Some upheld, recommendations

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.

Summary

Mr C complained that the council would not provide a suitable alternative to the National Entitlement Card in order for him to access the travel concession he was entitled to. Mr C had objections to the nature of the National Entitlement Card, which he described as an identity card. He sent the card back to the council on two different occasions requesting that an alternative, single use for travel card be made available. However, the council did not provide this. Mr C subsequently submitted a formal complaint, and thereafter complained to us about the way the council had handled his complaint.

We did not uphold the complaint that the council failed to respond appropriately to Mr C's request for an alternative card. We noted the scheme was nationally run and managed and it was not for the council to provide alternative versions of access to travel concession. We found evidence that they had contacted the national office to seek advice about Mr C's request. We did, however, note that the council could have told Mr C they had done this, which would have given him more confidence in the process.

We upheld Mr C's complaint about the council's complaints handling. We found this to be poor in a number of ways, including the fact that two of their responses did not reach Mr C, that Mr C had to contact the council to chase up responses, and that some parts of the responses suggested that they had misunderstood the complaints. We noted the council had committed to complying with the new model complaints handling procedure being implemented by the SPSO's Complaints Standards Authority in early 2013.

Recommendations

We recommended that the council:

• issue Mr C with a full apology for the failings identified in relation to the handling of his complaint.

Summary

Mr C complained on behalf of Mr A, whose mother (Mrs A) required permanent residential care. The council had assessed Mrs A's finances and decided that she was able to fund her own care. Mr A complained to the council about their handling of the financial assessment and, dissatisfied with their response, took the matter to a social work complaints review committee (CRC). Based on the evidence submitted to them, the CRC ruled that Mrs A should be self-funding. Mr C complained that the information the council submitted to the CRC was incomplete and misleading. Furthermore, he did not consider that there was any evidence that the CRC took into account relevant guidance and legislation when reaching their decision. Mr C also raised concerns about the information that was made available to Mr A before and after the CRC hearing, and that the CRC chairman failed to disclose a conflict of interest.

Our investigation found that the information provided to Mr A before and after the CRC hearing was complete and in line with the published CRC procedure. The council's submission to the CRC referred to the relevant guidance and legislation, but we noted that it misquoted a key part of the legislation and paraphrased other sections without providing a full copy of them. Although we recognised that it was for the council to submit information in support of their position on the case, we found no evidence of the CRC having scrutinised the evidence submitted to them or having sought out copies of the guidance and legislation. We considered their report to be poor in that it did not give any detail of the reasoning behind their decision. We felt this was important as the report was to be passed to the relevant council committe for consideration of the recommendations being proposed by the CRC. We found that the chairman had known Mr A's wife in the past. We accepted, however, that there was no way that he could have identified this potential conflict of interest before the hearing, and there was no suggestion that he did not carry out his duties impartially. However, we considered that he could, and should, have made this known on the day to ensure transparency.

Recommendations

We recommended that the council:

• arrange for Mrs A's case to be reconsidered by a CRC, with specific consideration given to the legitimacy of the department's decision in terms of relevant legislation and guidance;
• take steps to ensure CRCs record the reasoning behind their decisions; and
• remind CRC panel members that they should declare any potential conflicts of interest.

Summary

The council granted planning permission for a supermarket development opposite Mrs C's home. She was opposed to the development and had submitted objections during the planning application process. Her objections included concerns about the proposed development's impact on her ability to safely enter and exit her driveway, which is situated on a bend in the road, opposite the supermarket's access junction.

Mrs C became aware that a transport assessment had been undertaken in relation to the development. On looking into this, Mrs C became concerned and complained that the council's actions in relation to this assessment contributed to what she considered to be an unsafe road layout. She said that the council allowed the developer to conduct traffic surveys at times when traffic was diverted away from the road being assessed. She felt the council accepted a substandard traffic assessment and approved the planning application without question and then failed to ensure that certain planning conditions were met. She also complained about the council's handling of her correspondence about this.

