Some upheld, recommendations

Summary

Mr and Mrs C complained that the council failed to act appropriately, impartially or in line with their obligations when carrying out enforcement action against them.

We took independent advice from a planning adviser. We found that the council took appropriate action at specific points in the course of the enforcement process and had acted impartially. However, we found that the enforcement process took an unreasonable length of time to reach a conclusion and that the council could have carried out a more thorough assessment of the situation at an earlier stage. Therefore, we upheld this complaint.

Mr and Mrs C also complained that the council had handled information provided by a third party inappropriately and placed an unreasonable amount of weight on it. We concluded that the evidence did not support Mr and Mrs C's view that the council considered information provided by a third party in an inappropriate or unreasonable manner. Therefore, we did not uphold this complaint.

Finally, Mr and Mrs C complained that the council had failed to provide a reasonable level of communication with them during the enforcement process. This includes failing to meet with them despite their requests. We found evidence of good communication at certain points during the enforcement process. However, there was also clear evidence of several of Mr and Mrs C's requests to meet not being acknowledged or followed up by the council. This directly contradicted the council's position that there had been no requests to meet made by Mr and Mrs C or their agent. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for the failings that contributed to delays during the planning enforcement process and for not providing a reasonable level of communication at certain points, including failing to meet with Mr and Mrs C despite their requests. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Mr and Mrs C have requested that the council reimburse them for the Planning Consultant fees incurred in respect of the period after they consider the enforcement notice to have been complied with. They have advised of the price and they can provide a copy of the invoice. The council should consider whether it is reasonable and appropriate to reimburse Mr and Mrs C for these costs. This is a decision for the council to make and they should advise Mr and Mrs C of the outcome.

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

• Enforcement action should be carried out in an efficient and timely manner, allowing for individual circumstances on a case-by-case basis. Accurate assessments of the situation should be carried out at an early stage, allowing for individual circumstances on a case-by-case basis.
• Correspondence relating to planning enforcement matters should be responded to within a reasonable timescale. If a meeting is requested, this should either be arranged or an explanation provided for why on is not necessary or appropriate.

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 a tenant of the council and requested repairs after reporting issues with damp, leaks and the boiler. When C ended the tenancy they were charged for leaving items in the property. C complained that the council's responses to C's requests for repairs, for recharging them when they left the property and how they communicated were unreasonable.

C reported 90 repairs or faults over a tenancy of many years. With the exception of two occasions, the council responded within timescales as laid out in their repairs policy. Sometimes the fault required multiple attendances (due to access requirements or parts required) and led to the completion time taking longer but the initial response was within the target timeframe. We found that the council's response to C's requests for repairs were reasonable. We did not uphold this aspect of the complaint.

The council responded to C's complaints sometimes verbally, in writing or both. It was good practice to seek practical resolutions to complaints and the council made attempts to do this with bringing forward inspections and arranging tradespeople to attend C's property. We found that not all of the points C raised were responded to when they were first raised as a complaint, requiring C to raise the same point on multiple occasions and in some instances (such as the complaints about communication and previous faulty repairs) not being responded to at all. This was unreasonable.

After the council received C's complaints they responded at the frontline resolution stage five times. The council did not advise C on how they could escalate their complaint as part of these responses after it was clear that C remained dissatisfied. It was unreasonable that the council failed to advise them of how to escalate the complaint. Therefore, we upheld this aspect of the complaint.

Lastly, the council were clear in the information which they provided to C in the tenancy agreement and terminations, that there was a requirement that C remove all belongings from the property after their tenancy ended. Not doing so would result in C being charged by the council for the removal costs. The council followed their process and their actions were reasonable. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to respond to all of the complaints they raised. 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 council should advise complainants how to escalate their complaint if they remain dissatisfied.
• The council should respond to all points of complaint raised by a complainant.

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 and Mrs C complained about the actions taken by the council following their child's (Child A) disclosure that they had been inappropriately touched by another pupil. Mr and Mrs C complained that the council's education service had not reasonably followed their own procedures to safeguard their child.

