Some upheld, recommendations

Summary

Miss C complained about the care and treatment the board provided to her late father (Mr A). Her concerns related to the board's out-of-hours service and care provided at Dumfries and Galloway Royal Infirmary.

Mr A had been unwell and the board's out-of-hours service was contacted. Mr A was subsequently admitted to hospital with signs of infection but later discharged himself. He was then readmitted after it had been identified that he had staph aureus bacteraemia (SAB, an infection). Subsequently, Mr A suffered a gastrointestinal bleed (bleeding on the digestive tract, and a symptom of a disorder), and developed kidney failure. Mr A then also developed severe heart failure. He was discharged for palliative care and died shortly thereafter.

We took independent advice from a GP, a consultant in acute medicine and a nurse. In relation to the treatment provided by the board's out-of-hours service, we found that it was reasonable that a GP did not visit Mr A at home, based on the situation and what was known at the time. We did not uphold this complaint.

In relation to Mr A's admissions to Dumfries and Galloway Royal Infirmary, we found that during Mr A's first admission staff had provided reasonable reviews, tests and treatment for Mr A, and the level of clinical care and his treatment was reasonable. However, it had been identified after Mr A left hospital that he had SAB and we found that there was a failure to recognise or act on the seriousness of the SAB result and start proceedings to bring Mr A back to hospital and obtain treatment. In relation to Mr A's second admission, we found that Mr A was given intravenous potassium too quickly and that there was a delay in receiving a transoesophageal echocardiogram (an ultrasound test that uses sound waves to produce moving, real-time pictures of the heart) though it would not have changed his treatment. As such, we found that there were unreasonable failings in the clinical care and treatment provided to Mr A. We upheld this complaint.

In relation to the nursing care provided to Mr A, we found that there was a lack of evidence of day-to-day nursing care, significant failures in record-keeping by nursing staff and a scarcity of relevant nursing records. There were some areas of concern in relation to Mr A's fluid balance and shortcomings in the pressure care provided to Mr A. We also found failings in communication between nursing staff. Therefore, we found that there were unreasonable failings in the nursing care provided to Mr A. We upheld this complaint.

Miss C further complained that the board failed to communicate reasonably with her about Mr A's care and treatment. We found that medical staff had communicated reasonably with Miss C. However, we found there were shortcomings in how nursing staff communicated. In particular, there were limited references to communication, and where they existed, they were prompted by Mr A's family, not by staff. We therefore found there was a failure by nursing staff to communicate reasonably with Mr A's family. As such, we upheld this aspect of Miss C's complaint.

Miss C also complained that the board had failed to respond reasonably to her complaint. We found that there were a number of failures by the board in their handling of Miss C's complaint. We found that there was an unreasonable delay in acknowledging Miss C's complaint, a repeated failure by the board to meet their own timescales to finalise the complaint response letter or request a further extension and a lack of clear communication with Miss C. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the failings this investigation has identified. 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:

• A SAB result should prompt staff to review the patient, repeat blood cultures, give consideration to the investigations needed to find the source, and provide treatment. Relevant staff should be aware of the correct rate for administering intravenous potassium. Where a transoesophageal echocardiogram is planned, this should be carried out as soon as possible.
• The board should have systems in place to ensure the quality of day-to-day nursing care and record-keeping.
• Ward nursing staff should communicate with a patient and their relatives and ensure that any communications are appropriately recorded in the nursing notes.

In relation to complaints handling, we recommended:

• Complaint investigations and responses, including acknowledgement of receipt, should be in accordance with board's complaints handling procedure. The board should, whenever possible, inform a complainant about when they should expect to receive a response to their communication and if there is going to be a delay in providing this.

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 agreed to specialist reconstructive surgery, underwent their treatment, but experienced urinary incontinence thereafter. C said that they had believed the surgery would be of a routine nature and felt that they had not been not provided with adequate information about it; in particular, that a possible side effect was incontinence.

The board said that they could not comment on the information provided about the procedure as it was care provided by another board. We found that, while the procedure itself was carried out in another health board area, it was clear from the board's records that the procedure in question was discussed with C at a consultation within Borders NHS board and their agreement to proceed with the procedure was obtained.

We took independent advice from a urology (specialists in the male and female urinary tract, and the male reproductive organs) adviser. We found that the board failed to provide adequate information to C about the planned procedure prior to obtaining their consent. Therefore, we upheld this complaint.

C also complained that the board failed to provide them with reasonable aftercare in that they had to arrange follow-up care independently and had to undergo a further unnecessary test. The board said that C's discharge letter, outlining need for aftercare, was not copied to them by the board who carried out the procedure and acknowledged that C had to arrange follow-up care independently. We found that the board did not receive information about required aftercare from the other board and that the further test was necessary. Therefore, we did not uphold this complaint.

