Some upheld, recommendations

Summary

Ms C complained that during a regeneration process the council unreasonably failed to provide information to residents; misinformed them; or changed or denied information given to them about the process and their rights. This included information about 'right to buy'; financial assistance with moving costs; and rehousing options. Ms C also complained that the council unreasonably, without telling residents, closed and sealed the bin stores and rubbish chutes in the area, and unreasonably failed to repair street lighting despite requests to do so.

Our investigation found that much of the information provided to residents during the regeneration consultation process and the ongoing regeneration programme was either provided verbally to individuals, or informally at public meetings and open days. For this reason, it was difficult for us to determine what exactly Ms C had been told or promised. Although we, therefore, did not uphold Ms C's complaints about the information provided on the regeneration process, we made a recommendation to address some of the issues that arose around this process.

We did uphold Ms C's other two complaints. The council had explained that the bin stores and rubbish chutes were closed to prevent vandalism; fire setting; and theft. Although we considered that this was in itself reasonable, we found that the way the council went about it was not, nor were the responses provided to Ms C when she complained. The council told Ms C that the electricity supplier for the area had insisted that the bin stores be sealed up to prevent vandalism and to stop copper wiring being stolen from electrical switching boxes. However, Ms C said that the boxes were not actually in the bin stores but in cupboards next to them. During our investigation - but not until some months into it - the council acknowledged that they knew that the boxes were not actually in the bin stores. They said that council officers had referred to the 'bin store' when they meant the entire basement areas of the housing blocks. We took the view that had the council made this clear at an early stage of dealing with Ms C's complaint, this would have given more credibility to their responses, and would have reduced the stress and worry she experienced over this matter. The council were not able to provide us with evidence to show that the electricity provider had insisted that the bin stores and chutes were welded shut. We also found that responsibility for the street lighting was shared with the electricity supplier, in that they were responsible for power supply issues and the council were responsible for repairing defective lights. While there was evidence of some action being taken by the council, we found gaps in the process, and times when no action was being taken.

Recommendations

We recommended that the council:

• issue a written apology for the failures identifed in our investigation; and
• consider producing area-specific information leaflets for residents affected by regeneration projects and to record any information or advice given to individuals.

Summary

Miss C lives next to a sports facility, which was opened in 2006. She complained that the council failed to take responsibility for the escalating problems arising from the use of the football pitch, or to provide appropriate measures to resolve the nuisance. Miss C also complained that the council delayed in dealing with her complaint.

We explained to Miss C that we could not look at the decision to grant planning permission or any of the things that happened before she complained to the council in 2011, essentially because these were too old for us to look at. Our investigation did look at the recent action the council had taken to address concerns of nuisance arising from the use of the facility, and noted that there was evidence that they had engaged with Miss C, and others acting on her behalf. Although she said she thought more could be done to resolve the nuisance, Miss C did not identify what this was. We did not uphold this complaint. We were satisfied that the council took action to try to address Miss C's concerns, and in responding to our enquiry, they had agreed to meet Miss C to discuss any outstanding issues and whether a solution could be found.

We did, however, find that the council delayed in dealing with Miss C's complaint.

Recommendations

We recommended that the council:

• apologise for the delay in handling Miss C's complaint.

Summary

Mr C and Ms C live in a conservation area. They made five complaints about the council's handling of two related planning applications made by their next door neighbours to construct a two storey rear extension. A consequence of the proposed works was the blocking of an existing first floor bedroom window, and the insertion of a new window facing Mr and Mrs C's property. This had consequences for Mr C and Ms C's family's privacy, as the new window overlooked one bathroom and two bedroom windows in their home. Mr C and Ms C had received appropriate neighbour notification about the applications but there was no specific mention of the window in the description of the works or supporting statements. This meant that their attention had not been drawn to the proposed new window, and so they had not objected.

Our investigation upheld three of Mr C and Ms C's four complaints about the processing of the applications (both of which had been the subject of a site visit by the planning case officer). Having taken independent advice from a planning adviser, we found that the absence of objection was not material. The onus rested with the council to demonstrate that they had fully assessed the applications in accordance with the relevant development plan including relevant supplementary planning guidance with regard to privacy in the two reports of handling. We found that the council had not done that and so we upheld these complaints. We also upheld a complaint that the council had provided unsatisfactory and inconsistent responses to Mr C and Ms C's complaint (in relation to the effect of the conservation area designation).

