Some upheld, recommendations

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.

Summary

Mr and Mrs A’'s daughter (Miss A) has severe and complex additional support needs. Her enrolment in a school and experiences there presented challenges for all parties involved. Mrs C, an advocacy worker, complained to the council on Mr and Mrs A's behalf about various actions by the school in relation to their daughter's enrolment. At the end of the council’s complaints procedure, the chief executive accepted that some actions had been unreasonable, and upheld parts of the complaints. However, the chief executive did not accept that these actions represented discrimination, as Mr and Mrs A had alleged. Mr and Mrs A were dissatisfied with aspects of the council’s handling of their complaints and raised this with us.

We found that the council had taken an unreasonable length of time to respond, failed to apologise to Mr and Mrs A for the elements that were upheld and failed to advise Mr and Mrs A of the actions taken as a result of their complaints. Mrs C also complained that the council had unreasonably failed to respond to a particular part of the correspondence, but we did not uphold that complaint.

Recommendations

We recommended that the council:

• apologise to Mr and Mrs A - that they were not reasonably updated about the progress of their complaints during the final stage of the council’s complaints procedure; that a letter was not responded to within a reasonable time; for those parts of their complaints that were previously upheld; and for failing to advise them of the actions taken to address those parts of their complaints that were upheld;
• review their complaints handling processes to ensure that updates are provided without complainants having to approach the council, and that the provision of verbal updates is recorded;
• review their complaints handling processes to ensure consideration is given in each case as to whether apologies are appropriate;
• review their handling of Mr and Mrs A’'s complaints to find out why such serious issues were not upheld at the first stage of their complaints process, and consider whether all relevant learning has been identified;
• review their complaints handling practice to ensure that the requirements of sections 7.11 and 8.6 of their complaints handling process are undertaken in all appropriate cases; and
• consider whether appropriate learning is identified and available for staff regarding equality and diversity.

Summary

Ms C alleged that while her son was in his first year at primary school he suffered repeated physical assaults from another child. She complained that, despite her formal complaint, the council failed to take appropriate action and she had to move her son to another school.

To investigate the complaint, we took all the available information from Ms C and the council into account, including the complaints file and correspondence, and the relevant council policies. Our investigation confirmed that over a period of almost six months there had been numerous incidents. However, Ms C's child was not always the victim - on occasion he had been the perpetrator; or the incidents were accidents or involved numerous children. Each time, there was evidence to show that the council took the matter seriously and took appropriate action with reference to the sanctions and advice in their policy. From the next five months there were no incidents reported, but then an event involving a number of children took place. Ms C's son then made a statement to a teacher that resulted in child protection procedures being invoked. Almost immediately afterwards, Ms C removed her son from the school, and he was later transferred to another. As the evidence showed that the council did act on each reported incident, we did not uphold this complaint.

Ms C had also complained to the council about the way they had handled her concerns. We upheld her complaint to us about this, as our investigation showed that the procedures applied in responding did not clearly reflect the council's policy. One reply was inconclusive and other letters appeared to show that the council had investigated matters outwith their control, Similarly, a complaint of bullying was only partially upheld despite clear evidence that it had taken place.

Recommendations

We recommended that the council:

• make a formal apology to Ms C for failing to handle her complaint appropriately.

Summary

Ms C, who is an advice worker, complained on behalf of Ms A about the care and treatment that her late father (Mr A) received during the last three days of his life, and about how her complaint about this was handled.

Mr A's GP referred him to a medical admissions ward. Mr A went straight to the ward, and was asked to wait in the day room. He remained there for four hours before he was seen by a doctor, given a bed, and treatment was started. Information on his referral showed he was very unwell, indicating that he had pneumonia and kidney failure. Mr A was treated with antibiotics, and was transferred to a different ward the next day.

