Some upheld, recommendations

Summary
Mr C, who is a prisoner, submitted his request for a postal order in line with the instructions displayed by the prison in a notice to prisoners. Mr C's request was not actioned and he complained about it. In bringing his complaint to this office, he said hall staff failed to deal with his request for a postal order correctly.

The prisoner notice said that postal order requests ‘must be received by the cash office by Thursday morning to allow processing’. In response to our enquiries, the prison explained that Mr C submitted his request on the Thursday and his request was actioned by reception the same day before being passed to the cash office for processing. The prison said it appeared that when the cash office received Mr C's request, it had missed the morning cut off point and so was not processed until later.

In looking at Mr C's complaint, we considered the steps he took in submitting his request and the information available to him about submitting postal order request. We also considered whether the process in place was clear to prisoners. The available evidence told us that Mr C placed his request for a postal order in line with the instructions given by the prison displayed in the notice. The evidence also appeared to confirm that Mr C's request was processed properly by the prison. Therefore, we did not uphold Mr C's complaint. However, we were of the view that the information available to prisoners, about by when requests should received, was unclear, and made a recommendation to address this.

Mr C also complained about the prison's handling of his complaint. He said he was not given the opportunity to discuss his complaint with a manager; the response provided by the manager was inappropriate; and the internal complaints committee (ICC) and the governor unreasonably failed to take any action on his complaint. In line with prison rules, prisoners must be given the opportunity to discuss their complaint within a manager within the first 48 hours of submitting their complaint. This did not happen in Mr C's case so we upheld this part of his complaint. However, we did not agree that the manager's response was inappropriate or that the ICC and governor unreasonably failed to take any action.

Recommendation
We recommended that the Scottish Prison Service:
• revise the wording of prisoner notice to ensure the information provided reflects the advice given to Mr C in response to his complaint.

Summary
Mrs C runs a business that Scottish Water identified as receiving water without being billed. Business Stream took over the provision of water to the business in November 2010 and in January 2011 sent Mrs C a bill for outstanding water charges, which she found to be excessive. She asked for a water meter to be fitted to the premises so that she would only be billed for water used but, following a survey by Scottish Water, she was advised that this was not possible. Mrs C arranged for a plumber to inspect the pipework and he concluded that a meter could be fitted. This was done in June 2011. Mrs C complained that the water charges that accrued before the meter's installation were unreasonable and that the meter could have been installed several months earlier, lowering the costs.

Where no meter is in place, water charges are calculated on the rateable value of the property. We found it appropriate for these rates to apply up to the date of the meter being installed. In Mrs C's case, we were satisfied that the charges accrued prior to her meter being installed were in line with Business Stream's published rates. That said, during their inspection of Mrs C's premises, Scottish Water failed to identify that her pipework was suitable for the installation of a meter. They maintained this even after she highlighted her plumber's findings. We, therefore, concluded that there was an avoidable delay to the meter's installation.

Where Scottish Water are unable to fit a water meter, they will offer a contribution payment toward the cost of upgrading pipework so that installation can go ahead. Mrs C was offered a contribution of £750 and this was confirmed on more than one occasion. Scottish Water subsequently withdrew the offer, as no upgrade was required. We found Scottish Water’s communication about this to be poor, but that a good will gesture already offered by Business Stream was appropriate recompense. We also upheld Mrs C's complaint that Business Stream's complaint handling was poor and found that they had failed to offer her a £20 credit in line with their service standards.

Recommendations
We recommended that Business Stream:
• recalculate Mrs C's water charges for the relevant period based on her metered usage and adjust the balance of her account accordingly; and
• credit Mrs C's account with a further £20 in light of the failings identified.

Summary
Mr C, an advice worker, complained on behalf of Ms A. Ms A said that since July 2010 she had been regularly complaining about a communal leaking/dripping water tank. She said no effective repairs were carried out because of access problems to the flat above hers. The pipes froze in December 2010. This was reported but because of access problems the necessary repairs were not carried out. Mr C said that Ms A and her family continued to complain and raise their concerns but on Christmas Day 2010, the tank burst. Ms A's flat was flooded and she had to move out, first to her parents' house and then to a furnished flat provided by the council.

Although Ms A made a claim for compensation to the council's insurers, this was refused. Mr C said that the council had not acted on Ms A's complaints about the water tank, nor on her allegations that her upstairs neighbour was not living in the property. He complained that the council delayed unnecessarily in making an appropriate compensatory payment and failed to deal with his complaint in a timely manner.

As part of our investigation we considered the council's complaints file, all relevant emails and the repairs log for Ms A's flat. We also saw a transcript of calls to the council's customer care centre, and the council's complaints policy. We found that there was no record of all the calls alleged to have been made about this. We did, however, find that repair requests made were attended to. The documents also showed that the council had looked into Ms A's concerns that her upstairs neighbour had abandoned the property, but found no proof to substantiate this. However, we found that the council had not made a compensatory payment that Ms A was due in accordance with their usual practice. We also found that they delayed in dealing with Mr C's complaint.