C also complained that the board failed to handle their complaint reasonably. We found that the board did not respond to a specific concern raised in C's complaint and as such we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide them with adequate information about the procedure and its recognised complications prior to obtaining their consent and for failing to handle their complaint reasonably. 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 consent process should follow national guidelines. Consent should be taken, where possible, prior to the day of surgery. As part of the consent process, there should be a clear discussion of the risks and benefits (of having the surgery and not having the surgery) and of any alternative options; and those discussions should be clearly documented.

In relation to complaints handling, we recommended:

• Staff should handle complaints in line with the Model Complaints Handling Procedure, which includes responding to all aspects of 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 said that mail sent to him by recorded delivery, which arrived at the prison, had not been received by him. Mr C said that he did not sign the mail log. This is a document used by the prison to record that a prisoner has received recorded mail items that have arrived for them. Mr C believed the signatures shown were forged.

The prison concluded that all recorded delivery mail addressed to Mr C, and received at the prison on the dates in question, had been signed for by him.

Mr C said that the prison failed to handle his mail appropriately. He also complained that their handling of his complaints was unreasonable. Mr C was unhappy with the time taken to investigate the matter and felt no information was shared with him during the investigation. Mr C also said that no relevant investigation was carried out. He felt an expert should have been asked to analyse the signatures shown on the mail log.

We could not determine one way or the other whether the signatures shown on the mail log sheets in question were Mr C's and considered a proportionate investigation had been carried out. There was no evidence to cast doubt on the findings of the Scottish Prison Service's (SPS) investigation. On balance, and with the absence of any further reliable corroborating evidence, we concluded that Mr C's mail appeared to have been handled appropriately by the SPS. We did not uphold this aspect of Mr C's complaint.

In relation to the handling of Mr C's complaints, we felt that the investigation carried out by the SPS was reasonable and proportionate. However, we concluded that steps should have been taken at an early stage to notify Mr C that the investigation of his complaint would not be completed within the timescale set out in the Prison Rules. He should also have been advised of a new timescale and of any further delays in finalising the investigation of his complaint. In addition to this, we concluded that although several discussions were said to have taken place between staff and Mr C to keep him informed of the ongoing investigation, no record of when those discussions, or their content, were kept. In light of this, we upheld this aspect of complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not handling his complaints reasonably. 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:

• SPS should handle complaints in line with prison rules and complaint handling guidance.

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 on behalf of her adult son (Mr A) regarding two specific matters. The first concerned child protection procedures that been instigated following concerns for children in Ms C's care. Ms C complained that the council unreasonably requested a police report on Mr A. The guidance for the protection of children in Scotland means that it was reasonable for the social work department, as lead agency, to request any police check on an adult in Ms C's home, given the information that had been reported to them by the children's school. We did not uphold this aspect of the complaint.

Ms C also complained that there was a failure to document the basis on which a police report was requested. Section 91 of the Child Protection guidance states that when information is shared, a record should be made stating the purpose and form in which the sharing occurred. The social work records did not contain any information on why the request was made and we considered this to be unreasonable. The police request was in a standard form but it did not include parameters on the request limited to the alleged incident and we considered that it would have been reasonable to expect that this information should have been documented. We upheld this aspect of Ms C's complaint.

The second matter related to communication and access to social work services. Ms C complained that, despite being advised Mr A had a new social worker, there was a failure to advise Mr A of their name. Mr A was not transferred to adult services and therefore he would not have a named social worker. Mr A was not made aware of this and he was under the impression he would have access to a named social worker rather than the duty social worker. We found there was an unreasonable failure to communicate this. On balance, we upheld this aspect of the complaint.

Ms C also complained that there was a failure to refer to adult services and carry out an assessment for Self-Directed Support, despite stating this would be done. The decision not to refer Mr A to adult services under the children with disabilities and adult services transition arrangements was reasonable; however, the failure to document and explain this to Mr A was unreasonable. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for (1) failing to document why the police report was requested in the social work records and failing to ensure the actual request was confined to parameters relevant to the alleged incident; (2) failing to advise Mr A how he could access social services and providing him with incorrect information that he had been allocated a new social worker when this was not the case; (3) failing to document an assessment which showed that Mr A did not meet the criteria for transfer to adult services and assessment for Self-Directed Support, and advising Mr A that he would receive an assessment by adult services including a Self-Directed Support assessment when this was not the case; and (4) failure to confirm to Mr A that he was not eligible to transfer to adult services and why he did not meet the criteria for referral to adult services under transition arrangements. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Clarify how long the 2.5 hours per week provided to Mr A will be funded by children's services and how this is being monitored and reviewed. Clarify with Mr A how he can continue to access this service at present.
• Provide Mr A with details of how he can access an adult services assessment by self-referral so that it can be determined whether the council has an obligation to meet eligible needs.

