Some upheld, recommendations

Summary

Mr C complained that Scottish Water (SW) delayed in reinstating a permanent water supply to his property and that their communication in relation to this matter was unreasonable.

Mr C requested a mains supply lead replacement. After completing works, the new pipes were attached to the water supply system. Shortly afterwards, his neighbours reported that they had no water. It was established that during the works at Mr C's property, the joint supply to his neighbours had been cut. Mr C was unhappy because he said that he had been misled by SW into believing that the water supply at this property was not a joint one. SW considered that a public health issue had arisen as the neighbours' water supply had been disrupted and they took action to install a temporary overland water supply. They also apologised for the incorrect information they had given. At the same time, they detailed the works they would carry out to renew the existing pipework to the rear of Mr C's property and to the boundary of each of his neighbours (SW are only responsible for the water main in the street and communication pipe up to and including the stop-cock. The water supply to individual premises inside a property boundary is the responsibility of the property owner).

It was SW's view that, notwithstanding any incorrect information they may have given Mr C, it was in fact his responsibility to establish the actual situation with regard to the supply pipes; they did not hold records about these nor were they part of the public supply network. Their role in this was only to remove the lead pipe belonging to them and lay a new pipe from the public water main to the boundary of Mr C's property where it connected to the private pipework. The temporary mains pipe was laid and it was not until a year later that it was removed.

We found that despite any incorrect information SW may have given, it was Mr C's responsibility to determine whether or not his water supply was shared. Delays were caused by this, but they were not of SW's making. Therefore, we did not uphold this aspect of the complaint.

In relation to communication, we found that there was a great deal of confusion by SW in the way they dealt with the correspondence and there were omissions and delays in sending replies. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to communicate in a reasonable way. 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:

• Correspondence, including complaints correspondence, should be acknowledged and responded to in accordance with stated 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

Mrs C complained that the council failed unreasonably to respond to her complaint about flooding at her home and, that they failed to provide a reasonable emergency out-of-hours service.

We found there to have been confusion with the councils complaints handlers on whether Mrs C's original contact was a request for service, and not a service complaint. Mrs C then asked for her complaint to be escalated to Stage 2, where she experienced several months delay awaiting a response. Only after this office's involvement did Mrs C receive an appropriate final letter. Therefore, we upheld this aspect of the complaint.

However, we found the council to have responded reasonably to Mrs C's request for an out-of-hours service, and they did so in line with the system they had in place at that time. There is no statutory requirement for the council to maintain a comprehensive out-of-hours service for customers with issues on the local roads network, and in the event of someone calling their out-of-hours number, they would be given other appropriate advice. Therefore, we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to deal reasonably with her 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 and follow the council's complaints handling procedure.

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

Mrs C complained about the actions of her child's (Child A) school following reports of bullying. She explained that her child had been bullied most of their school life and that the bullying had mostly been carried out by one other child. Mrs C acknowledged that the school had taken some actions and the situation had started to improve. However, incidents later continued, leaving her child increasingly upset and anxious. In light of this, Mrs C felt the school had not done enough to prevent the bullying incidents and provide support to her child. Mrs C also complained about whether the incidents of bullying had been recorded appropriately by the school. Finally, Mrs C complained about how the council had communicated with her during and after the complaints process.

In respect of the first complaint, we concluded that the school had taken reasonable and appropriate steps to address incidents of bullying experienced by Child A. We noted that the school had appeared to have taken a number of steps to prevent interactions between Child A and the other child, provide support to Child A and put in place measures to address the other child's behaviours. The approach taken by the school appeared to be tailored to the individual circumstances of Child A and the type of bullying they were experiencing. We acknowledged that there were times where the other child had interacted with Child A in an upsetting way despite these measures being in place. However, we recognised that it can be very difficult to prevent such incidents from happening completely. Overall, we concluded that the school took the reports of bullying seriously and made reasonable efforts to assist Child A and prevent further incidents from happening. Therefore, we did not uphold this aspect of the complaint.

