Some upheld, recommendations

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.

Summary

Mr C complained that when he went to the practice for root canal treatment, the dentist fractured a crown and broke a portion of a front tooth. The dentist put in the existing crown, which lasted for two days. Mr C returned to the practice, but a further repair only lasted a day. Mr C obtained an emergency appointment with another dentist who inserted a temporary crown. On returning to the first dentist for further treatment Mr C explained he had been in a lot of pain and was unhappy that he had to pay for a new crown.

The practice said that Mr C had agreed to save the tooth and in order to carry out root treatment it was necessary to drill through the inner surface of the tooth/crown. At that point it was not possible to ascertain how much tooth structure was present below the crown. The practice said that the first dentist explained this to Mr C and that a fractured crown is a recognised problem which occurs fairly commonly after root treatments. The practice went on to say that it was also relatively common for temporary crowns to fall out, as normally they are only used for two weeks until permanent restoration can take place.

Mr C complained to us that the treatment options were not explained to him and he was not told the crown could be damaged. After taking independent advice from a dental adviser, we found that clinically the treatment which had been provided was appropriate. However, we upheld part of Mr C's complaint as we found no recorded evidence that the dentist had communicated the risks to him.

Recommendations

We recommended that the dentist:

• reflects on the importance of completing detailed records regarding communication with patients.

Summary

In 2007, Miss C was diagnosed with ulcerative colitis, a form of inflammatory bowel disease (IBD) causing ulcers or open sores to form on the colon. She suffered severe flare-ups in 2008 and 2010, and had to be admitted to hospital. Miss C explained that she was very aware of her own body and recognised the pattern of symptoms that would lead to flare-ups. She developed bleeding in 2011 and was referred to a gastroenterologist (a clinician specialising in the treatment of conditions affecting the liver, intestine and pancreas). Miss C complained that, although she was sure that she was heading towards another flare-up, the gastroenterologist did not take her concerns seriously and provided investigations and medications that did not help her. Ultimately, she developed a severe flare-up, and needed surgery.

We did not uphold most of Miss C's complaints. It was not possible to determine from the records what conversations had taken place between her and the gastroenterologist, or how seriously her concerns about her condition were taken. However, we found clear evidence that medication decisions were affected by what she had said. We also accepted independent medical advice that the treatment plan put in place for Miss C was appropriate for her symptoms and in line with national guidance. Our adviser said that Miss C's treatment did not deviate from the British Society of Gastroenterology’s Guidelines for the management of inflammatory bowel disease in adults (the BSG Guidelines).

Miss C also complained that the board did not obtain her medical records from another health board that had treated her previously. We were satisfied that procedures were in place to obtain records where necessary. However, on this occasion, the gastroenterologist had decided to conduct a fresh review of Miss C's symptoms, which we considered reasonable.

Although we found the treatment decisions to have been appropriate and made with reference to information from Miss C, we were critical of the standard of communication with her, and upheld her complaint about this. We found that staff could have done more to empathise with Miss C during her admission, and to explain the reasoning behind treatment decisions that she did not agree with.

Recommendations

We recommended that the board:

• provide details to the Ombudsman of the facilities they have in place to meet the BSG Guidelines' requirement to provide patients with access to an IBD helpline;
• consider asking their clinical team to review how they communicate with patients in terms of explaining decisions made about their treatment; and
• ask the clinical team to consider how they can ensure patients' comments, concerns and treatment options are discussed empathetically.

Summary

Mr C complained on behalf of a neighbour (Ms A) that Scottish Water’'s actions in respect of flooding were unreasonable. He said that Scottish Water had accepted that there was water coming in under Ms A's property, but had said that there was no evidence this was caused by their sewerage network. Ms A lived beside a beach and Scottish Water said that the flooding could have been caused by seawater.

We noted that Scottish Water only have funding to deal with capacity issues (where their sewers overflow) that cause internal flooding to a property. If the cause of external flooding is a simple blockage that can be easily fixed, they will do so, but if it is a structural problem, this may be more difficult to deal with. Our investigation found that there had been external sewage flooding around Ms A's home. We took the view that if the flooding was considered to be external, and Ms A had agreed that it was, then Scottish Water's actions would have been reasonable. However, we found evidence indicating that there was enough water under the floor of Ms A's bedroom to cause damage to skirting boards and internal plasterwork. There was also a report of odour, and damp meter readings were very high. We, therefore, upheld this complaint, as we considered that Scottish Water should have looked further into the reports of internal flooding at Ms A's property. Had they then identified internal flooding, they should have taken further action.

Mr C also complained that Scottish Water's communication with him and Ms A had been unreasonable. We did not uphold this complaint, as we did not find any evidence of this.

Recommendations

We recommended that Scottish Water:

• issue a written apology to Ms A for the failure to carry out further investigation into the reports of internal flooding at her home; and
• carry out further investigations to try to identify if the internal flooding was caused by their sewerage system. They should assess both the cause of the flooding and the risk of this occurring again in the future.

Summary

Ms C runs a dog grooming business from home. She complained that Business Stream phoned her and asked for details of her business without giving reasons for the call, then emailed her saying that they were the licensed provider for the water and waste water services for the business element of her property. She then received demands for payment for 2011 to 2013. Ms C complained of delay in notifying her that she was liable for these services, and that the charges were inaccurate and Business Stream would not engage reasonably with her to resolve the matter. Ms C complained also about the handling of her complaint.

Our investigation found that, although there was a gap between the date the account was opened and their first contact with Ms C, there was no delay on Business Stream’s part in processing and issuing their invoices. While the unexpected bill clearly caused Ms C concern, there was nothing to suggest that the charges were incorrect, and we did not uphold her complaints about this. We did find that there were instances where Business Stream failed to handle Ms C’s complaint in accordance with their service standards, and so we upheld this aspect of her complaint.

Recommendations

We recommended that Business Stream:

• apologise for the failure to respond to Ms C in accordance with their service standards; and
• reduce Ms C's account as compensation for these shortcomings.

Summary

Mr C, who is a prisoner, complained that his personal officer had failed to engage with him appropriately. He was also unhappy with the prison governor's response to his complaint. We were unable to comment on whether the personal officer had encouraged or motivated Mr C in line with the relevant guidance or on whether he had had a positive relationship with her. However, there was no evidence that she had attended or completed the required reports for his integrated case management conferences or that she had sent anyone to attend in her place. In addition, most of the entries that the personal officer completed on the prisoner record system were made after Mr C referred his complaint to us.

There was little documentary evidence that the personal officer had engaged with Mr C before he complained, although we noted that she had been absent from work for part of this time. We found that Mr C had not received the service and support from the personal officer scheme to which he was entitled, and in view of this, upheld this aspect of his complaint. That said, our investigation found that the prison governor had responded promptly to Mr C's complaint, and that her comments about trying to resolve the matter were reasonable in the circumstances. We did not uphold his complaint about this, as we found that the governor had dealt with Mr C's complaint appropriately.

Recommendations

We recommended that the Scottish Prison Service:

• issue a written apology to Mr C for the failure to provide him with the service and support he was entitled to receive from the personal officer scheme;
• consider whether it would be appropriate to change Mr C's personal officer in light of our findings; and
• consider if a review of the personal officer scheme should be carried out.