Some upheld, recommendations

Summary

C complained about the council's handling of a planning application submitted by their neighbour. The planning application was for a number of alterations to C's neighbour's property. C objected to the application, as they had a number of concerns about the proposed alterations, including what they considered to be inaccurate plans and information submitted by the neighbour. Despite C's objections, the council approved the planning application.

C complained to the council about their handling and assessment of the application. They stated that there were inaccuracies within the Report of Handling and that the council had not addressed the points raised in C's objection appropriately. The council acknowledged that there were a number of failings in how they handled and assessed the planning application. However, they concluded that their decision on the application would have been the same had these failings not taken place.

In C's complaint to us, they explained that they were not satisfied with the council's response and that the council should have taken further action in response to the aspects of the complaint they upheld. C also had further concerns about the council's handling of the application and the assessment that led to their decision.

We took independent advice from a planning adviser. We found that the council's stage 2 complaint response provided a reasonable explanation for why the decision to approve the planning application was appropriate. Furthermore, the council's decision-making was in line with relevant guidance and legislation. Although C disagreed with the council's decision on the planning application, we were satisfied that this was a decision the council were entitled to reach. However, we did identify one failing in respect of the application validation process that was not addressed in the council's response. In light of this, and the failings already identified by the council, we upheld this complaint.

C also complained that the council had failed to take reasonable and appropriate action in relation to the drainage provisions that were part of the planning application. C said that there was a lack of detail in the planning application in relation to drainage and that the council had been unclear about whether this was a matter for the planning department or building standards. The council stated that the information contained within the planning application was sufficient to allow an appropriate assessment of the application. They also clarified that a development of this nature would not require a building warrant.

We found that the information provided in the council's complaint response was accurate. As such, we were satisfied that the nature of this development meant that more detailed information, plans or drawings were not necessary. We also accepted that building standards would not have a role in this matter should the development lead to unexpected water run-off. While acknowledging that the council's Report of Handling contained inaccurate information, we concluded that the council acted appropriately and did not fail to carry out any actions they were obliged to. Therefore, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Given the failings identified in both the council's stage 2 investigation and our investigation, consider whether it is expedient to revoke the planning permission granted for the application and require a new application to be submitted.

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

• Reflect on how this planning application was validated, handled and assessed. Consider whether there are any learning and improvement points that can be put in place.

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 a home visit to attend to their late spouse (A) concerning A’s PEG (a tube into the stomach to enable non-oral feeding) which was leaking. A family member of C had called the district nurses and was put in touch with an enteral feeding (a method of supplying nutrients directly into the gastrointestinal tract) nurse who agreed to visit the next day. The nurse advised C that the leak appeared to be due to constipation. C complained that the nursing care provided to A was unreasonable. The nurse also filed an Adult Support and Protection Referral (ASPR) with social work due to concerns about A’s safety. C complained that the ASPR was not appropriate.

We took independent advice from a community health nurse. We noted that the partnership's pathways and referral process indicated that unscheduled care from the community enteral feeding team should be provided within four hours (or an alternative care plan identified). We found that an urgent response was required in this case as A was bedbound and dependent on the PEG for providing all nutritional needs, including administration of medications essential for managing long-term conditions. Any malfunction of A’s feeding and medication regimes would result in detriment to their wellbeing. The visit to A should have been classed as ‘unscheduled care' and A should therefore have been seen within a four-hour time period in terms of the process. In relation to the overall nursing care, we were critical that there was no detailed documentation of the assessment and examination during the visit, and no treatment plan recorded (other than advising the family to contact the GP to arrange an x-ray). However, we noted that the nurse followed up with the GP, which was good practice. We also noted that a subsequent hospital scope indicated that the nurse’s diagnosis of constipation appeared reasonable. In view of the lack of detailed records or care plan, and the failure to comply with the partnership’s own timeframes for reviewing A, we considered that the care and treatment was unreasonable and we upheld this complaint.

In relation to C’s complaint that the ASPR was not appropriate, our role is not to decide whether the concerns raised in the ASPR were justified (that is, whether or not A was in fact at risk); rather, we had to consider whether the nurse’s decision to make the referral was reasonable, based on their knowledge of the situation and their concerns. We found that the nurses' concerns were appropriate and sufficient reason for making the referral. As such, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the poor record-keeping and for failing to meet their timeframes for unscheduled 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:

• Unscheduled care should be provided within the timeframes in the partnership’s policy, with clear records of the examination, findings and treatment plan.