The second complaint related to how the school recorded incidents of bullying. Mrs C had submitted a freedom of information (FOI) request to determine what incidents involving Child A had been recorded on the SEEMiS system used by schools in the council area. The FOI revealed that one incident had been recorded on the SEEMiS system. Mrs C understood this to mean that only one incident of bullying had been recorded by the school. The council explained that, at the time of their complaint response, bullying incidents were recorded by the school in SEEMiS. However, previous incidents had been recorded in paper format.

The council's anti-bullying policy stated that schools should ensure that bullying incidents are recorded and monitored using SEEMiS. From the information we reviewed, it is apparent that the school was not using the SEEMiS system for a significant period of time while this policy was in place. The council advised us that the Scottish Government Supplementary Guidance did not place a statutory duty on councils to record incidents using SEEMiS. They also highlighted that there would be a period of transition towards using SEEMiS in schools and this would take time. We recognised the council's perspective but measured the school's actions against the specific council policy in place at the time. This policy appeared to be clear that SEEMiS should be used by schools at that point in time, not that there was an intention to move towards its use. Therefore, we upheld this aspect of the complaint.

Mrs C also complained about how her complaint to the council and subsequent correspondence was handled. We concluded that the council's handling of the actual complaint itself was reasonable. However, we noted that Mrs C had contacted the council to query some of the contents of their Stage 2 (investigation stage) response. The council did not respond to this for 27 days, during which time Mrs C had approached the executive director of education and children's services. As a result of this delayed response, the school term had ended and the head teacher could not be reached due to being on annual leave. This led to a delay in Mrs C receiving clarification on the issues she had raised. We considered that the council's communication after their Stage 2 response was issued to be unreasonable. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to record bullying incidents on the SEEMiS system, in line with the relevant council policy and for not acting on or responding to post-complaint correspondence within a reasonable timeframe. 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:

• Correspondence received after a Stage 2 response has been issued should be acted on and responded to within a reasonable timeframe.

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 time taken for the board to refer him to specialist care for pain in his hip following a hip replacement.

We found that for several years the board's actions were reasonable. However, at one point, the board recognised the possibility of infection but chose not to aspirate (drain fluid from) Mr C's hip. We considered this to be unreasonable and that Mr C should have been refererred for specialist care. We upheld this aspect of the complaint.

Mr C also complained about the boards handling of his complaint. We found that the board complaint handling was reasonable and, therefore, we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide reasonable treatment in relation to pain in his hip. The apology should meet thestandards 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 develop a written policy for the investigation of painful hip replacements that takes into consideration the content of the European Consensus Document on Periprosthetic Infection (https://www.efort.org/wp-content/uploads/2013/10/philadelphia_consensus.pdf).

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 actions of the prison health care service. Following a medication spot check, Mr C was found to be short of antidepressant tablets, and as a result his medications were stopped with immediate effect. Mr C explained that his medication count was short as his medication safe was broken into recently and everything was taken. In response to his complaint, the board explained they would not reinstate Mr C's medication. They also stated they had made enquiries with the Scottish Prison Service (SPS) and were informed that Mr C had not reported his safe being broken into.

Mr C complained to us about his medication being stopped and about the enquiries the board made into whether or not he had reported his safe being broken into.

In respect of the complaint about Mr C's medication being stopped, we took independent advice from an GP adviser. We noted that, ideally, a GP would not withdraw anti-depressant medication suddenly. However, we found that this may not be the case if there is poor compliance with the requirements of the medication. We also highlighted guidance about prescribing medication in a prison setting and noted that Mr C had signed a medical agreement treatment form that acknowledged his medication may be stopped if not appropriately managed. After reviewing Mr C's medical records, we noted that an early entry had suggested potential drug misuse. Based on the review of the information available, we concluded that healthcare staff's decision to stop Mr C's medication was appropriate and their actions reasonable. Therefore, we did not uphold this complaint.

