Some upheld, recommendations

Summary

Mr C complained that there were several errors in a letter that a doctor sent to his GP after he attended a clinic about his stomach problems. He said that this showed the doctor had not paid attention to him during the consultation. We obtained the doctor’s notes of the consultation and asked for his comments on the matter. The doctor said that he believed that the notes he took and the letter he dictated following the consultation with Mr C were accurate. Our investigation did not find any evidence to support Mr C’s complaint that there were errors in the letter.

Mr C also said that the doctor sent the letter to the wrong medical practice. Our investigation found that the letter had been sent to the correct practice and did not uphold this part of Mr C’s complaint. However, we found that when Mr C complained to the doctor about the letter, the doctor sent the complaint to Mr C’s practice, but did not respond to it.

Recommendations

We recommended that the board:

• write to Mr C to apologise for the doctor's failure to respond to his complaint.

Summary

An advocacy worker (Ms C) complained on behalf of Mrs A, whose husband (Mr A) had been treated by the board. Mr A had become ill in October 2010, and his GP prescribed antibiotics for a presumed chest infection. Mrs A became concerned about his condition later the same day, however, and believed that her husband was having a stroke. Mr A attended the accident and emergency department of a hospital and was admitted. Records show that Mr A was found to be confused, with slurred speech and impaired mobility, but investigations found that he had not had a stroke and did not have an infection. No confirmed cause was established for his confusion, and he was discharged with a suspected Transient Ischaemic Attack (a type of stroke, sometimes called a mini stroke, that shows no evidence on CT scans but resolves in around 24 hours).

Mrs A complained that Mr A was discharged home whilst still very confused. She questioned the level of investigation into his condition. She also said that her husband had been diagnosed with lung cancer six months after his hospital admission and asked whether this should have been diagnosed at the time.

After taking advice from our medical adviser, we upheld two of Mrs A's complaints. We found that staff thoroughly investigated the cause of Mr A's confusion and reached appropriate conclusions. A chest x-ray taken during his admission did show an abnormality that was suspicious of, but not diagnostic of, cancer. We noted that the radiologist's report recommended investigation of this once Mr A's condition improved, but found no evidence of follow-up arrangements being made or of Mr A and his family being told of the finding.

We were unable to comment as to the extent of Mr A's confusion when he was discharged home, as when he was admitted the board failed to obtain detailed information from Mrs A about his usual state. However, we noted that a care plan and discharge plan were completed stating that arrangements had been made to provide Mr A with support at home, but found no evidence of the described actions having been taken. There was also a lack of evidence of staff discussing discharge arrangements with Mrs A. As such, we were left with doubts as to whether it was appropriate to discharge Mr A.

We did not uphold Mrs A's complaint that the board failed to provide a follow-up appointment for her husband, as we could not find evidence to show that this should have happened.

Recommendations

We recommended that the board:

• apologise to Mrs A for the issues highlighted in our decision;
• draw Mr A's case to their staff's attention to ensure that discharge arrangements are properly followed up and documented and that patients' families are routinely consulted about their perceptions of the need for support at the time of discharge; and
• consider carrying out an audit of actions that are actually undertaken in the discharge planning process against the benchmark of their discharge planning documentation.

Summary

Mrs C became pregnant at the age of 40. Her pregnancy appeared to progress well, but at just over 37 weeks it was discovered that her baby had died. Mrs C’s baby was stillborn the following day. Mrs C made a number of complaints about the care that she, her baby and her husband received both during and following her pregnancy.

Mrs C was concerned that she had been placed on a midwifery led care pathway. Having taken advice on this from our medical advisers, we found that this was appropriate, as she had no apparent risk factors. Her age was taken into account appropriately, with an extra appointment for a fetal growth scan (a scan to detemine the growth and health of the baby) with an obstetrician at 12 weeks. We also found that Mrs C’s care complied with the governmental guidelines 'Pathways for Maternity Care' and did not uphold this complaint.

Mrs C also complained that the systems of routine scans and antenatal checks did not provide enough care to mothers and babies. She was concerned, in particular, that no further midwifery appointments were offered after 35 weeks, and that additional checks were not carried out on her. We found, however, that the care in place was appropriate, that Mrs C had had a suitable number of midwifery appointments at the appropriate stages throughout her pregnancy, and that a balance had to be struck between positive elements of providing reassurance and detecting disease for which there is an intervention, and negative elements of creating anxiety and possibly unnecessary early delivery. We did not uphold this complaint.