Recommendations
We recommended that the council:
• apologise to Ms A for the delay in making her compensation payment; and
• the chief executive emphasise to all relevant staff the importance of responding to complaints and complainants in a timely manner and, where necessary, providing appropriate updates.

Summary
Mr C lives in a tenement flat. He complained about procedures adopted by the council in connection with a fresh application for a Housing in Multiple Occupation licence for the flat immediately above his own.

The complaint had eight aspects, including that the council delayed unreasonably in replying to Mr C's query about the applicant's display of a site notice and failed to inform him of an available right of appeal to the sheriff.

We upheld these two complaints, as our investigation found that the council failed both to respond to Mr C's query and to properly advise him about the availability of appeal. We did not find any evidence that anything had been handled incorrectly in respect of the other six points.

Recommendation
We recommended that the council:
• review their notes of guidance to applicants cited to attend sub-committee hearings on Housing in Multiple Occupation licence applications to include a warning that failure to attend might have important consequences in respect of making a valid appeal to the sheriff.

Summary
Mrs C complained about the way an ambulance crew treated her mother (Mrs A) who had fainted and had been slipping in and out of consciousness. Mrs C said that the crew had shouted at her mother, handled her roughly and treated her as if she was drunk. Mrs C also complained about the time the Scottish Ambulance Service (the service) took to respond to her complaint.

We did not consider the specific complaint about the crew's manner as this was subject to the differing interpretations of those involved. Having taken advice from one of our medical advisers, we found that the crew carried out an appropriate assessment of Mrs A's clinical condition and that it was correct for them to decide to take her to hospital. We also found, however, that the board took too long to formally respond to the complaint.

Recommendations
We recommended that the service:
• remind staff who have a responsibility to investigate complaints about the timescales in the NHS complaints procedure; and
• apologise for the overall time taken to investigate the complaint.

Summary
Ms C complained about the treatment she received from a GP employed by the board. She visited the medical practice complaining of neck pain, muscle weakness and fatigue. Blood tests were taken and Ms C was told that she was fine. However, she was found to have low levels of vitamin D and was prescribed a calcium supplement. Ms C subsequently developed indigestion, heart palpitations, eyesight deterioration and shortness of temper. She complained to us that the GP was dismissive of her symptoms.

About six weeks after the first consultation, Ms C's condition deteriorated to the extent that she found it difficult to walk. She began taking medication that she sourced on the internet and adjusted her diet. This resulted in some improvement to her energy levels, but she deteriorated again. She went back to the GP, and it was discovered that her original blood tests had shown a vitamin B12 deficiency. Specialist investigations confirmed that this was the cause of her symptoms.

After taking advice from one of our medical advisers, we upheld most of Ms C’s complaints. We found that the board had used a number of locum (temporary) doctors throughout the period in question, which had led to a lack of continuity of care. We found that the medical practice's clinical records were unsystematic and lacked any clear management plan for Ms C. As such, an important diagnosis was missed by incoming staff. Although Ms C's B12 deficiency was overlooked we were, however, satisfied with the efforts that the GP then made to minimise the potential impact of this oversight and we did not make any recommendations about this.

Ms C had also complained about the system the medical practice had in place for requesting, tracking and reporting blood tests. While we concluded that the system in place at the time was not fit for purpose, we found that they have since introduced a procedure which is in line with good working practice. On her complaint about the board’s complaints handling, we found that many of the points Ms C raised went unanswered and we made recommendations to address this.

Recommendations
We recommended that the board:
• remind complaint handling staff of the importance of answering all points raised by the complainant; and
• take steps to ensure their complaint handling staff work in accordance with the NHS Scotland complaints procedure.

Summary
Mrs C complained about aspects of nursing care that her late father (Mr A) received in hospital in the two months before his death. The complaints included that Mr A was not provided with basic nursing care in relation to personal and oral hygiene or to ensure that he had adequate food and drink. Mrs C also complained about the time her father spent waiting in accident and emergency to be admitted to a ward and that the staff failed to listen when the family pointed out Mr A's inabilities to care for himself.

We took advice from one of our medical advisers, who is a senior nurse. We upheld two of Mrs C's three complaints. We found that the records showed that the level of nursing care provided was appropriate, but it was unacceptable that Mr A had to wait for more than seven hours to be admitted to hospital. Also, although Mr A was in hospital for about six weeks, there was little evidence of communication from the nursing staff to his family, even in the final days of Mr A's life. We, therefore, found that communication from the staff to the family was inadequate and that the record-keeping about this should have been better.

Recommendations
We recommended that the board:
• remind nursing staff of their responsibilities to ensure that record-keeping is maintained in accordance with the Nursing and Midwifery Council Code and Record Keeping guidelines; and
• apologise for the failure to admit Mr A to a ward within an acceptable timeframe.

Summary
Ms C has joint power of attorney for her mother (Mrs A). Mrs A has vascular dementia and can become agitated and present challenging behaviour. As she is reluctant to take her medication, her family often disguise it in fruit juice.

