and guidance issued by the Royal College of Obstetricians and Gynaecologists. Without further independent evidence, we could not say for certain what the doctor discussed with Mrs C about the examination, as her recollection of events differed to those of the doctor. Our medical adviser said that it is good practice for oral consent to be documented, and that the General Medical Council recently issued guidance that a patient's consent to an intimate examination should be obtained and recorded. We noted that this guidance was not in place at the time of Mrs C's examination, however, so although we made a recommendation we did not uphold that complaint.

Whilst we found that the board regularly updated Mrs C on the progress of her complaint, we found that there was a significant delay of three months in providing a full response and we upheld that element of her complaint. We concluded, however, that the response was not contradictory, but provided more detailed information than a previous letter to Mrs C about her complaints.

Recommendations

We recommended that the board:

• ensure that verbal consent for intimate examinations on the labour ward is recorded in a patient's medical records; and
• ensure that complaints are responded to in a timely manner, by carrying out a review of how Mrs C's complaint was handled to identify potential improvements.

Summary

Mr C's business experienced a significant increase in water consumption in December 2011. However, it was not until a further bill arrived in May 2012 that he became aware of an underground leak on the pipework. Mr C noted that Business Stream state on their website that they will notify customers when they identify abnormally high water usage at properties. He complained that Business Stream failed to live up to that commitment, causing his business to incur unnecessarily high bills. Mr C also complained about Business Stream's communication when dealing with his concerns.

Our investigation found that Business Stream's policy is to notify customers if they identify an increase of more than two and a half times the normal level of water usage. We were satisfied that Mr C's water meter was read twice per year in line with normal practice and that, while his water usage increased before May 2012, the increase was less than the two and a half times threshold. As such, we would not have expected Business Stream to contact him before the May 2012 meter reading. After this reading, Business Stream took immediate action to check that it was correct and to phone Mr C. In line with their procedure, when he could not be contacted, they wrote to him to advise him of the high water consumption. We were generally satisfied that Business Stream took reasonable steps to identify the leak and bring it to Mr C's attention.

We found that Business Stream had followed the relevant policy or procedure with regard to each of Mr C's concerns. However, in every case we found their communication with him to be poor. We also found that a policy referred to by their staff was misleading and had likely added to the confusion when explaining Business Stream's position.

Recommendations

We recommended that Business Stream:

• apologise to Mr C for the confusion caused when dealing with his enquiries; and
• consider clarifying the wording of their Burst Allowance Policy to make consistent reference to the 'supply boundary' throughout.

Summary

Miss C's mother had received care services through her local council for a number of years, but these were suddenly withdrawn. Miss C complained to the council and also asked the Care Inspectorate to investigate. The Care Inspectorate investigated four complaints about the council's termination of Miss C's mother's care arrangements and upheld two of those complaints. Miss C was, however, concerned about the way this was investigated, and how the available evidence was used. She asked that they review their decision on two of her complaints. She then complained to us about delays in the Care Inspectorate's handling of her review request and about the lack of any action being required of the council when her complaints were eventually upheld.

We found that, although there were certainly delays in reinvestigating Miss C's complaints, the investigation generally progressed reasonably and communication with her about the cause of the delays was good. The delays were caused by matters that were largely beyond the Care Inspectorate's control. That said, we were critical of the length of time that they took to decide that the two complaints should be reinvestigated. We upheld the complaint about the delay in investigating, but were otherwise satisfied with the Care Inspectorate's actions in terms of notifying the council of their revised decision and following up on the action they asked the local authority to take on the issues highlighted by their investigation.

Recommendations

We recommended that the Care Inspectorate:

• apologise to Miss C for the delay in coming to a decision to reinvestigate her complaint and to conduct the investigation; and
• consider incorporating into the 2012 complaints procedure a specific timescale for the initial assessment of whether a decision should be reviewed.

Summary

Mr C complained on behalf of himself and his neighbours about the council’s handling of a planning application for the erection of a telecommunications mast near his home. Mr C said that he and his neighbours only became aware of this some seven months after it was approved, when work started at the site. He complained that the council failed to carry out the necessary public notifications on the planning application, failed to process the application correctly, and that their report on the planning application was misleading.

In response to our enquiries, the council said that they sent a neighbour notification letter to Mr C in the same way as to other notifiable residents. Although the letter did not appear to have reached Mr C, the evidence suggested that the council did send it, in accordance with normal procedure.