Recommendations

We recommended that the council:

• consider its position in securing the necessary works to alter the daylighting of Mr C and Ms C's neighbour's first floor room to remove the overlooking of bedroom windows in Mr C and Ms C's property.

Summary

Mr C's mother (Ms A) was admitted to hospital with chest pain. A CT scan (a special scan using a computer to produce an image of the body) was carried out, and suggested an underlying tumour. The board decided that a biopsy (a sample of tissue) was required to diagnose Ms A's condition. The sample was taken at hospital two weeks later. The results confirmed that Ms A had high grade lymphoma (a type of cancer). A chemotherapy regime (a treatment where medicine is used to kill cancerous cells) was planned, but Ms A started to deteriorate and died four weeks after admission to hospital. Mr C was concerned about the time taken to diagnose Ms A's condition and that she had not been adequately hydrated when she was under the care of the board.

As part of our investigation, we sought independent advice from a medical adviser. He considered that the board needed to obtain a biopsy to diagnose Ms A's condition. He further explained that the biopsy would have been difficult to obtain because of its location and the risks involved. The adviser considered it reasonable that medical staff were fully appraised of the situation and had to consider the best way of obtaining a biopsy. We accepted the adviser's view, and did not uphold this complaint.

Mr C also complained that Ms A had not been adequately hydrated. Ms A's medical notes indicated that instructions had been given to administer intravenous (IV - administered into a vein) fluid to rehydrate Ms A. This therapy was started two days after the instructions to do so had been given. We were critical of this and upheld this complaint.

Recommendations

We recommended that the board:

• bring this issue to the attention of staff involved and all other relevant staff and ensure that where IV fluid is considered to be required for a patient it is recorded and commenced without delay; and
• issue a written apology to Mr C for failing to ensure that Ms A was adequately hydrated.

Summary

Ms C complained about the care and treatment that her late father (Mr A) received in hospital before his death. She said that staff failed to recognise and manage her father's pain and to act on her concerns about this. During our investigation, we took independent advice from one of our medical advisers. We found that there was no evidence in Mr A's medical records to suggest that he was in pain, and there was evidence that staff had recognised and acted on Mr A's agitation.

Ms C also said that Mr A was left sitting in a chair that he could not get out of unaided. Although our investigation found that the times that Mr A was in the chair were not recorded, our adviser said that it was reasonable for staff to get him out of bed, as moving and being in an upright position would have helped to prevent complications such as chest infections and venous thrombosis (a blood clot forming in a vein).

Finally, Ms C complained that a junior doctor did not pass on or discuss her concerns with senior colleagues and that she had difficulty in being able to speak to senior doctors. We did not find any evidence that this was the case. However, we did find that staff did not make it sufficiently clear that Mr A was dying before he was discharged from the hospital. We also upheld Ms A's complaint that staff delayed in responding when Mr A's family and carer used the assistance buzzer.

Recommendations

We recommended that the board:

• consider whether they should provide training to staff on giving difficult messages / bad news to patients and families; and
• provide confirmation that the nurse call system is now set at a volume that nursing staff can clearly hear.

Summary

Mr C fell from his bicycle at speed and landed on his head. His GP was concerned that he might have suffered a spinal injury and arranged for him to go to hospital. Mr C was x-rayed, and discharged with a diagnosis of a soft tissue neck injury. Three days later, the hospital contacted Mr C, saying that, following a re-examination of his x-ray, it was possible that he had a cracked rib. Mr C went back to the hospital where he was given scans that confirmed the cracked rib and also identified cracked vertebrae. Mr C was fitted with a neck collar.

Mr C complained that there was a failure to carry out an appropriate assessment at the hospital when he first attended and that he was discharged home without a neck support. He also complained that when he next attended the hospital there was a delay in providing him with a neck collar once the fractured vertebrae had been confirmed. Having looked at the medical records and taken independent advice from our medical adviser, we found that the cracked rib should have been identified from the x-ray when Mr C first attended hospital. We upheld that complaint and made recommendations to address this. However, we did not uphold his other complaint, as our investigation found that the remainder of his care and treatment was appropriate.

Recommendations

We recommended that the board:

• apologise to Mr C for failing to identify his rib fracture; and
• review the arrangements in place for assessing x-rays and remind relevant staff that attention must be paid to all information on the film including information outside the focus of the subject of the x-ray.