Mrs A had a fall and was admitted to hospital. Her daughter complained about the care and treatment her mother received when she was there. She said that the board failed to take her advice about medication and that this led to her mother receiving it intra-muscularly. She complained that this was inappropriate. She also complained that the board failed to proactively manage her mother's care and that this led to a worsening of her condition. She further alleged that her discharge failed and that Mrs A required to be readmitted to hospital.

We obtained advice from one of our medical advisers, a specialist in acute medicine for older people, who read Mrs A's clinical records. We did not uphold the complaint about administering medication as we found no evidence in the notes to suggest that the family had told staff about how they had given this to Mrs A. Our adviser said that, in his view, the notes suggested that the board acted appropriately in the circumstances. However, because the notes omitted information that could have been expected, we decided on balance that the board did not managed Mrs A's condition proactively and upheld that complaint. We also found that the board had handled Mrs A's discharge appropriately but had failed to properly address Mrs C's written complaints as they should have done.

Recommendation
We recommended that the board:
• apologise to Ms C with regard to their failure to proactively manage her mother's care.

Summary
Ms C was diagnosed for a second time with cancer in the left breast and a lumpectomy (operation to remove a lump) was carried out. Ms C complained that the board failed to carry out the consultant's agreed monitoring programme of six monthly clinic reviews and annual mammograms. She said that when attending her second six monthly clinic review she was advised by one of the doctors that her next clinic review would be in one year's time due to the volume of patients. Ms C was also dissatisfied that a mammogram appointment was supposed to have been arranged but that she had to raise it with the doctor and arrange it herself. She also complained that the board's response to her complaint contained inaccurate information, in that they said she had undergone a mastectomy (opertation to remove a breast) and reconstructive surgery, which was incorrect.

The board had advised Ms C that she was being reviewed in accordance with the agreed monitoring plan of two six monthly clinic reviews, followed by yearly reviews and yearly mammograms. The board also told her that the doctor had not said that the yearly clinic reviews were due to the volume of patients, but that they were based on patient need.

We did not uphold the complaint about the monitoring programme. Although we considered that the wording of the consultant's monitoring plan was open to interpretation, our medical adviser said that the frequency of clinic reviews was appropriate and in line with the Scottish Intercollegiate Guidelines Network for the management of breast cancer in women. We could find no objective evidence to support Ms C's concern that she had been told that her next clinic review would be in one year's time due to the volume of patients.

Our medical adviser also considered that it was not unusual or inappropriate for a mammogram appointment not to have been made prior to Ms C's last six monthly clinic review. This was because it is safer to book appointments from the clinical assessment than to have requests made many months prior to the mammogram due date.

During our investigation, the board acknowledged that a mistake had been made in their response to Ms C's complaint. The board explained that Ms C's medical records had recorded the surgical options of mastectomy and reconstruction, but that these procedures had not been carried out. We upheld this complaint, noting the importance of responses to complaints being clear and accurate to ensure confidence in the professionalism of the NHS.

Recommendation
We recommended that the board:
• apologise to Ms C for incorrectly stating in their complaint response that she had undergone a mastectomy and reconstructive surgery.

Summary
Mrs C is a council tenant. In 1997, she moved from one property to another in an exchange scheme. It was a condition of the scheme that Mrs C accepted her new house in its current condition and that no non-emergency/non-statutory repairs would be carried out during the first six months. Mrs C told us that when she took over the house, she reported that there was a chip in the bath tub. She said that the council refused to repair the bath and told her that she had to take the property as seen. In 2011 Mrs C transferred again. The council made a pre-transfer assessment, and assessed the bath as 'damaged'. They sent her an invoice for more than £600 to cover the cost of replacing it. Mrs C said that the damage referred to was the same chip that existed when she moved into the property.

In deciding to hold Mrs C liable for replacing the bath, the council relied on the 'Application to Exchange Houses' form and the end of tenancy document completed by the council officer who inspected the property in 1997. They also referred to a copy of the pre–transfer report prepared before Mrs C vacated the property in 2011.

Our investigation found that the 1997 forms were largely incomplete, with only the section about the décor of the property filled in. There was no record of the condition of the bath. The council took the view that because the documents did not say the bath was damaged, this meant the damage occurred after Mrs C moved in. We, however, took the view that as there was nothing in writing to show that the bath was inspected at the end of the previous tenant's tenancy, this was not evidence that it was undamaged at that date.

The council also told us that when they carried out the pre-transfer inspection in 2011 they told Mrs C that she would be charged for the bath. When we looked at the relevant report, we found that although the fact that the bath was 'chipped' was noted, there was no indication that this was rechargeable. There was no agreement by Mrs C in the declaration section to either undertake repairs herself or pay the cost of repairs, and she had not signed the report. We saw no evidence that disagreed with what Mrs C had told us, and we upheld her complaint. The council have since cancelled the invoice and re-emphasised to staff the importance of completing documents about the inspection of property at the end or start of a tenancy.

Recommendations
We recommended that the council:
• review their decision to recharge Mrs C and do so with fair cognisance of the information available and/or not available including Mrs C's version of events; and
• review their procedures in relation to the completion of documents relating to the inspection of property at the end or commencement of a tenancy, ensuring that all sections are completed as required.