We took independent advice on the other matters from one of our planning advisers who said that the council acted appropriately and advertised the application in accordance with the regulations. The council had, however, acknowledged there were failings in notifying objectors of the outcome of the application and apologised for this. Our adviser said that their remedial action was not sufficient and that further steps should be taken, so we made recommendations that reflect this. We also noted that in the planning report the council incorrectly named the newspaper in which the application was advertised, but considered it unlikely that consideration of the application was prejudiced by this.

In terms of processing the application, our adviser explained that it would be normal practice for there to be some consultation between the council's planning and roads departments. It was clear that there was no record of consultation in this case although the council repeatedly said that it had happened. Based on the evidence on file, it was not possible for us to determine whether or not it did happen, and we were critical of the council for failing to keep a record of the consultation. However, the adviser said that as road safety was not an issue in planning terms, the outcome of the consideration of the application would not have been adversely affected if there had been no consultation. Our adviser also explained that the council were required to consider the application against their development plan; a plan which he said was well in line with good practice on such policies. There was no requirement for the council to have a spatial strategy for telecommunications equipment or to suggest alternative sites for masts. On land ownership, our adviser said it would be reasonable for the council’s planning department to take the information in the signed ownership certificate from the applicant at face value and that there was no requirement for anyone to obtain the owner’s agreement to the submission of an application.

On the accuracy of the report, our adviser said that the 30 metre distance referred to in the site section of the planning report would not have misled the planning committee. He explained that the determining issues in this case were consistent with policy and that the omission of consideration of the tree preservation order and information on the deciduous nature of the trees was not prejudicial.

Recommendations

We recommended that the council:

• make staff aware that the planning report incorrectly stated the newspaper in which the application was advertised and take steps to try to ensure that such errors do not happen in future;
• feed back to the staff involved our adviser’s views on the importance of objector notification and the potential environmental justice implications;
• amend their procedure to reflect our adviser’s views on objector notification; and
• adopt a more rigorous mode of recording significant information, such as the outcome of informal consultation with Roads, for the purposes of subsequent audit.

Summary

Mr and Mrs C live next to the site that was chosen for an integrated nursery, primary and secondary school academy with community leisure facilities, including an all-weather pitch and multi-use games area. Planning consent was obtained in November 2006 and the campus opened for school use and evening and weekend hires in late 2011. Mr and Mrs C complained from the outset about noise, foul language and rude behaviour in the games area, and, after evening hires of the games area for hockey, football and rugby were restricted, also complained about similar noise from users of the all-weather pitch. They told us that the council failed to take reasonable steps to provide an accurate description of the development during pre-development consultation; and failed to take reasonable action in respect of their complaints of noise and anti-social behaviour.

Our investigation found that the consultation took place in June 2006, with the application for planning consent. The evidence we saw showed that the intention to locate the games area near Mr and Mrs C’s home was disclosed at the outset and in the officer’s report on the application, and we did not uphold this complaint.

The council had, during their consideration of the complaint about the noise, accepted fault and apologised. Their second stage response also accepted fault and upheld six of nine points that Mr and Mrs C raised. However, Mr and Mrs C remained unhappy, as they said there was a lack of effective action by the council to reduce the nuisance and distress they were suffering. Our investigation found that problems have continued and the council have not done all they could to resolve this. We upheld this complaint and made recommendations with the aim of addressing this.

Recommendations

We recommended that the council:

• demonstrate measures they have taken or propose to take to implement the policy of zero tolerance of anti-social behaviour including foul and abusive language; and
• reach a decision on the installation of fencing in appropriate locations to reduce general levels of noise affecting the property of Mr and Mrs C and their neighbours.

Summary

Ms C lives in a tenement flat. The space between the tenement in which her flat is situated and the next tenement was occupied by a single storey shop. In December 2004, the owner obtained conditional planning consent to demolish the shop and build a three storey town house in the gap. However, they did not do this and, shortly before planning permission expired, a different applicant applied for planning permission for the site. Under new planning procedures introduced in August 2009, that application should have been taken forward without notifying neighbours of the plans and should have been determined by planning officers under delegated procedures. However, the council did notify neighbours. When Ms C went to see the plans, there were none for the newer application, and the file on the earlier application had been mislaid. The new applicant was apparently unable to provide the council with a copy of the 2004 approval and related plans.

