Some upheld, recommendations

Summary

Mr C, who is a prisoner, complained that the Scottish Prison Service (SPS) treated him unfairly compared to another prisoner who was allowed to use his own electric typewriter, which his family had brought into prison. He also complained that the SPS failed to explain clearly and fully why he could not have his electric typewriter brought in.

We looked at what Mr C told us about his complaint, the SPS records and policies about personal property in prison. Our investigation found that the dates of Mr C’s request for his electric typewriter and his complaint to the SPS were several weeks apart from the other prisoner’s request. The SPS had treated the other prisoner’s case as an exception, as at that time they had no recognised supplier for an electric typewriter. We concluded, therefore, that it was reasonable for the SPS to treat Mr C’s request in line with their policies and procedures, as they had by then sourced a new recognised supplier. We did not uphold this complaint.

The SPS were not able to provide us with any formal documentation about their final investigation of Mr C’s complaint. Having read the written responses to Mr C’s initial complaint, however, we concluded that he did not receive a clear and full explanation and, therefore, we upheld this complaint.

Recommendations

We recommended that SPS:

• ensure that investigations are carried out in reasonable time and that a record is kept.

Summary

Ms C complained about the council's actions in relation to blasting by the operators of a quarry in her area. She said that the council failed to ensure that a full and complete environmental impact assessment was carried out on the residential area beside the quarry, before they approved blasting at the quarry for 20 years. We did not find any deficiencies in the environmental assessment and the associated process. A specific assessment on the residential area was not required.

Ms C also said that the council failed to ensure that there were adequate planning conditions in relation to the blasting at the quarry. She complained that the council had unreasonably given the quarry operators permission to carry out test blasting at the quarry with inadequate safeguards for public safety and public amenity. The council had allowed the blasting under an earlier planning consent, as the more recent consent had not been implemented at that time. We found that the blasting operations were not excluded from the earlier consent. However, the council had an agreement with the quarry operators that the conditions in relation to blasting in the more recent planning application would apply. We considered that this was to be welcomed from a practical point of view, as it allowed a detailed monitoring scheme for the blasting to be drawn up.

We were also satisfied that the council had put reasonable safeguards in relation to the blasting in place. They had taken the relevant national planning advice into account and there was also a scheme for monitoring blasting vibration in place. We found that it was appropriate for a firm of environmental consultants to monitor the blasts. It was also common practice for the results of the monitoring to be kept at the site and made available for inspection by the planning authority at all reasonable times. In addition, there was a notification procedure in place to inform residents of the blasts. That said, we did comment to the council that they should consider occasionally monitoring the blasts themselves. We also found that the council had delayed in responding to complaints about the blasting and upheld Ms C's complaint about this delay.

Ms C made a further complaint that the council had obtained evidence that a condition regarding the quarry's hours of operation was being breached, but had failed to take enforcement action. The council said that it was their position that they had monitored the noise level at the quarry and no harm was being caused. They stated that the quarry operators had made an application to change the operating hours. They said that no enforcement action would, therefore, be considered until a decision was made on this application.

If a member of the public complains to us that there has been administrative fault or service failure by an authority in reaching a decision, and that he or she has suffered injustice or hardship because of this, we may look at the complaint. We can consider the process and procedures involved. We cannot, however, question the decision if there is no evidence of maladministration. We found that the council had followed the correct procedures in relation to this matter. We were also satisfied that it was appropriate for the council's enforcement officer to advise the quarry operators to make an application to vary the condition in relation to the operating hours.

However, at an early stage in our investigation, the council's chief executive had given assurances that the council would continue to monitor the operations at the quarry to ensure that there was no loading or unloading of lorries outwith the permitted hours. The council had failed to honour these assurances in view of their decision that no harm was being caused and enforcement action would not be taken.

Recommendations

We recommended that the council:

• write to the Ombudsman and Ms C to explain why they failed to honour the assurances given that they would continue to monitor the operations at the quarry to ensure that there was no loading or unloading of lorries outwith the permitted hours.

Summary

Mr C suffers from a chronic, degenerative back condition and had since 2009 been in contact with housing partnership about draughts in his home, water coming in around his front door and the replacement of his solid fuel heating system. He provided evidence from his occupational therapist and GP that he was unable to cope with his heating system and the cold, draughty conditions in his home. The partnership attended Mr C’s property on a number of occasions to carry out repairs to the windows and doors. Mr C considered, however, that the repairs carried out were inadequate and temporary. He said that the partnership should have replaced his windows to resolve the problem.

The partnership told Mr C that they had a programme of replacement windows and heating systems for all of their stock and that his home was on their list for renewal. However, they advised that they would not be able to do either piece of work until after 2015. During the course of his correspondence with the partnership, Mr C had also asked them to resolve a number of issues for him, including making a number of minor disability adjustments to his home, providing flooring and giving him an immediate transfer and moving costs. The partnership carried out a number of adaptations at the request of his occupational therapist, and placed him on their transfer register with medium priority. However, they refused to immediately transfer him, pay for his moving costs or pay for floor coverings.

