Some upheld, recommendations

Summary

C complained to us on behalf of their late relative (A) regarding treatment A received from the board leading up to their death. C said that the board had failed to provide reasonable nutritional care and treatment after A was admitted to the Royal Infirmary of Edinburgh suffering from complications due to poor nutritional intake. They considered that the board had unreasonably delayed in diagnosing the likely cause of this nutritional deficit. C also said that the board had failed to reasonably communicate with A and their family, as they were only informed of the likelihood that A would die with around 48 hours' notice, previously believing A was due to be discharged.

We took independent advice from an appropriately qualified adviser. We found that the board had provided reasonable nutritional care and treatment, with no delay in diagnosis. We therefore did not uphold those aspects of the complaint.

However, we also found that the board had failed to appropriately assess A's likely prognosis and communicate this to them or to their family. As such, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A's family for failing to reasonably identify and communicate their prognosis. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The board should carry out reasonable and realistic assessments of a patient's prognosis, clearly communicate those assessments to the patient and, where appropriate, to their family, and make a record of these discussions.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C, a support and advocacy worker, complained on behalf of their client (B) about the care and treatment their child (A) received in the early months of their life. A was born prematurely, suffered a number of medical problems following their birth and died a few years later. A was initially cared for in Aberdeen Maternity Hospital's neonatal unit. A was transferred for treatment in the High Dependency Unit (HDU) at Royal Aberdeen Children's Hospital. C asked us to investigate the standard of care and treatment that A received at Royal Aberdeen Children's Hospital. B said that A suffered a number of desaturation episodes which caused A to turn blue. They attributed this to staff being slow to react. A's feeds were increased upon admission to Royal Aberdeen Children's Hospital. B said that A's health began to deteriorate from this point. B said that A should have remained in Aberdeen Maternity Hospital's neonatal unit given A's weight at five months was still below that of many neonates, or else transferred to another neonatal unit elsewhere in Scotland. They complained that, whilst A was in Royal Aberdeen Children's Hospital, the level of supervision was insufficient, particularly over weekends.

We took independent advice from a consultant paediatrician and a paediatric nurse. We found that, while A's condition was complex, there was nothing to suggest that moving A to the HDU at Royal Aberdeen Children's Hospital resulted in a drop in the level of care and support available. We also found that the overall approach to managing and monitoring A's weight was reasonable. We did not uphold these aspects of C's complaint.

In relation to nursing supervision, we found that nursing staff reasonably monitored A throughout their time in the HDU, maintaining detailed and thorough records and appropriately escalating any issues identified to the medical team. We did not uphold this aspect of C's complaint.

In relation to medical supervision, while the nursing staff appropriately monitored A's condition and escalated A's management to medical colleagues when changes were observed, we found that these were not acted upon within a reasonable time in every case. On one occasion no medical staff attended for four hours following escalation by nursing staff. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's parents for the unreasonable delay in fulfilling a request for a medical review of A.The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The board should have a system in place to alert a more senior member of the medical team to attend when requests for medical reviews cannot be fulfilled by the relevant medical staff within a reasonable timescale.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained the Scottish Government had repeatedly failed to provide them with accurate information about agricultural grants that they were entitled to apply for. C said they had repeatedly visited the local office without receiving accurate information. C had complained about their experience but they had not received a response for a year. C said the Scottish Government response would not have been issued had they not repeatedly chased it up.

We found that there was very little evidence of the Scottish Government's complaint investigation. It was a matter of fact that C was responsible as the business owner for confirming that they had applied for all the entitlements they were eligible for. There was no evidence C had done this. In addition, for some of the years, C said they were poorly advised, the application had to be completed online, and C could not have been assisted with a paper application. We found the Scottish Government were not responsible for ensuring C applied for the correct entitlements. Therefore, we did not uphold this aspect of C's complaint.

