Some upheld, recommendations

Summary
Ms C made several complaints about her dental practice. She complained that her dentist failed to deliver the appropriate treatment and service when she asked him to check on her bridge. She also complained that either the dentist or the dental practice failed to ensure that the dental hospital received her x-rays within a reasonable time, and that the failure to do so led to a delay in her being seen at the dental hospital and so exacerbated the decay in the teeth supporting the bridge.

On investigation we found that the actions of the dentist did not result in the loss of the bridge. The bridge had failed due to Ms C having extensive decay in both supporting teeth. The dentist had provided Ms C with appropriate advice, which was to have a new bridge fitted or otherwise for him to refer her to the dental hospital. Therefore, we did not uphold this part of Ms C’s complaint.

Ms C asked to be referred to the dental hospital. Following the referral, x-rays were required by the dental hospital. However, due to a lack of record-keeping by the dental practice, our investigation was unable to establish what had occurred regarding the taking of the x-rays and when they were sent to and received by the dental hospital. We, therefore, found that the dentist or the dental practice failed to ensure that the dental hospital received the x-rays within a reasonable time and upheld this part of Ms C’s complaint.

We accepted that, as a result, Ms C had to wait a number of months before being seen and given a diagnosis at the dental hospital. While we considered that part of this delay was caused by the dental hospital not having Ms C’s x-rays we also considered that part of the delay was also due to Ms C’s personal circumstances. Furthermore, while the delay caused by the lack of x-rays was unfortunate we considered that it would not have had any effect on the outcome in Ms C’s case and we, therefore, did not uphold this part of the complaint.

Recommendations
We recommended that the practice:
• review their record-keeping so that telephone calls received and made in relation to a patient’s treatment are recorded; and
• review their practices and procedures so as to ensure that a patient’s
x-rays, where appropriate, are sent to and received by the dental hospital.

Summary
Ms C has been undergoing psychiatric treatment for a number of years and had been diagnosed with 'Bi-Polar Type II Rapid Cycling Mood Disorder'. In May 2010 she attended a consultation and was told that her diagnosis had been changed to 'Complex Personality Disorder'. Despite advice that the team would gradually reduce her medication, Ms C stopped taking her medication right away. She reported that this has made her feel considerably worse. She was also concerned that the board told her she needed a chaperone when attending any consultation where there would be discussion of her condition and treatment. Finally, she also complained that some of the copy clinical notes she was provided with were hand-written and illegible.

The complaint was investigated and independent psychiatric advice was obtained. At this point the difficulties of psychiatric advice were explained (that it was rarely that objective investigations, like blood tests, could be relied upon) and that changes in diagnosis were perhaps more probable in this area of medicine. It was confirmed that as an initial diagnosis had taken four years it was likely that Ms C's presentation was atypical and it was, therefore, reasonable to review her diagnosis and medication.

The investigation also showed that after an alleged incident involving Ms C, there had been significant concern expressed by a senior member of staff about his personal safety. A collective decision had later been taken by board staff that a chaperone should be present with Ms C and any practitioner when her clinical care and treatment were being discussed with her. This satisfied the board's own responsibilities to their staff while not prejudicing Ms C's clinical care.

After consideration, Ms C’s complaints were not upheld. However, the investigation confirmed evidence that the clinical notes given to Ms C after she requested them were, in part, difficult to read. In the circumstances, while upholding this complaint, it was recommended that the board should provide Ms C with a written transcript.

Recommendation
We recommended that the board:
• provide Ms C with a written transcript of the relevant notes.
 

Summary
Miss C was a student at the university. She complained that guidance on how to complete a piece of coursework was made available to students after the date that it was due to be handed in. She also complained about the university's failure to limit noise outside their buildings during classes and exams. Miss C was ultimately expelled from the university. She attempted to appeal this in line with the university's disciplinary procedure, but received no response to her appeal.

We found that students on Miss C's course were potentially disadvantaged by the university's failure to provide the coursework guidance in advance of the hand-in date. We did not consider that they should have done any more to restrict the level of noise outside campus premises. Although we found no evidence that the university deliberately ignored Miss C's appeal, we recommended that they consider clarifying their disciplinary procedure's guidance on how to submit an appeal.