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, an advocacy worker, complained to us on behalf of their client (B) about the care and treatment the board provided to B's spouse (A). During our investigation, we took independent advice from an adviser in respiratory and internal medicine.

In 2011, A's GP referred them to the board, after an x-ray showed irregularities in their lungs. For around two years, A was followed up at the respiratory medicine clinic with chest x-rays. Medical staff concluded the lung irregularities were unlikely to be cancerous and A was discharged. Around that time, A was diagnosed with rheumatoid arthritis (a long-term condition that causes pain, swelling and stiffness in the joints). In late 2017, A was diagnosed with small cell lung cancer at Ninewells Hospital that had already spread to their liver. A died shortly afterwards.

C complained that between 2011 and 2013, the board failed to diagnose A with lung cancer. We found A was given appropriate follow-up with chest x-rays and it was reasonable the lung irregularities were not considered to be cancerous. We did not uphold this complaint.

C complained that between 2013 and 2017, A was experiencing symptoms of lung cancer that were wrongly attributed to rheumatoid arthritis. We found that it was reasonable A was diagnosed with rheumatoid arthritis. We found A had not reported cancer related symptoms at their rheumatology reviews. We also found that as small cell lung cancer is very aggressive, the symptoms would usually develop over months and not years. We did not uphold this complaint.

C also complained that A's discharge letter from Ninewells Hospital was unreasonable, as it contained incorrect information about A's condition. The board acknowledged there was an error in the discharge letter. We found the discharge letter was unreasonable due to the error and we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the failings in the board's complaints handling. 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:

• Patients' discharge letters should contain accurate information about their condition and the outcome of investigations.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the Model Complaints Handling Procedure (MCHP). The MCHP and guidance can be found here: https://www.spso.org.uk/the-model-complaints-handling-procedures.

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

Ms C complained about the care and treatment she received from the board for her ongoing health problems. She said that the board initially failed to appropriately diagnose and treat her health condition and then failed to provide her with appropriate care and treatment for her condition. Ms C said she was advised by the board that she had multiple sclerosis (MS) and she never had any reason to doubt the diagnosis, until ten years later she discovered she had a condition which inhibited the absorption of vitamin B12, when she found that supplementing her diet with liquid vitamin B12 resulted in her experiencing improvements in many of her symptoms.

We took independent medical advice from a consultant neurologist (a specialist in the diagnosis and treatment of disorders of the nervous system). We found that Ms C’s initial diagnosis of probable MS was appropriate. The evidence suggested that the description given to Ms C of the level of certainty of her MS was reasonable and in line with the actual status of her diagnosis at that time. We found that vitamin B12 deficiency would not be expected to have presented with the pattern of relapsing–remitting disease in Ms C’s case. We considered that there was no indication to have administered vitamin B12 injections in the early stage of Ms C’s illness, as there was no evidence that her condition related to vitamin B12 deficiency. Therefore, we did not uphold this part of the complaint.

In terms of Ms C’s subsequent treatment, Ms C raised a number of issues, including that the board did not order a further spinal MRI to compare with the spinal MRI done at the time of her diagnosis. We found that the main purpose of MRI scans in a case such as this was to secure the diagnosis, rather than to monitor progress and there was, therefore, no clear indication to repeat the scans any more regularly than was actually done. We considered that the board provided Ms C with appropriate subsequent care and treatment and did not uphold this part of the complaint.

Ms C also complained that the board failed to respond to her complaint about her diagnosis and treatment appropriately. We found that the board’s responses to Ms C’s complaint failed to address all the issues raised; the responses were issued outwith the timelines set out in the NHS Model Complaints Handling Procedure; and the board failed to keep Ms C updated on the reason for the delays and give her revised timescales for completion. We, therefore, upheld this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to address all the issues raised in their responses to her complaint; for issuing the responses outwith the timelines set out in the NHS Model Complaints Handling Procedure and for failing to keep her updated on the reason for the delays and give her revised timescales for completion. 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’s responses to complaints should address all the issues raised, be issued within the timelines set out in the NHS Model Complaints Handling Procedure and keep the complainant updated on the reason for the delays and give revised timescales for completion.

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 attended A&E at Wishaw General Hospital complaining of chest tightness, sweating, nausea and palpitations (a noticeably rapid, strong, or irregular heartbeat due to agitation, exertion, or illness). C felt that their concerns were not fully listened to and concerns about side effects of medication were not taken into account.

We took independent advice from a consultant in emergency medicine. We found that the assessment C received was of a reasonable standard for a patient presenting with chest pain and appropriate investigations were carried out. We did not uphold this aspect of the complaint.