The Scottish Government's response to C's complaint had, however, fallen below a reasonable standard. Appropriate records had not been kept and there was no evidence the Scottish Government had followed their complaint handling procedure. We upheld this complaint, and asked the Scottish Government to continue to provide evidence they were monitoring their complaints effectively and were able to identify delays. The Scottish Government were able to provide evidence showing the steps they had subsequently taken to improve their complaint handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to investigate their complaint in line with the Scottish Government's procedures. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Accurate and comprehensive records of complaints investigations need to be kept.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of themselves and their neighbours. The council planned to redevelop the site of a former school, which is situated behind their properties. C raised a number of questions, concerns and objections on behalf of the local residents regarding plans for the site, maintenance of the area and the council's management of works being carried out on the site. Despite regular email and phone contact with the council, C complained that residents were not kept informed about work planned on the site or how their concerns would be addressed. C was also dissatisfied with the way their complaints about the situation were handled.

We found that the council generally recognised the impact the development had on the residents and took steps to address the issues that they raised. Whilst internally, they acted reasonably with regard to management and maintenance of the site and could show the reasoning as to why certain decisions had been reached, we found that the council's communication with C was poor. On a number of occasions, C would ask specific questions about aspects of the development, but would receive very general responses. This led to confusion and mistrust on the residents' part. While we found the council's communication to be poor, we considered that the council reasonably managed, maintained and repaired the site. We did not uphold this aspect of C's complaint.

In relation to complaint handling, we were critical of the council's handling of C's complaint. Whilst they responded to C's various calls and emails in good time, we again found that specific points raised by C were not addressed directly. We also found that, although C had direct access to a number of key members of staff, this meant that C's concerns were not escalated through a formal complaints process and largely went unresolved as a result. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified in the council's handling of the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The council should contact C to check whether there are any outstanding concerns that have not already been responded to and that these are agreed in writing and responded to in full.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about how the council handled and assessed a planning application. The planning application related to a proposal for an extension to an existing business premises and was approved by the council. C's own business premises are located nearby and C raised concerns about how the extension would impact their business and the local area more generally. In response to C's complaint, the council acknowledged there were some failings in how the application was assessed and omissions in the Report of Handling. However, they concluded the application would have still been approved even if there were no failings in how it was assessed.

C complained that they did not think the council took appropriate action in response to the acknowledged failings and considered there to be other failings that the council did not identify in their stage 2 response. In addition to this, C complained about the council's sale of the land that the proposed extension is to be built on. In C's view, the sale of the land was not appropriately carried out by the council.

In respect of the first aspect of C's complaint, we took advice from an independent adviser with a background in planning. The advice we received, and accepted, was that there were further shortcomings in the assessment of the application and the content of the Report of Handling that were not identified by the council. While a number of C's outstanding concerns related to disagreements with the council's decision, we considered there to be examples of the council either failing to appropriately consider certain matters or not recording them in sufficient detail in the Report of Handling. As such, we upheld this complaint.

In respect of the second complaint, C was of the view that the land sold was classed as common good land and should not have been subject to sale. They also considered the council's sale of the land not to be in line with the European Commission's state aid rules. We concluded that the evidence did not support either of these conclusions and, therefore, did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to consider certain matters appropriately in their assessment of the planning application and for the fact that the Report of Handling did not contain sufficient detail about parts of their decision-making. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Given the failings identified in both the council and our investigations, comment on their view remains that there are no grounds or good planning reasons to revoke the planning permission. Provide justification for the decision reached to both C and this office.

What we said should change to put things right in future:

• Planning applications should be assessed thoroughly and in line with relevant guidelines. Reports of Handling should be appropriately detailed and contain clear justifications for the conclusions reached.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the way that the council had dealt with their reports of noise in their home, and the way in which the council had handled their complaint about this.

The council had previously accepted numerous failings in connection with the issues raised by C. The council acknowledged failures with respect to communication and confirmed they would carry out further investigations and undertake works to address the soundproofing in the property, particularly relating to the transference of noise from a lower level flat.