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

• Ensure there is a clear transition process between children with disabilities and adult services. This should include information for families of children with disabilities telling them how they can access adult services. This should include what the process is, how decisions are made and how they are communicated with families and who the contact point is.
• Ensure assessments are adequately recorded on social work files.
• Ensure contemporaneous notes are recorded on social work files documenting why child protection concerns have been raised and reasons for seeking information from the police.

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 had concerns in relation to changes to the recycling system introduced by the council. Ms C told the council that she had a disability and needed reasonable adjustments in relation to the recycling system. The council took steps to visit Ms C and explain the changes to the system. Ms C remained unhappy and complained to the council. Her complaint was not upheld and the council concluded that there was no failure to provide reasonable adjustments under the Equality Act 2010. Ms C was dissatisfied with this response and brought her complaint to us.

Ms C complained that the council failed to consider her request for reasonable adjustments appropriately. Although we noted that council officers had attempted to assist and engage with Ms C, it was not apparent from the evidence available that the council had appropriately taken into account how Ms C's disability impacted on her ability to use the recycling system. We did not find evidence that the council considered the adjustments in a systematic way. We upheld Ms C's complaint.

Ms C also complained that the council had not carried out an appropriate equality impact assessment in relation to the changes to the recycling system. We found that the council had performed equality impact scoping exercises at two stages during the implementation of changes to the recycling system. These assessments did not identify that the proposals would result in negative impacts on people with disabilities. We found that the council has acted in accordance with their guidance in relation to equality impact assessments. While we did not identify failings, we suggested that the council may wish to review their assessments in light of the evidence about Ms C's experience of the recycling system. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to appropriately consider making reasonable adjustments. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Contact Ms C to seek further information about how her disability impacts upon her capacity to use the recycling system. Refer to the Equality Act 2010 Statutory Code of Practice Services, public functions and associations (2011) and reconsider whether or what reasonable adjustments can be made. Inform Ms C of their decision and provide reasons.

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

• Officers should be aware of the duty to consider reasonable adjustments. Evidence of this consideration should be documented.

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

Land adjacent to C's property was used as the site compound during road construction carried out by contractors on behalf of the council. The compound was accessed by a temporary haul road which ran close to C's home. Construction vehicles used the road daily and vibration equipment was used to keep the road surface smooth.

After cracks developed on the façade of C's property and some of their neighbours' properties, C complained to the council about structural damage they believed was caused by the works. They also complained that the council's Environmental Health Officer (EHO) failed to return calls when C had left voicemail messages asking them to come and measure noise, dust and vibration levels.

C complained that a dilapidation survey should have been carried out by the council. We took independent advice from a planning specialist. We found that the road was constructed in accordance with the approved planning application. The council had taken appropriate action to address C's concerns over potential structural damage by conducting a survey of C's property (and neighbouring properties). We, therefore, did not uphold this complaint.

In relation to whether the council took reasonable steps to investigate C's complaints of vibration, noise and pollution, we took independent advice from an environmental health specialist. We found that the EHO initially took appropriate action. They attended C's property and then contacted the contractor, advising them of the relevant procedure. They closed the complaint when C made no request for monitoring, giving C their number to contact should C change their mind. Although it was C's position that they had left a number of messages for the EHO, there was no available evidence to indicate that further complaints were raised with the EHO. We did find, however, that the council team responsible for delivery of the road construction project were aware of C's concerns about noise, dust and vibration and ought to have passed these on to the EHO for action to be taken. On the basis that they failed to do so, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to take reasonable steps to investigate their complaints of vibration, noise and pollution, and for failing to oblige the contractor to provide evidence that levels were acceptable. 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:

• Council officers should ensure communication takes place between departments to relay complaints to the relevant service.

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 requested that their child (A) defer their entry to primary school. C also requested an additional year of early years funding for the nursery school A was attending. When C's application for funding was denied, they submitted an appeal which was also refused. C complained about the actions of the council in relation to the matter.

In relation to the consideration of the initial application for deferral and early years funding, we found that while there were elements of communication that could have been better, overall the actions of the council were reasonable. The deferral application process had an emphasis on the parent and nursery providing information and evidence to support the application. The council reasonably followed the appropriate process when considering the deferral application. We did not uphold the complaint.