We found that the education service had acted in accordance with their policy and guidance by discussing the matter with Child A and making a referral to social work. In the circumstances, we found that the steps taken by the school to safeguard Child A were a discretionary matter for the council's education service to determine and we were satisfied that the matter was appropriately considered and a number of measures were put in place. We did not consider that there was an obligation for the council to exclude the other child involved from school. In light of this, we did not uphold Mr and Mrs C's complaint about the council's education service.

Mr and Mrs C also complained that the council's social work service failed to provide them with reasonable support. We took independent advice from a social worker. We found that reasonable action had been taken by social work, including an assessment of the situation and contact with the school, the police and the families involved. We did not uphold Mr and Mrs C's complaint regarding the action taken by social work.

Lastly, Mr and Mrs C complained about how the council had handled their complaints. We found that there was a delay in responding to the complaint made on their behalf by an MSP and that they were not kept updated on the progress of their complaint or provided with a revised timescale for the response. We also found that the council's responses did not address all the concerns Mr and Mrs C raised. Therefore, we upheld this aspect of Mr and Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for the delay in responding to the complaint made on their behalf by an MSP and that they were not kept updated on the progress of their complaint or provided with a revised timescale for the response. The council should also apologise for their responses not addressing all the concerns raised. 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:

• 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/how-to-handle-complaints.

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, an advocacy worker, complained on behalf of his clients (Mr and Mrs A). Due to long-standing conditions, Mrs A was deemed to require personal care and had received self-directed support payments in order to employ a personal assistant (PA). Mr A also had personal care needs and the couple identified a PA who would be able to provide the required care for them both.

Mr and Mrs A, along with Mr C, met with a social worker to discuss how to get the necessary care in place. Mr C stated that the social worker told Mr A that he would be financially assessed and it was likely that he would have to make little or no contribution towards his care. In addition to this, Mr C stated that Mrs A was told that Mr A's assessment and support would not affect her.

After this meeting, Mr and Mrs A started using the services of the PA whilst the council's financial assessment process was ongoing. Later, the council sent Mr and Mrs A separate letters advising that they had to make a financial contribution of £49.98 per week each towards their respective care. In addition to this, the council advised Mr and Mrs A that they had incurred a debt of around £2000 for the care already provided.

Mr C complained about the council's financial assessment process and the information that was provided to Mr and Mrs A. In his view, the council did not provide Mr and Mrs A with appropriate information, and this contributed to them incurring a significant and unexpected debt.

We took independent advice from social worker. We concluded that the financial assessments had been carried out appropriately and in line with the relevant guidance at the time. Therefore, we did not uphold this aspect of the complaint.

In respect of the information provided to Mr and Mrs A, we concluded that the council did not provide appropriate information about how they would be jointly financially assessed. When reviewing the evidence, we placed particular weight on the social worker's statement which was contained in the council's investigation report. In their statement, the social worker confirmed that they were not aware Mr and Mrs A would be financially assessed as a couple. This meant that they did not have accurate information in order to make an informed decision about the care they received. In addition to this, we took the view that the council's standard documentation could have detailed how people would be financially assessed in a clearer fashion. In light of this, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs A for failing to provide accurate and appropriate information about how Mr and Mrs A would be financially assessed in respect of their personal care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• In light of the failings identified, the council should revisit their decision not to waive (either in full or in part) Mr and Mrs A's debt. The council should provide an explanation and rationale for their decision to both the SPSO and to Mr and Mrs A.

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

• Relevant social work staff should be fully aware of the council's Non-Residential Community Care Charging Policy and Procedure.
• Standard paperwork included in the Non-Residential Community Care financial assessment should clearly detail the process and potential charges involved.

In relation to complaints handling, we recommended:

• If a failing is identified as part of a complaint investigation, this should be acknowledged and addressed in the stage two response.

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 that the council failed to take appropriate action in response to reports of bullying of their children (Child A and Child B) at primary school. C said that the reports of bullying were not investigated appropriately and the council denied that many of them occurred.