After a period of a few months, C made a further complaint to the council about failures to take appropriate action and keep C updated with respect to efforts to proceed with soundproofing. C was dissatisfied with the council's response and brought their complaint to our office.

We found that the council took reasonable actions with respect to identifying an appropriate action plan, in installing acoustic underlay, as a first step in attempting to address the noise issues. However, restrictions in response to the COVID-19 pandemic, which were outwith the council's control, resulted in delays in the council being able to carry out the proposed works. For these reasons, we did not uphold the complaint regarding delay.

However, we found that the council unreasonably failed to communicate with C throughout the lockdown period during 2020 and therefore failed to keep C appropriately updated as to the plans in place to undertake the works. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to communicate effectively regarding the plans to progress agreed works. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The council should communicate with C regularly to agree the purpose and scope of any additional survey, and/or agree works to be undertaken (at present installation of acoustic underlay), and arrange to complete the work agreed as soon as reasonably practicable, once Scottish Government restrictions in response to Coronavirus allow. The council should communicate with C to agree and arrange appropriate monitoring to robustly test the effectiveness of the acoustic underlay and/or any other works carried out. Should monitoring reveal that the works have not resolved the noise issues, the council should communicate with C to agree further steps, including consideration of those set out in their complaints responses, to address the noise issues at the property.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the actions of their housing association. C had moved from one association property to another nearby. Some months after the move, C was presented with a bill for repairs. C disputed both the need for the repairs and the cost which they considered excessive. C also said they had been overcharged rent, by four days, without adequate explanation and that their complaint had been mishandled by the association.

We found the damage had been recorded by the association following a void inspection. While it was not the SPSO's role to assess the extent of the damage, the inspection had been carried out in line with the association's procedures, and they were able to provide evidence showing the damage had been recorded immediately after the vacation of the property, in line with its published procedures. We did not uphold this aspect of C's complaint.

C noted the association had agreed to collect the keys from them, but had failed to do so. This had resulted in a four-day delay but C had not been notified this would result in additional rent charges. C noted they had moved out of the property on the day agreed and the only available paperwork supported their positions. The association accepted that they had agreed to collect the keys from C and that they could not provide evidence to show what had been agreed in this respect. They would, therefore, adjust the rent account by the days in dispute. We upheld this aspect of C's complaint.

We found the handling of C's complaint was inadequate. The association had not agreed the complaint with C or discussed it with them. As a result their response had not addressed all the issues C had raised nor obtained all relevant evidence from them. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to follow their procedures, the delay in informing them of the void inspection's findings and for failing to follow their complaints procedure properly. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets
• Confirm to C in writing when their rent account has been adjusted.

In relation to complaints handling, we recommended:

• Staff dealing with complaints should be familiar with the Model Complaints Handling Procedure, understanding the importance of communication and the need to demonstrate thorough investigation of the points raised.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C was previously resident in England and received a package of care from the local authority to assist them with activities they are unable to do due to poor mobility and mental health needs. C chose to move to Scotland and asked their social worker to contact Fife Health and Social Care Partnership (the partnership) so their care could continue.

After moving to Scotland, C was aware that two adult protection referrals (referrals made to social work services about an adult at risk from harm) about C were made to the partnership.

The partnership assessed C and determined that they did not meet the criteria to receive a package of care. C complained that the partnership failed to support them with their move and failed in their duty to ensure continuity of care. C also complained that the partnership did not investigate or act on the adult protection referrals appropriately. C was unhappy with the way in which their complaint was handled and with the communication they received from the partnership.

As a result of their complaint investigation, the partnership found that they had failed to follow their usual process and that the correspondence from C's social worker was not responded to as it should have been. They apologised for this and upheld C's complaint. They also highlighted that it may have been helpful to connect C with non-statutory support. The partnership told us they offered to connect C with non-statutory support as a part of their complaint investigation, but that this was refused by C. They apologised that C felt the way they communicated with them about their complaint was not appropriate.