In respect of the second complaint, the board acknowledged that they had not appropriately described their enquiries in their responses to Mr C. The board had spoken with SPS staff and stated that SPS had confirmed Mr C had not reported his safe being broken into. However, Mr C had, in fact, reported his safe as being broken into to SPS staff. The board accepted this error had caused Mr C further concern and apologised for this. We considered this likely to be a case of miscommunication rather than any attempt by the board or SPS staff to mislead. However, although we considered the enquiries made by the board to be in good faith, we concluded that they could have been clearer and taken into account the content of Mr C's complaint more closely. Furthermore, the outcome of the enquiries could have been relayed to Mr C more accurately. On this basis, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to make reasonable enquiries to the SPS about what happened to his medication and whether his safe had been broken into. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-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 about the care and treatment provided to her late father (Mr A) at the Royal Alexandra Hospital. Mr A had dementia and was admitted with drowsiness, fever, confusion, and crackles in the lung. Ms C felt that there was not sufficient screening for sepsis when Mr A was admitted, that he was not given appropriate pain relief, and that discharge was unreasonable. Ms C also raised concerns about the nursing care provided to Mr A.

We took independent advice from a consultant in acute and general medicine, and from a nurse. We found that Mr A was appropriately assessed when he was admitted to hospital, that his pain was managed appropriately, and that his discharge was reasonable. We did not uphold this aspect of Ms C's complaint.

In relation to nursing care, we found that whilst there were some areas of nursing care which were reasonable, there were a number of failings. Namely, we found that there was limited evidence of care planning being carried out appropriately, there was no 'Getting to Know Me' document completed (this document should be completed for all patients with dementia). We also considered that a non-verbal pain assessment tool should have been used, but noted that the board had acknowledged this. We upheld this aspect of Ms C's complaint.

Ms C further complained about communication and complaints handling. We found that there was a failure to appropriately communicate with Ms C when her father was in hospital, particularly as she was his power of attorney and next of kin, and we upheld this aspect of her complaint. We also found that in relation to complaint handling, there was confusion regarding whether Ms C's complaint was in fact feedback, and this resulted in a delay in acknowledging the complaint. We also found that the response was delayed and the reasons for this were not clear. 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 provide Mr A with reasonable nursing care and treatment; failing to communicate reasonably; and failing to handle Ms C's 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:

• Appropriate care planning should be carried out and should take into account the specific needs of patients with dementia.
• A 'Getting to Know Me' document should be completed on admission for all patients with dementia.
• Communication with relatives should be proactive, well documented, and should appropriately involve the input of power of attorneys and next of kin.

In relation to complaints handling, we recommended:

• Prompt action should be taken to determine whether someone is making a formal complaint.
• Complaint acknowledgement letters should be sent out as per the complaints handling procedure.
• Responses should be sent where possible within 20 days and without undue delay in line with the board's complaint handling procedure.

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

Mrs C complained on behalf of her daughter (Miss A) that, when Miss A attended the Queen Elizabeth University Hospital on several occasions with groin pain and leg swelling, she did not receive appropriate treatment. Miss A was eventually admitted to hospital and was later diagnosed with secondary cancer.

Mrs C said the board unreasonably misdiagnosed Miss A's condition during her initial visit to A&E at the hospital. She said that they told Miss A she had strained her groin, when in fact she had a large blood clot there.

We took independent medical advice from a consultant in emergency medicine and from a consultant in general medicine. We found that although the diagnosis given at the time was incorrect, it was consistent with Miss A's recorded history and examination findings and was not unreasonable. We did not uphold this aspect of the complaint.

Mrs C said that the board unreasonably delayed in reaching a diagnosis of Miss A's condition. Her concerns included that it took several months of visits to the hospital before Miss A was admitted. We found that the clinicians who saw Miss A at the hospital could, and should, have exercised discretion and carried out further investigations of Miss A's condition at an earlier stage. We also found that the delay in Miss A being admitted to hospital and given a diagnosis, was unreasonable. Earlier investigation would almost certainly have identified the abnormal tissue causing Miss A's problem and led to the subsequent diagnosis of an underlying secondary cancer. While further early investigation might not have resulted in a different outcome, Miss A could have been spared the pain and anxiety caused by the delay in diagnosis of secondary cancer. Therefore, we upheld this aspect of the complaint.