We upheld Mr C's complaint about the heating system as our investigation found that the partnership’s funding arrangements allowed them to consider replacing the system as a disability adaptation, but that they had failed to consider this. We did not uphold his other complaints as we found that the partnership had taken appropriate steps in relation to repairs to the property and in response to Mr C’s needs. We did not consider that it was reasonable for the partnership to carry out the further changes that Mr C had requested.

Recommendations

We recommended that the partnership:

• review the current practice for dealing with requests for heating replacement under aids and adaptations funding, to ensure that such requests are dealt with taking into account relevant funding guidance; and
• consider Mr C's request for a replacement heating system as an aids and adaptations referral taking into account the relevant funding guidance.

Summary

Mrs C, an advocacy worker, complained on behalf of Miss A, who had hurt her leg by tearing her anterior cruciate ligament (ACL) in a skiing accident in March 2010. Miss A was referred to the hospital where she was seen by a consultant orthopaedic surgeon, who arranged for her to undergo ACL reconstruction surgery about seven months after the accident. Screws were used to reattach tendons between her knee and thighbone.

Two months after the operation, Miss A fell and hurt her knee again. She went to an accident and emergency (A&E) unit and was referred back to the consultant. X-rays taken at A&E showed that the screw in Miss A's thighbone had become dislodged. However, due to the amount of pain she was in, and the level of swelling, the consultant was unable to carry out a full examination. He noted that Miss A had a good range of movement and concluded that the screw was likely in the soft tissue, holding the ACL reconstruction in place. A few days later, Miss A's pain increased and her knee began to lock. She returned to A&E where further x-rays found that the screw was inside her knee joint. Surgery was arranged to remove it and to re-do the ACL reconstruction.

After taking independent advice from our medical adviser, we upheld this complaint. We found that there was very little detail recorded at the time about what procedure the consultant initially performed. However, from the x-ray evidence we were able to establish that the ACL reconstruction had been placed in a less than satisfactory position. We also found that the advice given to Miss A by the consultant after her second fall was inappropriate. Although the x-ray evidence was not conclusive, it was most likely that the screw had migrated into the knee joint, and in any case, it was known that the screw was not in the thighbone. As such, the ACL graft was not performing its intended task and we took the view that revision surgery should have been arranged at that time.

Recommendations

We recommended that the hospital:

• apologise for the issues highlighted in this case; and
• draw our adviser's comments to the consultant's attention.

Summary

Mr C complained about the admisitration processes for outpatient appointments and complaint handling.

The SPSO investigation found that there had been a delay in Mr C being allocated his original outpatient appointment and the board acknowledged this. However, our investigation did not find that the system was 'chaotic' as Mr C claimed. To the extent identified, that is the delayed initial appointment, this complaint was upheld.

On the matter of a verbal complaint made when Mr C attended for an appointment on the wrong day due to a failure to confirm a re-arranged appointment in writing, The investigation could not establish why he was told that a person whom the board have been unable to identify would come to speak to him. No one came to speak to Mr C within 10 minutes at which point Mr C began to suffer chest pains and was taken to the accident and emergency. He was then admitted to a ward for observation for 24 hours. He asked the ward staff to pass a message to Mr A to ask him to come to speak to Mr C on the ward. This did not happen before Mr C was discharged.

Our investigation could not establish who Mr A was. The board told us that there were no male members of the complaints team in the hospital that Mr C had attended. The board tried to establish who Mr A was but no one of that name could be found on the staff lists at the time of the incident.

On the matter of the complaints handling, our investigation found that although some of Mr C's complaints had been responded to in a comprehensive and timely manner there had been some matters that were not addressed. Mr C had also asked to be reassured that the issues he had raIsed had been brought to the attention of senior managers and/or the chief executive of the board. Our investigation established that although the complaints were brought to the attention of the chief executive, Mr C was not informed of this fact. Therefore, to the extent of the failings identified, this complaint was upheld.

Recommendations

We recommended that the board:

• apolgise for the delay in providing the inital outpatient appointment; and
• apologise for the failings identified in the complaints handling.

Summary

Mrs A was an elderly woman with cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember). She was admitted to hospital in April 2011 after falling at home and had an operation to repair a fractured hip. Mrs A developed an abnormally large volume of fluid in her feet and ankles and a leg infection. In July 2011, she was transferred to another hospital for treatment but was considered too frail for an operation and returned to the first hospital several days later. Mrs A was transferred to a third hospital at the end of August and died several months later. Mrs A's daughter (Ms C) complained about numerous aspects of her mother's care and treatment, including wound management and treatment, falls prevention, loss of hearing aids and teeth, the suitability of the ward and failure to carry out a Doppler test to assess her blood flow.

Our investigation found that the care and treatment in relation to wound management and treatment, the suitability of the ward, and failure to carry out the Doppler test was reasonable. There was no evidence to suggest that a Doppler test should have been carried out earlier, and the tissue viability nurse visited Mrs A at frequent intervals, documented their assessments and plans and took into account the overall requirements of Mrs A’s health and wellbeing. On the loss of hearing aids and teeth, we recognised the impact of this on Mrs A, but we were unable to establish how these were lost. It can be very difficult to prevent the loss of such items and we found staff took reasonable action to find and replace them. However, in relation to falls prevention, we found that the hospital failed to adequately risk assess, keep the assessment under review or have a cohesive falls prevention plan as part of the overall care plan.