Recommendations
We recommended that the university:
• apologise to Miss C; and
• consider reviewing their Code of Discipline to include guidance to students as to how to submit an appeal against the Disciplinary Committee's decision.

Summary
Mr C, an international distance learning student on a postgraduate course at the university, complained that the initial communication of a change of assessment method was not communicated to him with reasonable clarity and within a reasonable timescale. He also complained that the university did not reasonably communicate the remit of the mitigating circumstances board to him; and did not reasonably communicate the decision of the mitigating circumstances board, and the consequences of that decision, to him. In addition, Mr C complained that the university’s response to his request for an academic appeal was not reasonable, both in terms of content and response time.

We found from looking at the evidence that the university knew about the proposed change at least two months before they told Mr C. Mr C was sent an email about the change eight weeks before the examination. Given his circumstances, our view was that this was a tight timescale for him to make the necessary arrangements to sit the examination abroad. Taking this into account, and as the university’s mitigating circumstances board accepted that communication of the change of assessment method may not have been as clear and timely as could reasonably be expected, we upheld this complaint.

We also found that the university focused on Mr C’s apparent misunderstanding of what constituted mitigating circumstances, and how it was not the appropriate process to use. Instead, the university said Mr C could have used the student complaints procedure. However, Mr C did raise concerns, both with staff and via comments on the mitigating circumstances form, but at no point was he directed to the appropriate process. We accepted that Mr C had a responsibility be familiar with university processes. In addition, we found that Mr C asked for clarification of the mitigating circumstances board’s decision, and what that meant for him. The university missed the opportunity to clarify the situation and, instead, simply told Mr C that his claim was valid. Therefore, on balance, we upheld this complaint.

We did not uphold Mr C’s complaint about the academic appeal, as we found from looking at the correspondence and the appeal regulations that the university’s response was reasonable in terms of content and response time.

Recommendations
We recommended that the university:
• apologise to Mr C for failing to communicate with him about the change in assessment method for a module with reasonable clarity and within a reasonable timescale;
• in future, inform students in writing: of proposed changes to assessment, as soon as formal proposals are made; and confirmed changes to assessment, as soon as confirmation is obtained. This information should include detail about the changes; and
• in light of this case, clarify their guidance to students and staff on what the mitigating circumstances process can and cannot be used for.
 

Summary
Ms C was a council tenant from 2003 until 2010. Before she vacated the property, a housing officer carried out an inspection. Their written report noted there was writing on the walls in the bedrooms and poor décor in the stairway, but did not note any repairs to be carried out, or if any such repairs were to be the responsibility of the tenant or the council. The report was signed by the housing officer but not by Ms C.

After Ms C moved out, the council undertook a vacant house inspection which noted a number of repairs and cleaning jobs to be carried out. Ms C was initially charged around £1,700 for these, although the invoice was later reduced to just over £1,200. Ms C complained she had not been notified prior to leaving the property that there was repair work to be carried out and, therefore, had not had the opportunity to undertake the work prior to the council doing so. The council said that Ms C had been aware of her obligations as tenant through her tenancy agreement, and the 'Vacating Your Tenancy' booklet that was given to her at the inspection. We, however, upheld this complaint given that Ms C had not signed the report, and that none of the repairs or cleaning subsequently charged had been noted on the report. We found that she had not had sufficient notification of or opportunity to undertake the repairs.

We did not uphold Ms C's second complaint that the council had not undertaken work she had requested during her tenancy. There was no evidence available to show that Ms C had made such requests. We also found it reasonable that the council chose to undertake repairs prior to a new tenant moving in, in order to bring the property up to a reasonable standard for re-let.

We upheld Ms C's final complaint that the council failed to provide details about the two invoices issued. We found the information provided to be unclear and, on two occasions, erroneous. The council provided further information to us about what the remaining charges were for, and we relayed this information to Ms C.