We considered both C's and the council's records of events, the school incident book, copies of emails between C and the council, and the school's anti-bullying policies. Whilst we recognised that the case was one that had been difficult for all involved, we found that the council had not always appropriately logged incidents in the incident book in line with their policy. We also found that on some occasions, though the school investigated incidents, they did not communicate with C regarding the investigations. Finally, we found that there appeared to have been several reports of incidents where there was no evidence they were investigated. On this basis, we were unable to conclude that the council had taken action in line with their anti-bullying policy and we upheld this aspect of the complaint.

C also complained about the council's communication during the complaint process. Having reviewed the correspondence, we found that the council corresponded appropriately with C, and handled the complaints in line with the complaints process. We did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C, and Child A and B, for the failure to appropriately investigate and record allegations and incidents of bullying. 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:

• Allegations and incidents of bullying should be investigated and recorded in line with council policies.

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 is the parent of a teenaged adult (A). A was admitted to an acute admissions ward of a mental health unit as an informal patient. The following day, A contacted C from the ward. A told C that they were in possession of razor blades and intended to self-harm. C contacted the ward to advise them of this and ward staff obtained the razor blades from A. A day later, A contacted C and told C they had left the hospital. C contacted the ward and the police, and A was returned to the ward. A was transferred to another location shortly afterwards. C complained that A had not been properly searched or reasonably assessed on their first arrival at the ward. The board told C that the routine risk assessment at admission had shown no indication A was at risk of absconding, and that this had led to the decision not to lock the ward door. They also said that a check of A's belongings when they were admitted had led to razor blades being taken from A's possession. C was dissatisfied with the board's response and brought their complaint to us.

We took independent advice from a mental health nurse. We found that A had not been properly searched upon their arrival, that it was unreasonable that the board had not carried out a medical, nursing or joint assessment on the day of A's admission and that the standard of assessment and care-planning at the point of admission fell significantly below professional expectations. We upheld C's complaint.

C also complained that the board unreasonably failed to call C, as they had promised, following C reporting A was in possession of razor blades and intended to self-harm. We found that the available written evidence and staff recollection did not support C's recollection that they had been promised someone would call them back. Therefore, we did not uphold C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A that they were not properly searched or reasonably assessed upon their arrival at the ward. The apology should meet the standards set out inthe SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

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

• Medical/nursing assessments should be carried out and clearly documented as part of the admission process, and each patient has a documented initial care plan based upon the information gathered during the admission assessment process.
• The belongings of patients assessed as being at imminent risk of harm to self or others are checked for the presence of harmful objects or substances.

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 sustained a serious pelvic injury with internal bleeding following a road traffic accident and was admitted to Ninewells Hospital where he underwent surgery to repair the internal bleed and his fractured pelvis. Mr C suffered a further internal bleed and complained that there was a delay in identifying this bleed. Mr C also complained that the physiotherapy input he received following his surgery was unreasonable and may have caused his fracture to move; and that he was provided with inappropriate pain relief and his respiratory rate was not monitored properly.

The board considered that Mr C was monitored appropriately and that any delay in identifying the internal bleed was due to the fact that the CT scan was occupied by another patient. The board also considered that the physiotherapy input and pain relief provided were reasonable.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system), a physiotherapist and a general physician . We found that Mr C was appropriately reviewed and monitored and that there was no unreasonable delay in identifying the internal bleed. We also considered that the pain relief provided was appropriate and Mr C's respiratory rate remained stable. We did not uphold these complaints. However, with regards to the physiotherapy input, we found the standard of record-keeping to be poor and there was a failure to establish a treatment plan with agreed goals. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to obtain all relevant information about him prior to beginning treatment and failing to establish a treatment plan with agreed goals. 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:

• Physiotherapy records should meet the minimum documentation standards and the quality of records should be audited regularly.
• The physiotherapist should reflect on their handling of this case and discuss their learning from it in a supportive manner with their line manager.