C also complained about the response they received to their complaints. We found that while some of the board's actions were reasonable (a resolution was sought; C spoke with the consultant about their concerns; C was offered to add their account to the medical record), overall the board's complaint handling was unreasonable. We found that the board had not responded to all of the points that C raised as complaints, and the board acknowledged this failing in a later complaint response. We also found that the board should have been clearer when advising C of which stage of the complaints process they were at and should have managed C's expectations about the next steps if a resolution could not be reached. Therefore, we upheld this aspect of the complaint.

C also complained about the board's application of their Unacceptable Actions Policy (UAP). We found that the board had acted in line with process. While they had warned C that they had a UAP and why they considered C's actions were unreasonable, they did not formally restrict C's contact with them through the UAP. We did not uphold this complaint.

Recommendations

In relation to complaints handling, we recommended:

• The board should ensure that complaints communications are clear.

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 care and treatment provided to them by the board when they presented with abdominal pain. C complained that they were repeatedly unnecessarily catheterised, their symptoms and clinical context were ignored, and they were misdiagnosed as having a bladder tumour instead of an ovarian tumour.

We took independent advice from a nurse, a radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans), a urologist (a doctor who specialises in the male and female urinary tract, and the male reproductive organs), and a sonographer (a healthcare professional who performs diagnostic medical sonography, or diagnostic ultrasound). We found that both nursing and urology care and treatment provided to C was reasonable. However, we found that an ultrasound scan incorrectly interpreted a mass as being a bladder tumour, when in fact the mass represented a large ovarian tumour. Though this was a misinterpretation of the scan, we found that given the clinical information available at the time, this misinterpretation was not unreasonable. We did not uphold this aspect of C’s complaint.

C also complained about the board's handling of their complaint. We found that there were significant complaint handling failings, including failure to advise C in a timely manner which aspect of the complaint they would investigate; failure to update C in a timely manner throughout the investigation; incorrect information being contained in the complaint response and no apology being given for this. We therefore upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable handling of their complaint. 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:

• Staff should be aware of the scope of a complaints investigation and the relevant standards and processes that apply. Staff should be able to appropriately obtain and evaluate the evidence obtained and use this to give reasons for decisions reached; and complaints should be handled in line with the model complaint handling procedure. SPSO have issued a guidance tool to support investigations staff. This can be accessed here: www.spso.org.uk/how-we-offer-support-and-guidance. The model complaints handling procedure and guidance can be found here: www.spso.org.uk/the-model-complaints-handling-procedures.

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

Mr C complained about the care and treatment provided to his partner (Miss A) at Aberdeen Maternity Hospital. Mr C said that when Miss A attended a pre-caesarean section assessment, the doctor failed to identify that she was in the early stages of labour. Mr C also complained that the board failed to explain why their baby required antibiotics and a breathing tube after they were born, and that the board's handling of his complaint was unreasonable.

The board acknowledged that the doctor assessing Miss A had failed to carry out a full assessment. The board noted that the reasons why their baby required antibiotics and a breathing tube had been explained to Mr C by hospital staff and later in email correspondence. The board also carried out a comprehensive review of their handling of the complaint and identified areas for learning and improvement.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in the female reproductive system, pregnancy and childbirth). We accepted the board's view that the doctor failed to carry out a full of assessment of Miss A's condition when she attended for the pre-caesarean section appointment and that their handling of the complaint was unreasonable. We upheld these complaints on that basis and made further recommendations for learning and improvement. We concluded that there was reasonable evidence it had been explained to Mr C why his baby required antibiotics and a breathing tube at the time of the event and later in email correspondence. Therefore, we did not uphold this aspect of the complaint.

Recommendations

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

• The board should have a guideline in place for the management of patients attending the pre-caesarean section clinic. This should include standard questions to ask all patients such as about presence of vaginal bleeding, fetal movements, as well as contractions and leaking fluid vaginally.
• The board should have guidelines in place about the turnover time for issuing letters following debrief meetings.
• The board should have in place template letters which can be used when inviting patients for debrief meetings that make the purpose of the meeting explicit.

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

Ms C complained about the care and treatment provided to her by the board in relation to rheumatology (the branch of medicine that deals with rheumatism, arthritis, and other disorders of the joints, muscles, and ligaments), radiology (medical discipline that uses medical imaging to diagnose and treat diseases), and respiratory (the branch of medicine that deals with conditions affecting the lungs) care and treatment.