Recommendations
We recommended that the council:
• provide a full apology to Ms C for charging the works to her without properly advising her of the repairs and cleaning to be undertaken at the property; and
• consider waiving the remaining outstanding charges for the work subsequently undertaken at the property.
 

Summary
Mr C had been a council tenant for three years. He complained that during his time as a tenant he had been subjected to anti-social behaviour and that the council had failed to take effective action. As result of the antisocial behaviour he was forced to give up his tenancy in 2011 and he complained that the council had failed to take appropriate action at that time to meet his housing needs.

Our investigation found that during 2009 there had been faults in the council's handling of the matter. However, from December 2009 Mr C had made no further complaints until August 2010 and we found the council to have followed its policy in relation to Mr C's complaints from that period. In view of the faults identified during 2009, however, we upheld the complaint. We found that, when Mr C was forced to leave his tenancy in 2011, the council followed their policy and we did not uphold the complaint that they had failed to meet his housing needs.

Recommendations
We recommended that the council:
• apologise to Mr C for the failings identified in relation to their handling of the matter in 2009; and
• clarify whether the introduction section of the Edindex application form requires information on neighbour disputes or harassment to be passed to the Community Safety Team. If the information is not to be passed to any other section, the council should ensure that the application form is clear about the use of the information provided.
 

Summary
Mr C's daughter attends a school within the authority of the council. She was experiencing bullying at school, which was having a serious emotional impact upon her. Mr C was concerned that this was affecting his daughter's health and progress at school. He complained that the school did not operate an anti-bullying policy, that it had failed to investigate his complaints about bullying appropriately, and that the council had not followed its complaints procedure when investigating his complaints.

We upheld the complaints in relation to the anti-bullying policy. The school had followed a council-wide policy prior to June 2011, but had not implemented a stand alone policy as recommended within the council-wide policy. We found that until then the school had not in fact had a clear policy about how reports of bullying would be dealt with, or what outcomes and resolutions were to be aimed for. As, however, the school had demonstrated they had introduced an anti-bullying policy in June 2011, we recommended that the council provide evidence that this policy had been implemented and promoted to all pupils and staff at the school.

We did not uphold the complaint in relation to the investigations of bullying. We found that overall the school had taken appropriate steps to investigate incidents, that there had been an appropriate level of enquiry into allegations about other pupils, and also in relation to allegations of harassment by some of the teachers at the school.

We did not uphold the complaint that the council failed to follow its complaints procedure. We found that, although Mr C did not receive a response within the stated timescale at Stage 2 of the procedure, the reason for this was acceptable, as a thorough investigation was being conducted which included the interviewing of all parties involved, and given the complex issues raised which dated back over more than a year. We also found Mr C received responses from appropriate people in the council at both Stages 2 and 3 of the complaints procedure.

Recommendation
We recommended that the council:
• provide evidence that the school's anti-bullying policy introduced in June 2011 has been implemented and promoted to pupils and staff there.
 

Summary
Ms C, an advice worker, complained on behalf of Mrs A, whose husband (Mr A) was admitted to hospital in November 2009 due to depression and suicidal feelings. While he was in hospital, Mrs A and her husband found the staff's attitude to be poor. They also felt that there was a lack of support around the time of his discharge home. Some ten months later, Mr A was diagnosed with a rectal tumour. Ms C complained that staff at the hospital did not carry out investigations when Mr A advised them of rectal bleeding and changed bowel habits during his admission.

We found that there was insufficient evidence to confirm whether Mr A raised these concerns with staff during his stay. We were concerned, however, with the arrangements for his discharge and follow-up treatment and found that additional support to carry out day-to-day tasks could have been provided during his stay.

Recommendation
We recommended that the board:
• review their handling of Mr A's discharge and take steps to ensure future compliance with the guidance in the Scottish Government's Best Practice Template - 'Admission, Transfer and Discharge Protocol for hospital patients in Scotland.'
 

Summary
Mrs C told us that she accompanied her daughter to the medical centre to see a doctor, as her daughter had suffered an allergic reaction to silicone. An incident occurred within the premises. Mrs C's daughter was subsequently removed from the practice list for inappropriate violence and abuse towards staff.