Mrs C said that the postnatal care offered to her and Mr C was inadequate and did not offer enough support for their bereavement. We found that, although the postnatal care by the midwives was adequate, Mrs C was not contacted by a health visitor. The board said that a health visitor would not visit in the event of a stillbirth, but the advice we received indicated that contact would have been appropriate. We upheld this complaint and recommended the board reconsider their policy in this regard.

Mrs C also complained that the information offered by the board about loss in pregnancy was inadequate. We did not uphold this complaint as we found the information offered by the board through parentcraft classes was proportionate and appropriate.

Finally, Mrs C complained that the board did not fully address some of the issues she raised with them. We upheld this complaint as we found a number of errors in the information the board gave Mrs C throughout their correspondence with her. There was also an unnecessary delay in providing the results of a second opinion post-mortem report that Mr and Mrs C had requested.

Recommendations

We recommended that the board:

• provide us with evidence that they have reviewed their policy and clarified the role of health visitors in the event of stillbirth and neo-natal death, to ensure sufficient information is communicated effectively during the midwifery discharge process;
• provide Mrs C with a copy of the second opinion post-mortem report and offer her an appointment to discuss the findings; and
• provide Mr and Mrs C with a full apology for the failings identified.

Summary

After Mrs A had a knee replacement operation she was discharged home into the care of the district nursing service (district nurses visit and treat patients at home). Her daughter (Mrs C) complained about the care Mrs A then received - in particular, that two clips were not removed. Mrs C said that this caused her mother to suffer an infection, and that this was not properly treated in that on one occasion, dressings were not available. She also said that Mrs A was not provided with antibiotics quickly enough. Mrs C considered that her mother suffered unnecessarily because of this, and lost mobility and independence.

We investigated the complaint and took advice from our nursing adviser. We found that, contrary to what Mrs C thought, wound clips are not normally counted as they are put in and taken out, and are generally obvious. Although two clips were left in Mrs A's knee for a short time, the adviser could not conclude that this led to the infection. However, the adviser also said that the notes taken at visits were not of good quality and that not all actions taken were noted. Nevertheless, the records suggested that there was no delay in giving Mrs A appropriate antibiotics. Although it was regrettable that Mrs A contacted an infection, we could not determine with certainty that this was as a result of a lack of care. We did, however, uphold Mrs C's complaint that on one occasion the wound was not dressed.

Recommendations

We recommended that the board:

• emphasise to all district nursing staff the importance of adhering to the Nursing and Midwifery Council 2009 Guidelines 'Record keeping

Summary

Ms C complained about the way in which the university handled her academic appeal. The officer handling her appeal chose to process it as a complaint. We found that the officer had not followed the procedure appropriately. We found that written records of communications between the officer and Ms C and other academic members of staff had not been kept. We found this unreasonable, as it made it difficult to impartially assess what Ms C had been told. We also found that the officer had used a complaints process that did not comply with the university’s own complaints procedure, and we were critical of this. We made a number of recommendations to address the fact that procedures were not appropriately followed in Ms C’s case.

We did not uphold Ms C's other complaints, including that she had not been told she could consult with an independent student advice service, as we found that she could reasonably have obtained a copy of the university’s complaints process herself. We also did not uphold her complaint that she was graduated in her absence without her consent, as the university provided evidence that Ms C had been sent the date of her graduation ceremony in writing. We also accepted their position that should a student’s appeal change a degree award, they would be invited to another ceremony as long as they had not crossed the stage during a previous ceremony.

Recommendations

We recommended that the university:

• reconsider Ms C's AP1 form through their academic appeals procedure;
• provide us with evidence that their student complaints procedure is being adhered to;
• provide us with evidence that written records of communications in relation to student complaints files are being maintained; and
• amend the student complaints procedure to highlight the supportive role that can be offered to students by the students’ association’s independent student advice service.

Summary

Ms C complained that the Student Awards Agency for Scotland (SAAS) unreasonably refused her funding for a course, despite advising her course tutors that funding would be provided. She also complained about the delay in processing her application.

We found that SAAS did not provide information on their website or their 'Guide to Post Graduate Student Support' about restrictions on providing funding for students who had previously received support for courses from EU funding. However, they explained that these information sources were for guidance purposes only, and that only when an application was submitted could all criteria be considered. As this information was for guidance only, and as SAAS demonstrated that Ms C did not qualify for support, we did not uphold these aspects of her complaint. However, we did uphold her complaint that they failed to assess her application within their advertised timescales.

Recommendations

We recommended that SAAS:

• ensure that they comply with their advertised timescales when assessing applications and write to Ms C to apologise for failing to meet their timescales in this case.

Summary

Mr C complained that Scottish Water supplied water to his home at inappropriately low pressure. He was aware that they had installed pumps at the end of his street but said that they had failed to switch them on. He was unhappy with Scottish Water's handling of his complaint as they had not turned the pumps on and had not explained why they were not in operation.

