Some upheld, recommendations

Summary

Mr and Mrs C live in a house on a coastal strip below a site that contains two plots which received planning consent in 2005 (after a successful appeal to Scottish Ministers). A subsequent application was made in 2010 for full planning permission for an amended design on these plots. As part of the 2010 application the applicant provided an overlay comparing the earlier consent with the 2010 proposal.

Due to an error by the applicant's agent, first noted by a senior planning officer the day before a site visit, the case officer's report referred to the 2010 application as being at a lower height than the 2005 approval, although the finished floor levels were in fact about the same. The senior planning officer had requested an amended overlay from the developer, and this had been available to the planning committee the next day when they visited the site before deciding on the 2010 application. Mr and Mrs C made three complaints, two of which we upheld. We found that, had the error been uncovered earlier, then in the period leading up to the site visit an amended or supplementary report could have been provided (removing the references to the lower height of the 2010 proposals) and that a more appropriate methodology could have been used to demonstrate height levels at the site visit.

Recommendations

We recommended that the council:

• apologise to Mr and Mrs C for the defects identified in the way that they processed the 2010 application.

Summary

Mr C, an advocacy worker, complained to the council on behalf of a client (Mrs A).

The complaint was about the council complaints review committee (CRC)'s handling of her complaint about her husband's care package. Mrs A said that the CRC was unreasonably delayed; that it did not take all of her evidence into consideration concerning the care provider and the council's offer of a meeting to discuss the complaint; nor did it include important information in its report to the council's Health, Social Care and Housing Review Committee (HSCHRC).

We upheld Mrs C's first complaint, as our investigation found that the council had not arranged the CRC hearing within the statutory timescale nor within a reasonable length of time. We did not uphold the complaints that the CRC was not given sufficient evidence to show that the council had attempted to arrange a meeting between Mrs A and the care provider to try and address Mrs A's concerns; that Mrs A had not been given the opportunity to provide her evidence in writing to the CRC and to discuss this at the hearing; and that the CRC had not provided the HSCHRC with their decision and recommendations in line with their policy and procedures. We reached this conclusion as we found no evidence to show that the council had acted wrongly in these matters.

Recommendations

We recommended that the council:

• apologise for the delay in convening the CRC.

Summary

Ms C, a solicitor, complained on behalf of a tenant of the housing association (Mrs A). She said that the association had failed to take action to resolve problems with the sewerage and septic tank that Mrs A shared with three other properties, two of which were privately owned.

Our investigation found that the association had obtained professional advice on the matter. They considered that major renovation work was necessary to improve the sewerage system and septic tank, but this would require the consent of Mrs A's neighbours. The neighbours refused to agree and so the association were unable to arrange for the work to be carried out.

Ms C also complained that the association had blamed Mrs A for the problem by referring to the disposal of inappropriate items. We found that the association had evidence to show that some of the problems might have been caused by inappropriate use of the system. In response to this, they gave advice to all residents about how the system could be better used. We considered that it was appropriate for the association to tell residents about this. This position was supported by the council's area environmental health manager, who considered that the system could be managed by careful use and regular flushing.

Ms C's final complaint was about the association's failure to adequately respond to Mrs A's complaint. We found that the association's response did not confirm that it was a response to the complaint or how Mrs A could take the matter further. We also found that they had delayed in taking some of the action they said they would take, and had failed to keep Mrs A updated. Our investigation found that the association's letter was not an adequate response to Mrs A's complaint, therefore, we upheld this part of the complaint.

Recommendations

We recommended that the association:

• remind staff that responses to complaints should include information about how the complainant can pursue the matter should they remain dissatisfied; and where appropriate, complainants should be kept informed of the progress in relation to a matter; and
• issue an apology to Mrs A for their failure to adequately respond to her stage one complaint.

Summary

Mrs C suffered from lung cancer and chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed). She was receiving chemotherapy but after the second cycle her condition deteriorated and she was admitted to hospital, where she died a few days later.

Her daughter, Miss C, was concerned that while her mother was in hospital one of her medications, which was given by injection, was not always administered. She said that at times the injections were prepared and then left by her mother's bedside if they were not given. Miss C also complained that a pain relieving patch was not administered. The board said that the patch had been administered but was later removed. There was conflicting information from the board and Miss C about when this happened.

We investigated and took independent advice from one of our medical advisers, a senior and experienced nurse. She said that the Nursing and Midwifery Council (NMC) issue guidance on the preparation and administration of drugs and that the practices demonstrated in this case did not comply with that guidance. We upheld both complaints.

Miss C said that there were inaccuracies in the fluid monitoring charts, but we could not establish the accuracy of these, given the time that has passed since. The board did say that Mrs C, who was a retired nurse, liked to maintain her independence where possible and preferred to go to the bathroom when she was able. They said that this may have introduced some inaccuracy to the charts. Our investigation found that it was reasonable to allow Mrs C to maintain her independence where possible. The nursing adviser reviewed the charts and had no concerns, and we did not uphold this complaint.