We did not uphold most of Mrs C's complaints. The evidence that we examined in our investigation showed that no diversions were in place when the traffic surveys were carried out, and that the council had in fact considered the developer's traffic assessment to be substandard. They sought appropriate technical advice and worked with their adviser to ensure that amendments were made before planning consent was approved. We were satisfied that the council did not simply accept the proposals submitted by the developer, and we found that any outstanding issues were incorporated into conditions attached to the planning consent. That said, we found the council's record-keeping around this to be poor.

We found the council's actions on the two planning conditions that Mrs C felt had not been met to be reasonable. In one case, the council had not acted on a recommendation from their technical advisers to reword the condition, but we were satisfied that the action that they took reflected national guidance. We were, however, critical of the council's complaints handling and upheld Mrs C's complaints about this. The council had not shared with her the evidence that they presented to us, which clearly explained and supported the council's actions on the transport assessment. As such, complaints that could have been resolved quickly were allowed to carry on with no detailed explanation of the council's approach.

Recommendations

We recommended that the council:

• consider introducing a system to maintain clear records of issues that have been identified, the action proposed to address them, and the date and reasons for the council's decision in response to each proposed action; and
• take steps to ensure that staff responding to complaints do so in sufficient detail to explain the reasons behind the council's position.

Summary

Mr C complained that the council unreasonably issued him with a parking ticket. He said that there was a long-term agreement between local residents and the council that allowed residents to park on occasions when loading and unloading of cars was required. He also complained about the way the council dealt with his appeal and subsequent complaint. The council were of the view that no agreement existed and that residents were obliged to comply with the terms of the relevant road traffic order.

We were not provided with evidence of any agreement existing between the council and residents. Our investigation, therefore, found that the council acted reasonably by interpreting the road traffic order in the way they did, and we did not uphold Mr C's complaints that they acted unreasonably in this respect. However, we did find that the council failed to clearly separate the appeals and complaints processes and failed to respond to Mr C's concerns that the appeals process was in breach of article 6 of the European Human Rights Convention. As a result we upheld these aspects of the complaint.

Recommendations

We recommended that the council:

• contact Mr C to clarify his concerns about the compliance of the appeals process with human rights legislation, consider his comments, and then respond to him in writing; and
• carry out a review of their handling of this case with a view to establishing whether further guidance needs to be provided to staff to ensure appropriate separation between the appeals and complaints processes in future, and notify the Ombudsman of their findings.

Summary

Ms C, who is a planning consultant, submitted a complaint on behalf of her client (Mrs A). In 2008, Mrs A had obtained planning consent for an extension to her cottage, but did not take this forward. In May 2010, she placed a large residential caravan with wooden decking beside the cottage. The caravan was connected to Mrs A's electricity, water and sewerage facilities and Mrs A’s mother moved into it.

A neighbour objected to this, and a council enforcement officer investigated. They invited Mrs A to apply for retrospective planning consent for the caravan. When she did so, however, the committee who considered her application refused permission, and the council served an enforcement notice for the caravan to be removed. Mrs A appealed this to the Directorate for Planning and Environmental Appeals (DPEA). The appeal was unsuccessful but after Mrs A succeeded in challenging this at the Court of Session, DPEA again considered the matter. However, they again dismissed the appeals, giving Mrs A six months to comply with the enforcement notice.

Ms C made four complaints to us. She said the council had been unreasonable in refusing her offer to meet with them and engage in pre-application discussions, or to address her concerns about the relevance of a certificate of lawfulness of a proposed use or development. Ms C was also unhappy that the council delayed in handling her complaints. We upheld only one of her complaints, however, about complaints handling. This was because we found that the council in general acted appropriately in the action they took, and were entitled to make the decisions they had made.

Recommendations

We recommended that the council:

• apologise and provide an explanation for the delay in dealing with Ms C's third stage complaint.