The partnership said they gave C appropriate advice before C moved, and they assessed C (including the adult protection referrals) appropriately when they were resident in Scotland.

We found the partnership's failure to follow their usual process was unreasonable and that the partnership failed to reasonably support C prior to their move to Scotland. On this basis, we upheld this aspect of the complaint.

We considered that the partnership's assessment of C's needs was reasonable and in line with the relevant guidelines and legislation applicable to Scotland. On this basis, we did not uphold this aspect of the complaint.

We found the partnership did not keep any record of their discussion with C. In this circumstance, we would expect that the partnership keep an accurate record of what happened. We found that there was maladministration on the part of the partnership when handling C's complaint. On this basis, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to appropriately handle C's complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• When a potential resolution is identified during a complaint investigation and set out in the final response, this should be followed up and a record kept of the action taken.

In relation to complaints handling, we recommended:

• The partnership should ensure that complaints are handled in line with the Model Complaints Handling Procedure and that they keep a clear record of any discussion with the complainant and a record of any actions taken as a result of the complaint.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the treatment provided to their spouse (A) by the board. A underwent knee replacement surgery. After the surgery, A's health declined and A died approximately five months later. C raised a number of issues relating to the surgery itself as well as the care and treatment provided afterward.

We took independent advice about this complaint.

We considered C's complaint on how the board failed to carry out the surgery in a reasonable manner. We found the board carried out the surgery in a reasonable manner, based on the experience of the surgeon, operation note and postoperative x-rays. As such, we did not uphold the complaint.

We considered C's complaint that the board failed to provide reasonable nursing care after A's surgery. We found that while some elements of nursing care were reasonable, the main type of care provided by the board; wound care, was unreasonable. We found four key points which were unreasonable and that these could have been addressed if a referral had been made to the tissue viability service once it was clear that the wound was deteriorating. This referral was not made. Therefore, we upheld this complaint.

C also complained that the board failed to provide reasonable treatment to A after the surgery. We found that there was a delay in the provision of A receiving antibiotics and, while this was not best practice, it was not unreasonable. We found that the actions in response to A's deterioration, including transfusions, surgery and medication, were reasonable and A's condition was reasonably monitored. Therefore, we did not uphold the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide reasonable wound care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Allergies should be consistently recorded in patient's medical records.
• Appropriate wound assessments should be carried out for patients.
• Dressings should be removed immediately if it is known the patient is allergic to them.
• Where appropriate, referrals should be made to a tissue viability nurse specialist.
• Wounds should be treated with appropriate wound care products based on the wound assessment.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C held power of attorney for their parent (A) and complained about the management of A's medication during a hospital admission for treatment of a chest infection. A's medication Furosemide and Ramipril (both used to treat heart failure) were stopped for eight days. A was readmitted to hospital again having suffered a heart attack and died.

The board acknowledged it was not recorded who stopped A's medication and why they did so, and that there were failings in how A's medication was reviewed and managed prior to discharge.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly). After review of relevant medical records and statements, we found that while it may have been reasonable to stop A's medication at the time, there was a failure to record who made the decision and their rationale for the decision.

We also found the board did not give adequate consideration as to whether the cessation of A's medication may have had an impact on A's readmission, further heart problems and subsequent death.

We also found that A's discharge letter was not appropriately updated prior to discharge. We upheld three of C's complaints, however we concluded that the board's communication with C about the changes to A's medication was not unreasonable in the circumstances and this complaint was not upheld.

Recommendations

What we said should change to put things right in future:

• Individual staff, particularly the consultant responsible for A's care, should show they have included this complaint in their annual appraisal as part of reflective practice.
• That it has been considered whether the failures relating to the management of A's medication had an impact on A's need for readmission and ultimate death.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.