On considering the complaint about the process regarding the appeal, we found that when the initial application for early years funding was denied there was no clear route of appeal. It would have been reasonable, and more in keeping with relevant guidance, to have a clear process set out for parents, at least from the point in time when they become aware their application was unsuccessful, including information about the evidence required to support their request.

In addition we found that the council's explanation of their decision lacked detail. To ensure the council were exercising their discretion appropriately, they should have clearly articulated what evidence they considered, their view on it and how they reached the conclusion they did. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow an appropriate process when considering the appeal. 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:

• Ensure current active information is available to parents both online and via nurseries about the deferral process and appeals process.

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 a member of the housing association's staff communicated with them and their partner about storing refuse bins at the rear of their property. Taking account of the evidence, overall, we did not consider that there was sufficient evidence to conclude that the association acted unreasonably in this regard. However, we considered that subsequent correspondence with C could have been more helpful and the situation handled better. We also noted some good practice by the association and that ultimately the situation regarding the storage of the bins was resolved. Therefore, we did not uphold this complaint.

C also complained that the association did not respond reasonably to their complaint. During our investigation, the association acknowledged that the complaint was not handled in line with their complaint handling procedure (the CHP). We agreed that this was the case because the timeframe for response was not met; C was not kept updated; the complaint was not handled according to the CHP; and the response lacked objectivity and impartiality. Overall, we considered that the association's handling of the complaint was unreasonable. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in their 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.

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 partnership's response to the concerns C raised about the safety and wellbeing of their parent (A), the partnership's communication with C about A's care and support and the partnership's handling of C's complaints.

We took independent advice from a social work adviser.

We found that the partnership did not address C's concerns about A's safety and wellbeing when they were first raised but did when they were subsequently raised. We found that, on balance, the partnership failed to reasonably respond to C's concerns about A's safety and wellbeing and we upheld this complaint.

We found that the partnership did not initially provide correct information to C about A's care and support but that the circumstances were such that the staff member could not have reasonably been expected to have been able to give an accurate assessment of a complex scenario at the time. We determined that the staff member acted in good faith and tried to be helpful which was reasonable. Furthermore, advice was subsequently sought and A's family were made aware of the correct position. We considered that the partnership communicated reasonably with C about A's care and support and did not uphold this complaint.

We also found that the partnership failed to reasonably handle C's complaints in that they took significantly longer than expected to deal with the initial complaint, failed to appropriately categorise the initial complaint and failed to adequately respond to all points raised. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably respond to their concerns and for failing to reasonably handle their complaints. 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:

• Staff should be aware of how to appropriately respond to concerns raised by family members about the safety and wellbeing of service users in line with relevant legislation and internal policy/procedure.

In relation to complaints handling, we recommended:

• Staff should handle complaints in line with the Model Complaints Handling Procedure, which includes correctly identifying the stage at which a complaint should be considered, responding to complaints within timescales and where this is not possible advising customers and providing revised timescales and specific issues should be clearly and sufficiently addressed.

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, an advocacy worker, complained on behalf of her client (Mr A) about the partnership's actions regarding his tenancy while he was resident in a care home. Mr A was moved into a care home following a hospital admission as it was considered not safe for him to return to his tenancy. Concerns were raised about Mr A's mental capacity and at times he had been assessed as not having capacity to make decisions about his welfare. Mr A had on different occasions expressed a wish to return to his tenancy. Ms C complained that the partnership failed to provide clear information to Mr A about his residency status while residing in the care home; that they failed to support Mr A to return to his tenancy as per his wishes; and that they failed to take reasonable action regarding his tenancy which led to Mr A accruing significant rent arrears. The partnership said that while Mr A was allowed to leave the care home if he wanted to, it would be against their professional recommendation and they would not support him to leave. However, if Mr A did return to his tenancy, they would put in place appropriate supports.

We took independent social work advice. We found that Mr A had been given clear information about his residency status and we did not uphold this complaint.

We found that the partnership unreasonably delayed in resolving Mr A's situation which resulted in him living in the care home without a legal mandate. We also found the partnership failed to take reasonable action in relation to Mr A's tenancy, particularly when he was deemed to not have capacity, and this resulted in Mr A accruing rent arrears. Therefore, we upheld these complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to resolve his situation which resulted in him residing in the care home without a legal mandate and accruing significant rent arrears. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The partnership should make an appropriate contribution to Mr A's rent arrears and service charges which accrued from the day he moved to the care home up to the date he signed over his tenancy. This calculation should take into account all relevant factors, including the fact that he would not have qualified for housing benefit during this time.
• The partnership should take any necessary steps to fulfil Mr A's wishes to move to another care home without unnecessary delay.

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

• The partnership should use this case as an opportunity to reflect on social work practices and their application of the relevant legislation, policies and 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.