In the first half of 2010, Ms C sent four letters to the council’s planning service. Eventually in May 2011, the council prepared a report of handling about the newer application. In this, Ms C’s letters and those of others were treated as objections to the proposals. The relevant council committee, however, granted planning consent on conditions broadly similar to those in the initial approval. Despite the fact that the 2004 file had not been found, the May 2011 decision said that the development should proceed in accordance with plans submitted and approved in 2004. After Ms C pursued her complaint with the council, in February 2012 a third application was submitted. It was approved in August 2012 on the basis of plans compatible with those submitted in 2009 for a building warrant (which was approved in December 2009).

Ms C’s complaint to us had five elements. We upheld the first of these - that the council unreasonably took 18 months to present the further application to committee for approval - and made two recommendations to address the failings we found. We did not uphold the other four complaints, which related specifically to the report of handling and presentation to the relevant committee in May 2011.

Recommendations

We recommended that the council:

• apologise unreservedly to Ms C for their administrative shortcomings in the handling of the second application; and
• consider their policy with regard to the consequences of lost application plans for effective monitoring and enforcement, especially in the circumstances where a further application for any kind of statutory determination is made to them.

Summary

Mr C raised a number of concerns about the council's social work services child protection procedures. Mr C was unhappy about the action taken by social work services leading up to a child protection case conference, and about the accuracy of a social work report prepared for the case conference. Mr C also raised concerns about the way the council handled his complaint about this.

Our investigation found no evidence that the council had failed to follow child protection procedures in handling this case, and we did not uphold Mr C's complaints about this. We did find that they had failed to include all relevant information on their client system, and that some information had not been recorded accurately. However, the council had taken action to address this, so we did not make any recommendations about this. We also found that the council had failed to handle Mr C's representations in line with their complaints procedure.

Recommendations

We recommended that the council:

• apologise for their handling of Mr C's initial complaint; and
• ensure that statements are obtained from all participants when handling a complaint relating to an interview that involves a number of departments and/or agencies.

Summary

Mr C was unhappy about the way the council dealt with planning issues in connection with a neighbouring property and access rights to Mr C's own property. In particular, Mr C was concerned that a breach of a planning condition had been ongoing for a number of years.

During our investigation we confirmed that, as Mr C's concerns about access rights had been the subject of court action, we could not become involved in that. On his other complaints, we found that, although the council had considered and decided against formal enforcement action on the planning condition, there had been periods where no active monitoring of the site had taken place and we upheld that element of Mr C's complaint. We did not, however, find evidence that the council were treating the neighbouring site more favourably than they were Mr C.

Recommendations

We recommended that the council:

• apologise to Mr C for the failings identified; and
• ensure that the open enforcement cases continue to be proactively monitored and without breaching confidentiality, keep Mr C advised of progress.

Summary

Mrs C complained that a Local Review Board (LRB) set up to consider an appeal against refusal of a planning application was not properly constituted; that the minutes of the LRB meeting did not accurately reflect the what happened at the meeting; that the council did not adequately investigate her complaint about this; and that the council did not take appropriate action on the failings that their investigation found.

After taking independent advice from one of our planning advisers, we found that the LRB had been properly constituted under transitional arrangements put into place by the council. It took place about a month after an election at which some elected members who were trained to sit on LRBs were not returned to office or had retired. The transitional arrangements allowed all members who were trained to sit on the LRB, regardless of the ward they represented or whether there was more than one representative from a ward. We found that these arrangements were reasonable and that the LRB was both quorate (the required minimum number of people were there) and competent. Mrs C had also expressed concerns that the investigation into her complaint was conducted by a council employee, who might be biased in favour of their employer. Our investigation found the investigation was reasonable and appropriate and found no evidence of bias. We also found that the council took appropriate and robust remedial action where failings were identified.

We did, however, uphold the complaint about the minutes of the meeting. These did not adequately reflect the information placed before the LRB or its decision. The meeting considered 14 separate applications, and the background papers ran to over 4,000 pages. The documentation for this particular application accounted for over half those pages, within which were 293 objections either to the original application or to the appeal. These were not indexed and no mention of them was made in the minutes. It was, therefore, not clear what the members knew, did not know or discussed at the meeting, which is unacceptable. The minutes also referred to planning permission being granted but then referred to a condition that had to be complied with 'before planning permission is granted', which was confusing and inappropriate. Our adviser was concerned that some conditions were so poorly worded that they gave no idea of what was to be expected, and would not have been enforceable. Finally, the condition upon which approval was dependent required the agreement of a third party over which neither the applicant nor the council had any control. Our adviser said this was inappropriate and did not comply with national guidance on the work of LRBs.

Recommendations

We recommended that the council:

• consider re-convening the LRB.