Summary

Mrs C was admitted to hospital, suffering from increased confusion and needing more and more pain relief. She was also on a high dose of steroids for giant cell arteritis (GCA - inflammation of the blood vessels, usually in the head, which can cause blindness). She was transferred to another hospital nearly four weeks later, then back to the first hospital around three months after that. Mrs C's husband (Mr C) complained that she fell while in both hospitals and was concerned that these events had not been properly investigated. He also said that his wife's medication was not properly monitored, that the nursing care in relation to her deteriorating condition and pressure ulcer was inadequate and that his complaints were inadequately handled.

As part of our investigation we took independent advice from a medical adviser. They said that Mrs C had a complicated medical history, but that she had an unacceptable number of falls in the first hospital, and that the assessment of her being at risk of falling was inadequate. In line with national guidance, staff should have done more to prevent Mrs C from falling, and so we upheld the complaint that she was not properly monitored or assessed for this. However, we did not uphold Mr C's other complaints about his wife’s care. Our investigation found that after each of the falls both hospitals treated Mrs C's symptoms appropriately. We also found evidence showing that Mrs C was appropriately monitored and assessed for the medications she was prescribed. She received good personal care from nursing staff, and an appropriate care plan was implemented for a pressure ulcer that developed on her heel. This was dressed regularly but we noted that there was no wound chart for it - to have one would have demonstrated good practice in wound care management.

We also upheld Mr C's complaint about complaints handling. Our investigation found that, although the board's responses to the complaints addressed the issues concerned and explained the reasoning behind treatment decisions, they should have tried to address the underlying issues when responding to Mr C. In addition, the length of time it took the board to respond to the complaint was unreasonable, only occurring after we had started to investigate the complaint, some nine months later.

Recommendations

We recommended that the board:

• provide Mr and Mrs C with a full apology for the failings identified;
• ensure all relevant staff at the first hospital are aware of and implement appropriate falls prevention measures, including when to seek the advice of a falls specialist, in line with national guidance;
• remind relevant staff that when prescribing off-label (prescribing drugs in unusual circumstances or doses) the relevant protocol should be followed to ensure there is a proper record and the patient or, where appropriate, their family, is fully informed;
• take steps to acknowledge and address any clear underlying issue causing distress to the complainant as far as possible in complaint responses; and
• ensure that responses to complaints are sent out in a timely manner within the appropriate NHS complaints timescale.

Summary

In September 2010, Scottish Water realised that a property was wrongly listed as domestic. This meant that that any business occupiers had not been receiving bills for water and sewerage services. Scottish Water notified Business Stream. However, Business Stream were receiving a high volume of new customers at that time, and did not put the property into their system until January 2011, when they also wrongly identified it as vacant.

In May 2012, Business Stream became aware there was an occupier (Ms C) and billed her. Ms C had been in the property since June 2010 and had thought water charges were collected with business rates. As she had been unaware that her company was liable for the charges, she corresponded with Business Stream by phone, email and letter over some months to try to sort this out. There was no water meter at Property A, which meant the bill was calculated on the basis of rateable value. There is a re-assessment process, by which a customer can ask for the amount of water they are using to be estimated and billed on that basis rather than rateable value. Ms C submitted a re-assessment form in October 2012. This led to a reduction in the amount she was being billed from then.

When Ms C complained to us, she had received a bill for January 2011 to March 2013. The period until October 2012 was calculated at a higher rate, based on rateable value. Ms C was unhappy about the delay in billing her, the backdating of the bill and a number of customer service aspects. Business Stream had apologised for the delay in putting the property on the system and reduced the bill as a good will gesture. In the same letter, they said that they would only back date it to January 2012, however, this was a typographical error and she was unhappy when Business Stream clarified that they still intended to bill her from 2011.

Our investigation found that there had been mistakes on both sides. Ms C had an obligation to let utility providers know she had entered the property and to pay for the services provided. She had not done so. This had been an honest mistake but it did remain her responsibility. Business Stream had failed to process the information from Scottish Water quickly, and then wrongly noted the property as vacant. (They have since changed their audit process to improve this.) As a result of the mistakes, Ms C was being charged at a higher rate for some months but she had also received several months of water and sewerage services free. Business Stream had also taken £100 from the bill. Therefore, although we upheld her complaint that there was an unreasonable delay in setting up the account, we did not uphold her complaint that the backdated bill was unreasonable.