For the next two days Mr A’s condition remained stable and his vital signs (pulse, blood pressure, temperature and oxygen levels) were taken roughly every four hours. In the evening of the second day Mr A became increasingly unwell. This was noted by staff, who increased the frequency of checks on his condition to hourly. A doctor reviewed Mr A and identified that he needed more oxygen. He arranged for a special blood test to check oxygen levels in Mr A’s blood, and asked for a repeat of this test two hours later. There are references to the results of both these tests in the clinical notes, but only the first test was noted in detail, and the second set of results were not identified by the board in their response to Ms C’s first complaint. As a result, Ms C was mis-informed about these tests. This was because the test results were held on record electronically, and were not added to the clinical file. Despite further assistance with his breathing, Mr A died the following day.

We obtained independent advice on this complaint from one of our medical advisers. We upheld the complaint about the delay in getting a bed, as his advice indicated that Mr A should not have been kept waiting in the day room of the admissions ward for such a long time, and that this created risks for patient care. We did not uphold Ms C's complaints about vital sign checks and blood tests. Our adviser reviewed all the checks made on Mr A’s vital signs and found them to be appropriate. He also reviewed blood test results from shortly before Mr A’s death, and found that they were appropriate, but criticised the way in which the board held these records and reported them to Ms C. On complaints handling, Ms C had said that she did not get a final response until more than eight months after she first complained. While we found that further issues were raised at a meeting three months after the original complaint, we found there was still a substantial delay in providing a final response, and we upheld this complaint.

Recommendations

We recommended that the board:

• raise this case at the next meeting of its clinical directorate, specifically considering the risks involved in using day rooms as waiting rooms, and considers the introduction of mechanisms to avoid these risks;
• give careful consideration to the implementation of the early identification and treatment of sepsis (blood infection), using the 'Sepsis Six' initiative;
• remind doctors of the need to record all investigation results in the case notes immediately they are available, especially for tests such as arterial blood gases, where a formal laboratory result may not be printed;
• ensure that all electronic records are reviewed during complaints handling and are passed to the SPSO on request; and
• apologise to Mr A’s family for the failures identified in our investigation.

Summary

Mr C complained about the standard of care he had received in relation to a number of blood tests. He also complained about poor communication and the handling of his representations.

After taking independent advice from one of our medical advisers, we upheld the complaint about the blood tests. Although we found that the care and treatment Mr C received was reasonable, there was a lack of communication about the results of his blood tests. One of the tests that his GP had requested had not been taken, but Mr C was not told this and had continued to request the result. We also found that as Mr C had a low ASSIGN score (cardiovascular risk score - used to predict the likelihood of developing cardiovascular disease) some of the blood tests were unnecessary under the Scottish Intercollegiate Guidelines Network (SIGN). We did not uphold the complaint about the board's response to Mr C's representations as we found that it was reasonable.

Recommendations

We recommended that the board:

• clarify the system for improved and more timely communication of results by clinicians to patients; and
• ensure that medical officers familiarise themselves with SIGN 97 'Risk estimation and the prevention of cardiovascular disease' to ensure appropriate testing and treatment of patients based on their ASSIGN score.

Summary

Ms C visited her medical practice, complaining of pain in her lower abdomen, and was referred for an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body). When she contacted the practice for the results she was told that her GP had noted that no further action was required. A few months later, the health board contacted Ms C asking her to come back for a further scan. She initially cancelled this appointment because she had been told no further action was required. However, the hospital told her that another consultant had reviewed the first scan and thought it appropriate that she should attend for a follow up. The follow-up scan showed that cysts, which had been identified on the previous scan, had enlarged.

Ms C was unaware that cysts had appeared on the original scan and complained to the practice that she was not told about this. She remained dissatisfied with the practice response. We found that the original ultrasound scan was reviewed by two consultants and their opinion had been divided as to whether there was a need for a follow-up scan. We also found that the practice had not told Ms C about the cysts as they were an incidental finding, and not thought to be responsible for Ms C's abdominal pain.

Recommendations

We recommended that the practice:

• apologise to Ms C for the failure to explain that the cysts had been identified on the ultrasound scan;
• remind staff to ensure that all issues raised in complaints correspondence are addressed; and
• apologise to Ms C for failing to address all issues of the complaint.