Finally, we upheld Miss C's complaint about complaints handling. We found that there were unacceptable delays in responding to Miss C's complaints. The final response took four months rather than the 20 working days required by the NHS guidance on complaints handling. In addition, our investigation found that although it largely reflected the NHS guidance, the board's complaints procedure did not fully comply with it.

Recommendations

We recommended that the board:

• apologise for the deficiencies identified by our investigation;
• provide an update on the changes to the evening medication round;
• ensure all staff are aware of and comply with the NMC standards and board policy on administration of medication;
• report on the integration of the policy on the administration of medication to the board's staff induction programme;
• provide an update on the progress of changes to the complaints and advice team; and
• ensure that their complaints procedure fully reflects the NHS guidance on complaints handling.

Summary

Mr A had abdominal pain in the early hours one morning. The pain had been present the previous day, but had got much worse. Mr A's wife (Mrs C) contacted the ambulance service for assistance, but they did not send an ambulance so Mrs C took her husband to hospital. Mr A had acute appendicitis (sudden inflammation of the appendix). His appendix was removed that afternoon. He was discharged from hospital seven days later. Mrs C complained that the service failed to attend when she called them for Mr A, and did not deal with her complaints appropriately.

We did not uphold Mrs C's complaint that an ambulance was not sent. We took advice from one of our medical advisers, who said that Mr A's condition was not detrimentally affected by not being taken to hospital by ambulance, and that the decision not to send an ambulance was correct in terms of the service's protocol. We listened to the telephone call and reviewed the service's records and procedures together with information provided by Mrs C. We decided that although the emergency medical dispatcher's communication with Mrs C was not as helpful as it could have been, the decision not to send an ambulance was reasonable in the circumstances.

We upheld Mrs C's other complaint. We found that she received a response to her complaint after eight weeks, which was longer than the 20 working days the service aimed to work to, and she was not updated with an explanation of why there was a delay. We found evidence that service staff disagreed on who was responsible for sending the update. Our adviser thought that because the service's review of Mrs C's call focused on technical aspects, rather than taking a holistic view that included Mrs C's experience, it lacked any real empathy with her situation. Their investigation report recommended that Mrs C be given a more detailed explanation of the reasons for not sending an ambulance, but we noted that this was not provided.

Recommendations

We recommended that the service:

• review this call with the emergency medical despatcher involved, and ensure that they receive appropriate support for their customer care skills to achieve the standard aspired to in the service's 999 procedure;
• review how they respond to complaints relating to incidents where callers dispute the outcome, such as this case, to ensure that investigations and responses acknowledge and take into account the service user's experience, rather than being solely driven by compliance with protocol; and
• ensure all staff dealing with complaints know who is responsible for updating complainants at particular stages of the complaints process.

Summary

Mrs C complained about the care and treatment her father (Mr A) received while in hospital. Mrs C said that her family were asked to contact the ward on the day of Mr A's operation. She said that when they did this, they were made to feel over-anxious. Mrs C complained that after his operation, Mr A had been left alone without access to his buzzer, that staff failed to give Mr A prescribed laxatives, and that staff were generally rude and uncaring. However, Mrs C was mainly concerned that a nurse harshly treated Mr A.

We investigated the complaint and took advice from our nursing adviser. Our investigation found that because of Mrs C's allegation, action was taken under the health board's disciplinary policy and procedure. We also found that there was no evidence in the medical notes that Mrs C's family had been asked to contact the hospital. However, on the balance of probability, we upheld that Mr A had not had access to his buzzer and that staff failed to communicate adequately. We also upheld Mrs C's complaint that Mr A had not been given the laxatives as there was evidence of this in his medical records. We did not uphold the complaint alleging harsh treatment as there were conflicting statements about this, and there was no independent evidence to allow us to reach a decision.

Recommendations

We recommended that the board:

• remind staff to regularly ask patients about the accessibility of their buzzer on the ward and give consideration to completing a ward audit to establish that buzzers are accessible;
• make Mrs C and Mr A a formal apology for their failure in this matter; and
• provide evidence that remedial action has been taken to ensure a similar situation does not reoccur.

Summary

Mrs C had worsening hearing loss in both ears, with narrow ear canals that made use of in-ear hearing aids painful and intolerable. She complained that the board failed to refer her to the correct consultant at the right time, and that there was an unreasonable delay of a year in being sent to see the correct consultant. Mrs C also complained that she was not referred to a bone anchored hearing aid (BAHA) clinic when she first attended for investigations, and she questioned whether this clinic existed at all. BAHAs conduct sound to the inner ear directly through the bone, rather than through the air, which is how Mrs C's current in-ear hearing aids operate. In addition, Mrs C complained that the audiology clinic had no appropriate BAHA headband trial equipment available for nearly seven months.

We were critical of the board's lack of clarity in communicating with Mrs C about the availability of BAHA headbands, and we drew this to their attention. However, it is not for us to say how the board should use their resources, and it was clear that the lack of availability of BAHA trial headbands was a resource issue that the board had tried to remedy by ordering additional units. Therefore, we did not uphold this complaint.