We also looked at the customer service aspects of the complaint. There was evidence that Business Stream tried to resolve the complaint and there was some good practice in what they did. However, Ms C had to make the same points repeatedly and the communication was not always clear. They planned to meet Ms C, but failed to ensure the meeting went ahead. Failings in communication meant debt collection proceedings were started when they could have been avoided. We, therefore, upheld her complaints about complaint handling and debt collection.

Recommendations

We recommended that Business Stream:

• backdate the start of the assessed charges to a particular date;
• ensure there are no outstanding recovery charges on Ms C's bill; and
• apologise for the handling of Ms C's concerns and, in particular, for the length of time it took to conclude their handling of these.

Summary

Mr C complained that although Registers of Scotland (RoS) confirmed that they had made an error that affected his family's title to property, they refused to honour an agreement to compensate him for the loss or to fix the error. He also alleged that he had been asked by RoS to obtain a valuation of the ground concerned to assist in his claim against them but they later denied this. He was also unhappy with the way his complaint was handled.

We investigated the complaint, considered all the relevant information, including appropriate legislation, and made enquiries of RoS. Our investigation found that RoS had, in 2009 and 2010, confirmed that Mr C was entitled to make a claim against them on the grounds that they had refused to rectify the register. However, in July 2010, his claim was refused on the basis that there had been no rectification decision. The Keeper of RoS said that this was in accordance with her new practice. It appeared that no one told Mr C about this until 2011. The standards for dealing with Mr C's complaint had, therefore, changed without him being advised. In order to make his claim, Mr C had to obtain a valuation of the land concerned. He said that he had been told to do so by staff at RoS but that this had since been denied. We found that the staff concerned had retired but correspondence was available which indicated that Mr C's recollection of events was likely to have been correct. We, therefore, upheld both of those complaints.

Mr C had also complained that RoS failed to adequately address his formal complaints to them about these matters but the evidence did not support this.

Recommendations

We recommended that RoS:

• apologise to Mr C for the confusion and inconvenience caused and for the fact that he was not formally informed of the decision that his rectification application had been cancelled.

Summary

Mr C is a recreational deer stalker using land owned by Forestry Commission Scotland (FCS). He complained that the FCS refused him permission to use a pistol for the humane dispatch of wounded deer, despite this being a recognised method of humane dispatch. Mr C considered that the FCS’s refusal to allow the use of pistols placed him, and others, at risk. He raised his concerns with the FCS, then complained to us that they refused to answer relevant questions or to produce documentation that they referred to in defence of their position on pistols.

The FCS’s policy was that the use of a rifle was the only acceptable means for recreational stalkers to cull deer. However, when explaining their policy to him, they referred him to guidance that was relevant to FCS staff and advocated the use of pistols and knives. That said, the FCS advised that their staff were not permitted to use pistols. They also referred Mr C to their firearms policy, which applies UK-wide and advocates the use of pistols to dispatch wounded deer under certain specific circumstances.

We found nothing in any of the legislation or guidance that we reviewed that required the FCS to permit the use of pistols for the humane dispatch of deer. As such, we considered that the FCS had the discretion to decide not to allow the use of pistols on their land. We were satisfied that their policy in this regard was not unreasonable and that they had given due consideration to Mr C's request that he be allowed to use a pistol. That said, we found that the information provided by the FCS when communicating their policy was confusing, not relevant to recreational stalkers, and not specific to Scotland. We made similar findings in relation to their risk assessment for the humane dispatch of deer.

We were critical of the FCS's handling of Mr C's enquiries and complaint. We found that the information provided to him was confusing and that his specific questions were not answered directly. We acknowledged that the FCS had already accepted and apologised for this. Mr C's complaint escalated to the appeal stage. However, we found that there was no scope for the original decision to be challenged at that stage.

Recommendations

We recommended that FCS:

• create guidance for the humane dispatch of wounded deer that is relevant to recreational stalkers in Scotland and sets out FCS policy on the firearms that may be used;
• create a generic risk assessment for the humane dispatch of wounded deer that is relevant to recreational stalkers in Scotland and is consistent with the FCS policy of not permitting the use of pistols;
• arrange for Mr C and his syndicate members to attend a practical demonstration and discussion on the dispatch of wounded deer in line with FCS policy;
• apologise to Mr C for failing to properly consider his complaint appeal; and
• consider reviewing their complaints handling procedure to ensure that it allows for decisions to be properly reviewed upon appeal.