We took independent advice from a rheumatologist, a radiologist, and a respiratory physician. We found generally that the care and treatment provided to Ms C was reasonable. However, we identified that there was a scan which had been reported inaccurately, and this was unreasonable in that it missed acute inflammation. Therefore, we upheld Ms C's complaint about radiology but did not uphold her complaints in relation to her rheumatology and respiratory care and treatment.

Ms C also complained about the board's handling of her complaint. We found that there was an inaccuracy in the complaint response and upheld her complaint on this basis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for her scan being reported inaccurately and the response to her complaint being inaccurate. 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:

• Scans should be reported to a reasonable standard.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate.

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 about the University of Dundee on behalf of their client (A). A was a disabled student at the university. The university terminated A's studies on the basis that A had not met the required academic standard. C made a number of complaints about how the university handled matters. C complained that the university did not provide A with reasonable adjustments during their studies.

We took independent advice from an equalities adviser. We found that the university had appropriate regard to their obligations in terms of the relevant equalities legislation and guidance and that they took reasonable action to address A's concerns regarding equipment issues. We did not uphold C's complaint regarding the reasonable adjustments provided to A.

C complained that the university did not provide A with a first and second supervisor and with supervision meetings. We noted that the university appeared to have done most of what was required of them regarding the provision of supervisors and supervision meetings. However, we found that:

for a four-month period, A did not have at least two supervisors

the supervisors did not record the substantive outcomes of all A's scheduled supervision meetings

not all the supervision meetings that took place were recorded on the university's system.

Given that these were requirements in the university's procedures, we upheld C's complaint about the supervision provided by the university.

C complained that the university unreasonable terminated A's studies and unreasonably time-barred A's academic appeal. We did not find any evidence of administrative or procedural failings regarding the university's actions. We noted that, in the particular circumstances, the university had the discretion to decide whether to terminate A's studies and whether to time-bar the appeal. We did not uphold these aspects of C's complaints.

C complained about the way the university communicated with A. We found that the university did not:

set out their position to A after a deadline had passed without submission

explain to A that a particular email would be treated as an extension request

explain to A why the position regarding the extension request changed from being refused to approved within a few days.

We upheld C's complaint that the university failed to communicate reasonably with A.

Lastly, C complained about the way that the university had handled A's complaint. We found that the university did not give appropriate consideration to whether the outcome A said they were seeking should have been dealt with under the appropriate appeals procedures, rather than under the complaints handling procedure. We, therefore, upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the university's communication with them regarding the extension and for not giving further consideration to whether the outcome A said they were seeking should have been dealt with under the appropriate appeals procedures, rather than under the complaints handling procedure. 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:

• Communication with students regarding extensions should be clear, particularly where the position regarding an extension request changes.
• Procedures regarding the supervision of students should be followed.

In relation to complaints handling, we recommended:

• Consideration should be given to the outcome a complainant is seeking and whether that outcome would be more appropriately explored through the appeals procedures or other appropriate mechanism.

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 social work service provided to their family by the council. A social worker first had contact with the family after the police charged C's child (A) with an offence. Social work, as part of a multi-agency group, contributed to risk management plans. Under these plans, A's contact with peers and access to school and extracurricular activities was limited.

C complained that the risk plans were too restrictive and disproportionately impacted on A's educational attainment, wellbeing and social relationships. The council did not uphold C's complaint. We took independent advice from a social work adviser. We found that the social work service acted reasonably in the course of making and managing the restrictions. We found evidence of reasonable support and engagement with the family and social workers being responsive to the concerns, including reducing the restrictions when it was considered appropriate. We did not uphold this aspect of C's complaint.

C also raised concern that the service inappropriately shared confidential information about A with a health professional. We were not critical of the council's rationale for sharing the information. However, having reviewed the relevant guidance on information sharing, we considered that, before sharing the information, the council should have informed A's family of the intention to share information and provided reasons for this. We also found that the council's record-keeping of the information disclosure was insufficiently detailed. We upheld the complaint and made recommendations.

Finally, C was unhappy with the way the council handled their complaint. In particular, C raised concern that there was an unreasonable delay in responding and a conflict of interest given the involvement of a manager in the investigation. We found that the council took reasonable steps to extend the timescale to 40 working days, although it appeared they then missed the revised timescale by a small number of days. We did not find failings in relation to the investigation performed. On balance, we concluded that the council handled the complaint appropriately. We did not uphold the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to inform them about the intention to share the information or the reason for this; and failing to fully document the information disclosure. 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:

• Information sharing should be conducted in line with the relevant legislation and guidance. Where information is shared, an appropriate record of this should be maintained.

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.