When we looked into Mrs C's other complaints, we found that the BAHA clinic did exist. The board accepted there were difficulties and delays in progressing Mrs C's care and they apologised to her. Our adviser noted that a key referral should have been more clearly documented, and that Mrs C should have been considered for other hearing aid technologies more quickly, given that she was unable to use air conduction devices. We concluded that Mrs C did not see appropriate staff in reasonable time and, in particular, that she should have been considered sooner for referral to the BAHA clinic, and we upheld these complaints.

Recommendations

We recommended that the board:

• review pathways from Audiology to ENT (medicine of the ear, nose and throat), so that patients who do not benefit from air conduction hearing aids can be considered for other technologies in reasonable time.

Summary

Mrs C told us that her late mother (Mrs A) was admitted to hospital for oesophageal (gullet) enlargement to help reduce a thin membrane that had formed in her gullet. This was to be a day procedure. However, following the procedure, Mrs A suffered complications and remained in the hospital where further surgery took place. Her condition worsened and she was transferred to another hospital in the board's area where she died. Mrs C and her family complained to the board that Mrs A received inadequate care and treatment, communication and nursing care while a patient in the hospital. Mrs C said that there was a failure to take Mrs A's visual impairment into account, and was dissatisfied with the response she received to her complaint.

Two of our medical advisers reviewed Mrs C's complaint and Mrs A's medical records. After carefully considering their advice, we found that there was no evidence that Mrs A had not received appropriate care and treatment from the hospital and from nursing staff. We also found that, overall, the communication with Mrs C, Mrs A and her family was acceptable. We did not uphold any aspects of these complaints.

However, one of our advisers, a nursing adviser, was critical of the lack of documented information and care planning about Mrs A's visual impairment. We considered that the board failed to take Mrs A's visual impairment into account and upheld this complaint.

Recommendations

We recommended that the Board:

• ensure that, where a patient is visually impaired, this is recorded and taken into account of in their nursing assessment and care plan; and
• advise us of the outcome of any discussions with the Royal National Institute of Blind People concerning measures to improve the future care of patients with visual impairment.

Summary

Ms A requested that her first appointment with a new medical practice be longer than usual. Ms A was late for the appointment, and when the GP refused to see her she became upset. She wrote a letter about the situation while she was in the practice but this was not responded to. Within a few days she was informed that she had been removed from the practice list.

Ms A's representative (Ms C) complained to the practice on her behalf. They replied, saying that their views about the length of the scheduled appointment, how late Ms A had been and the behaviours she had displayed were different from those of Ms A. Ms A was dissatisfied with their response and raised her complaints with us.

We decided that the practice had reasonably fulfilled a request for a prescription and passed Ms A's records to her new practice. However, as they had not met the requirements of the relevant regulations for the immediate removal of a patient from a treatment list, we upheld Ms A's complaint that her removal had been inappropriate. We also upheld Ms A's complaint that the practice did not respond reasonably to complaints submitted about this matter.

Recommendations

We recommended that the practice:

• apologise to Ms A that her removal from their practice treatment list was not appropriate;
• review their procedure for the removal of patients from their treatment list to ensure that it complies with the relevant regulations, guidelines and guidance;
• apologise to Ms A that they did not respond reasonably to her letter; and
• review their complaints procedure to ensure that it is in line with the NHS Scotland complaints procedure.

Summary

Ms C completed work on a PhD (a postgraduate academic degree). The university examiners, however, decided that her thesis did not meet the requirements for a PhD, but did meet the requirements for a Masters degree. Ms C complained that the supervision and PhD support provided to her by the university was inadequate and did not give her a realistic expectation of the result of her thesis submission. She also complained about the academic appeal process and about the university's complaints handling.

We found, from the evidence, that Ms C's supervisors had concerns about her thesis. However, we could not say what the university staff said to her about this, prior to submission of the thesis. When the matter was discussed with the supervisors as part of the university's investigation into the complaint, they said they believed that their concerns were flagged to Ms C. There was insufficient evidence for us to say that they failed to communicate these concerns to Ms C and we did not uphold this complaint.

We upheld Ms C's complaint about the academic appeal process. When Ms C appealed the decision on her thesis, the university said the matter would be referred to an external person with the relevant expertise for a second opinion. However, the thesis was referred to an employee of the university for review. We considered that the university should have honoured the commitment they made in writing to Ms C, when they said they would refer the thesis to an external person for review.

Ms C also complained that the complaints process took too long and was inadequate in relying on verbal rather than written evidence. We found that the university had taken some time to investigate the complaints. However, it was clear that they carried out a detailed examination into the issues raised in her complaint. We did not consider that their investigation was unnecessarily prolonged, and were satisfied that the university did appropriately consider written evidence rather than relying on verbal evidence.

Recommendations

We recommended that the university:

• appoint someone external to the university with the appropriate expertise to review her thesis; and
• write to Ms C to apologise for their failure to get an external person to review her thesis, as stated in their letter.