Recommendations

We recommended that the board:

• take steps to ensure that ward staff comply with guidance on falls prevention; and
• apologise to Ms C for the failures identified.

Summary

Mrs C complained that her late husband Mr A (who had terminal cancer), had suffered during his illness up to his death. Mrs C stated that in her view, she could not believe so many things had gone wrong with the care and treatment Mr A had received from the practice over 17 months. These issues were a failure to follow up Mr A’s admission to a hospital in the board’s area after the hospital had discharged him; that a practice GP had provided incorrect information about Mr A during a home visit and that the practice failed to follow the appropriate processes and procedures when completing the Do Not Resuscitate Form (the DNR).

Our adviser considered all aspects of Mrs C’s complaint and said that Mr A had lung cancer and that it was the responsibility of the hospital clinician that arranged Mr A’s investigation to follow up and act on the results, not the practice.

Our adviser stated that a practice doctor had provided incorrect information during a home visit; however, the practice doctor had speedily corrected this and apologised.

The adviser stated that the DNR Form (as part of end-of-life care), assists with the management of terminally ill people and compliments the expertise of those using it. We took account of the adviser’s advice and considered that the practice had followed the correct DNR procedures. Mrs C’s complaint was partially upheld.

Recommendations

We recommended that the practice:

• re-examine along with the District Nursing Team as a whole, their role in this case within the Liverpool Care Pathway continuous Quality Improvement Programme (to include the completion of the DNR form), to see (and reinforce) if there are lessons to be learned and how they can be applied to prevent such a scenario arising in the future (reference to both complaints 3 and 4).

Summary

Mr C complained that a medical practice would not issue prescriptions that he considered were appropriate to accommodate his individual circumstances. Mr C wished, as standard, to receive 56 day prescriptions (not the 28 day prescriptions the practice issued to him), for a long standing medical condition. Mr C had only recently moved to the practice. He also complained that the practice did not deal with his complaint appropriately.

We took independent advice from our medical adviser. After careful consideration of the advice and taking into account that the practice had made Mr C a reasonable offer to try to suit his personal circumstances, we did not uphold the complaint. We also considered that the practice had appropriately addressed Mr C’s complaint in good time. They had not, however, advised him of his right to bring his complaint to us if he wished to do so, which they are required to do. We upheld this aspect of his complaint.

Recommendations

We recommended that the practice:

• ensure that, in any complaint response, SPSO details are included to provide a complainant with the opportunity to contact us if they wish to do so.

Summary

Mr C complained that the board failed to provide him with reasonable care and treatment for his mental health problems. He detailed a number of areas about which he was concerned, and he was also unhappy about the way in which the board handled his complaint. He said that the consultant concerned had lied in his response.

During our investigation, we took independent advice from our medical adviser who is a consultant psychiatrist. We found that that the frequency of the board’s contact with Mr C was reasonable. We also found that the frequent use of hospital admissions and the fact that a large team were involved in his assessment and treatment were examples of good clinical practice. Although some of the clinics that Mr C was to attend were cancelled, we did not consider that this was excessive. We also found that it was reasonable to arrange clinics in locations that would benefit the greatest number of patients. However, we found that Mr C had been prescribed with large doses of medication that were not appropriate for the disorder he had been diagnosed with. This led to him being over-sedated. For this reason, we upheld his complaint about care and treatment, although we noted that the board had since carried out a review of his medication. We did not uphold the complaint about complaints handling, as we found that the board’s response was reasonable and we did not consider that the consultant had lied.

Recommendations

We recommended that the board:

• issue a written apology for their failings in relation to prescribing medication, which led to Mr C's over-sedation.

Summary

Mr C's home was flooded with sewage and his insurance company arranged for him to stay in a nearby hotel. That evening, his home was again flooded with sewage. He complained to us that Scottish Water delayed in responding effectively to the sewage flooding. Scottish Water's code of practice states that they will usually attend within four hours if internal sewage flooding is reported. We found that an officer had attended the flood within four hours. A clean-up squad attended on the following morning and Scottish Water's contractors attended on the next day to try to resolve the problem in the sewer. We did not, therefore, consider that Scottish Water delayed unreasonably in responding to the sewage flooding.

Mr C also complained that Scottish Water failed to routinely inspect the sewer as part of their maintenance programme. There is no requirement for Scottish Water to proactively monitor and inspect the whole of their sewage system and it is not within our power to recommend that they adopt such a policy.

Finally, Mr C complained that Scottish Water failed to deal with his claim for compensation appropriately. We upheld this complaint. We found that Scottish Water had referred Mr C's claim for compensation to their insurers. However, they failed to tell them that a half brick had been found in the sewage system. We considered that they should have done so in order that the insurers could reach a sound decision based on all of the relevant evidence.

Recommendations

We recommended that Scottish Water:

• issue a goodwill payment of £200 to Mr C to cover his insurance excess; and
• apologise to him for failing to initially inform their insurers that a half brick had been found in the sewage system when they referred his insurance claim to them.