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 that the Scottish Ambulance Service (SAS) failed to respond reasonably to the request for an emergency ambulance service for their child (A). C expressed concern about the overall time taken for A to be taken to hospital; which was approximately two hours from the original call being made requesting an emergency ambulance, to A arriving at hospital and being reviewed by a doctor. C also complained about how SAS responded to their complaint about that matter.

SAS upheld C's complaint on the basis of a longer wait than would have been expected for this category of call and offered an apology for that wait. They explained that this was a very busy time for the service but confirmed that a call audit had concluded that the call was handled very well and was of high compliance with their dispatch system.

We took independent advice from a paramedic. We found that there were concerns with SAS's response for an emergency ambulance, including:

The delay in elevating the response level which relied on the subjective opinion of a non-clinical call handler.

The lack of clinical advisor input into the call which could have negated the limitations of the system and possibly changed the level of acuity, and as such the response time and time taken for A to reach hospital.

The decision of the original ambulance crew to wait on the second responding crew to transport A.

Therefore, we upheld the complaint that SAS failed to respond reasonably to the request for an emergency ambulance to attend to A.

In relation to complaint handling, we found that SAS's response to C's complaint was appropriate. We also noted that their apology was in line with SPSO guidance. Therefore, we considered that SAS reasonably responded to C's complaint and we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to respond reasonably to the request for an emergency ambulance to attend to 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:

• Clinical advisors should be able to assess a patient's condition in line with current guidance - which provides that a clinical advisor's first point of contact should be at 45 minutes from the time of call within the yellow patient cohort. If a decision is made for this not to happen, the reasons for that decision should be clearly recorded.
• Patients should be transported by ambulance using the appropriate harness.

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 at the Royal Infirmary of Edinburgh. Ms C complained that she was unreasonably prescribed a drug, uniphyllin, in order to treat her asthma.

We took independent advice from a consultant in respiratory and general internal medicine. We found that it was reasonable to prescribe uniphyllin for Ms C's asthma and long-term breathing difficulties. Therefore, we did not uphold this aspect of the complaint.

Ms C experienced a tonic-clonic seizure (type of seizure that involves both stiffening and twitching or jerking of a person's muscles) whilst taking the drug and said that she was not advised that this was a possible side effect. We considered that it would have been reasonable for Ms C to have been provided with information so that she could be involved in decisions made about her care and the possible side effects of medication. We upheld this aspect of Ms C's complaint.

Ms C also complained that she was given an increased dose of the drug without the effect of this being monitored. We found that the symptoms Ms C was experiencing were not necessarily a sign that the dose she was given was too high. An increase was also reasonable for maximum therapeutic effect. We did not uphold this aspect of Ms C's complaint.

Finally, Ms C complained that there was an unreasonable delay in advising her to stop taking the drug after she had a seizure. We considered that it would have been reasonable for Ms C to have been advised in A&E to stop taking the drug when she was admitted after her seizure. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to advise her of the possible side effects of the drug and for failing to advise her when she attended A&E with a seizure that she should stop taking the drug because she was at risk of further seizures. 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:

• To ensure General Medical Council good practice is followed when considering treatments to ensure patients are aware of significant side effects.

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 has autistic spectrum disorder (a developmental disability that affects how a person communicates with, and relates to, other people). After attending an advice clinic, Mr C was assessed by a psychologist. He was then referred to a community mental health service to see if they could help him with social skills and managing anxiety. The community mental health service did not consider they could meet Mr C's specific needs; and they explained that he might be able to access support from a charity instead.

Mr C complained that after his psychology assessment, he was not referred for care and treatment suitable to his needs. We took independent advice from a psychologist. We found that Mr C was appropriately assessed and referred for help with social skills. We found that the community mental health service gave the referral careful consideration. We also found it was reasonable that they refused it, as the charity was better equipped to meet Mr C's needs. We did not uphold this aspect of the complaint.

Mr C also complained that the board failed to handle his complaint in a reasonable manner. We found that the board did not communicate clearly with Mr C about his complaint, in particular in relation to the scope of their investigation. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to handle his complaint in a reasonable manner. 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:

• The board should communicate with complainants in a way that is clear and easy to understand.

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.