Differing accounts of what happened have been given by Mrs C and her daughter compared with those of the practice nurse and practice manager. Mrs C wrote to one of the doctors saying that her daughter had not been abusive towards staff and asked that she be allowed to re-register. After the medical centre cancelled a meeting to discuss Mrs C's concerns, she made a formal complaint to the board as she was concerned that the medical centre were not interested in resolving the issues she had raised. The board explained to Mrs C the complaints process for family health services and acted as an intermediary between her and the medical centre.

The complaint we investigated was about the way that staff treated Mrs C's daughter on the day she attended the practice, and the way in which the medical centre handled the complaint. We found that there was insufficient evidence to support the complaint that staff had mistreated her daughter. However, we established that the medical centre did not respond to the complaint in full in good time, and we concluded that there was evidence of poor complaints handling.

Recommendations
We recommended that the practice remind staff dealing with complaints to:
• respond to all the issues raised and ensure that the letter is clearly addressed, dated and contains relevant information on who has carried out the investigation and issued the letter; and
• respond within the time frame set out in the guidance document 'Making a Complaint about the NHS'.
 

Summary
Mrs C complained about the care and treatment that her late husband (Mr C) received from the board's out-of-hours service and in hospital. Mrs C said the response from the out-of-hours service was inappropriate, as the attendant arrived without batteries and sterile gloves and asked her to provide these. Mrs C also said she was refused an ambulance, and so took Mr C to hospital in her car. As there were no independent witnesses to the out-of-hours service's visit to Mrs C's home, we could not prove what took place. Therefore, in the absence of any direct objective evidence, we did not uphold this complaint.

Mrs C said the board failed to diagnose and treat her husband. We found from looking at the clinical records and after taking advice from one of our medical advisers that, although there were issues with a delayed gastroscopy and poor recording and communication about Mr C's' mobility, we could not conclude that the board failed to diagnose and treat him. We did not, therefore, uphold this complaint, although we made a recommendation related to it.

Mrs C said the board failed to record and/or pass on Mr C's wishes about resuscitation, and that Mr C was later resuscitated after a collapse. The board appeared to accept Mrs C's account that she was not given an indication that Mr C was ill enough for her to advise hospital staff of his wishes about resuscitation. However, when she felt his condition had deteriorated, she told a nurse, although the nurse did not record this or pass the information to medical staff. The board said there would be a review and confirmed to our office that nursing staff had been spoken to. As Mrs C's evidence was not disputed, we concluded that the board failed to record and/or pass on her husband's wishes about resuscitation and upheld this complaint.

Mrs C said the board provided poor general care. We found from looking at the clinical records and taking advice from one of our medical advisers that, while it was clear that the events of Mr C's final days were deeply upsetting for Mrs C and her family, we could not conclude that the board provided poor general care to Mr C. We did not uphold this complaint.

Mrs C said there was poor communication from staff to her and her husband. We found there had been failings in communication and we upheld this complaint.

Finally, Mrs C said the board failed to order a post mortem to confirm the cause of death. We found from looking at the evidence, and taking advice from one of our advisers, that medical staff were confident of Mr C's final diagnosis and, therefore, there was no need for a post mortem. Our adviser agreed with this, in terms of Crown Office and Procurator Fiscal Service guidance and the clinical records. However, our adviser's view was that it was inappropriate for medical staff to presume what Mr C's wishes regarding a post mortem might have been, and that it would have been reasonable for them to have offered Mrs C the option of a hospital post mortem. However, as there was no requirement for the board to order a post mortem to confirm the cause of death in this case, we did not uphold the complaint.

Recommendations
We recommended that the board:
• ensure that clinical records document a patient's mobility, and that such information is communicated to relatives/carers on discharge;
• review their threshold for initiating discussions with patients/carers about resuscitation, given the record of a 'guarded' prognosis in this case; and
• review their practice on when a hospital post mortem should be offered to relatives/carers.