Scottish Water said that they were supplying Mr C with water at above the guaranteed pressure of one bar. As Mr C was dissatisfied with this explanation, they offered to carry out an analysis of the pumps, which they did. The analysis revealed that it would not be cost-effective to bring the pumps into operation. We did not uphold his complaint as we were satisfied that Scottish Water had given the matter appropriate consideration. However, we found that they had never explained to Mr C why the pumps could not be switched on and we recommended that they apologise to Mr C for failing to deal with this aspect of his complaint.

Recommendations

We recommended that Scottish Water:

• apologise to Mr C for failing to provide him with an explanation.

Summary

Mrs C owns a property that is leased to a council tenant by a letting agent.

Mrs C complained that there was an unreasonable delay by the council to act on her agents' request to make a direct payment of local housing allowance to them, not her tenant, because the tenant had rent arrears. Mrs C complained about the council's communication with her agents. She also complained about a failure to respond to her request to send the case to appeal, and to handle her complaint in accordance with the council's complaints procedure.

We upheld most of Mrs C's complaints. Our investigation found that the council had delayed in taking action to pay Mrs C's letting agents direct, combined with a failure to respond to her letting agents' enquiries when the payment was not made. When they responded to Mrs C's complaint, the council had already accepted that there was a failure to respond to the letting agents' correspondence and to provide advice about the appeal procedure in the decision notice. There was also evidence that the council did not meet their customer care standards in the handling of Mrs C's formal complaint. We did not, however, find that anything had gone wrong in respect of Mrs C's request for an appeal, as although she was told about her right of appeal, no request was received from her or anyone acting on her behalf.

Recommendations

We recommended that the council:

• make a payment to Mrs C; and
• take steps to ensure that their procedures, and notices issued to landlords about appeal procedures, comply with the housing benefit regulations and Department of Works and Pensions' good practice guidance.

Summary

Mr C obtained a building warrant for a new double garage and bed and breakfast accommodation. Around 18 months later he found that the building warrant was based on the council's approval of plans for an earlier, incorrect foundation slab.

When trying to resolve matters, Mr C experienced delays. He complained that the council made further administrative errors and provided conflicting information as he tried to proceed with his development.

The council accepted and apologised that they stamped the wrong plans for the development. This error resulted in a building warrant being based on drawings that were different to the work that would be carried out. To resolve this, the council suggested that Mr C resubmit the correct plans as part of a forthcoming amendment of warrant application. We found that this was a simple administrative error, but felt that the council's proposed solution contributed to Mr C's problems with progressing the work. Had the stamping mistake been dealt with separately from the amendment application, he would have been able to progress with construction.

We found no evidence to confirm Mr C's assertion that the council lost plans for his building warrant application. However, we found that they made administrative mistakes on two occasions when providing stamped copies of plans for the building warrant's approval.

Mr C also complained that the council were responsible for unacceptable delays when dealing with his application for amendments to his plans. We did not find this to be the case. We were satisfied that delays were caused by the time taken to verify the appropriateness of an infiltration system Mr C had installed. We found that they had correctly followed their procedures in doing so.

Mr C sought to amend his plans so that a link door between his existing property and the new bed and breakfast accommodation was sealed. He complained that the council provided conflicting information to him and his architect about the feasibility of sealing the link door. We were unable to establish what information had been provided verbally, but were satisfied that the written advice the council gave to Mr C's architect was reasonable and in line with national guidance.

Recommendations

We recommended that the council:

• refund all fees associated with amendments and extensions to Mr C's building warrant.

Summary

Ms C was liable for council tax. When she received a bill, she emailed the council for assistance because she was having difficulty paying. The council did not respond to her email. They later took recovery action for her council tax arrears, which resulted in a charge being added to her account. Ms C complained that the charge was added to the account even though she was making regular payments. She also complained that her emails were not answered and about the quality of the complaint response letter she received from the council which she said contained spelling and grammatical errors.

We did not uphold the complaint about the charge because we found that Ms C's council tax account was in arrears and she did not make reasonable attempts to contact the council to make a payment arrangement. Although we noted that she had emailed them, we did not think that sending one email during a four month period (while aware that they had not yet replied) amounted to a reasonable attempt to contact the council. However, we upheld her complaints that the council did not respond to emails and about the quality of their complaint response.

Recommendations

We recommended that the council:

• review their processes for responding to email contacts to ensure that, where appropriate, emails are acknowledged and dealt with within the published timescales; and
• reflect on the quality of written communications, as demonstrated by this complaint, and take appropriate steps to ensure that they are of a satisfactory standard.