Mrs C also said that the board failed to deal with her complaint about Miss A's care and treatment appropriately. We found that the board had delayed in responding to Mrs C's complaint, failed to provide her with any updates and that, following repeated contact by Mrs C's MSP's office, a full response was eventually forthcoming. This was contrary to the board's complaint handling procedure and we, therefore, upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and Miss A for the delay in admitting Miss A to Queen Elizabeth University Hospital and investigating and diagnosing her condition at an earlier stage; and for failing to provide Mrs C with appropriate updates on her 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:

• In future cases of this type, staff should admit patients to Queen Elizabeth University Hospital and carry out further investigations at an earlier stage, in order to reach a diagnose within a reasonable timeframe.

In relation to complaints handling, we recommended:

• Where the board needs longer than the 20-day timescale to issue a full response, they must explain the reasons to the complainant, and agree with them a revised timescale whenever possible, in accordance with the board's complaints policy and procedure.

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 her late mother (Ms A) had received from the practice before Ms A completed suicide.

She complained that the practice failed to identify that her mother had a personality disorder. We took independent advice from a GP adviser. We found that it had been reasonable for the practice not to diagnose that Ms A had a personality disorder. We did not uphold this aspect of the complaint.

Ms C also complained that the practice failed to manage Ms A's anti-depressants and that they had failed to take appropriate action when she stockpiled medication. We found that the practice had acted reasonably in relation to these matters and did not uphold these aspects of the complaint.

Ms C then complained that the practice had failed to call her back, after she had contacted them to raise concerns about her mother's behaviour. We found that there was no evidence that Ms C requested or was promised a follow-up call by the practice. In view of this, we found that it was reasonable that the practice did not call her back. We did not uphold this aspect of the complaint.

Ms C complained that the practice had failed to take action when Ms A reported abuse of her children. We did not find any evidence in the practice's records that Ms A had reported physical abuse of her children. However, we considered that there was evidence of emotional abuse by Ms A to her children and that social work input should have been arranged in relation to this. We upheld this aspect of Ms C's complaint.

Finally, Ms C complained that the practice had unreasonably failed to deal with her complaint appropriately. We found that the practice had made a reasonable attempt to respond to the issues raised. It was also reasonable that one of the GPs named in the complaint carried out the investigation, given the size of the practice. That said, we found that the practice had unreasonably failed to provide updates on the investigation or information about when they expected to issue a final response. In view of these failings, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for their failure to ensure that social work input was arranged and for failing to keep her updated on the complaint. 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:

• GPs should be familiar with the indications of emotional abuse in children and the referral mechanisms in place for social work assessment.

In relation to complaints handling, we recommended:

• When there is a delay in responding to a complaint, the practice should tell the person making the complaint about the reasons for the delay and when they can expect a 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

Mrs C complained about the care and treatment provided to her late father (Mr A) during an admission to Glasgow Royal Infirmary. At the time, Mr A had a long standing cardiac and respiratory (heart and lung) illness and was admitted with a chest infection, shortness of breath, confusion and hallucinations.

We took independent advice from a consultant in respiratory medicine. We found that many aspects of the care provided were reasonable. However, we found no evidence that an inhaler review had been appropriately performed or planned. On balance, we upheld this aspect of Mrs C's complaint.

Mrs C also had concerns about the nursing care provided to Mr A, and the way in which his discharge was handled. We took independent advice on these matters from a registered nurse. We found that the dietary monitoring performed was reasonable and we found no failings in the way nurses interacted with Mr A. We concluded that the nursing care provided was reasonable. Similarly, we were not critical about the way Mr A's discharge was handled. We found no evidence of unreasonable failings and concluded that the handling of the discharge was reasonable. We did not uphold these complaints.

Finally, Mrs C complained about the way her complaint was investigated by the board. We did not find failings in the way the board investigated or responded to the complaints raised. However, we found that the board did not update Mrs C about the delay in responding to her, in accordance with the NHS Scotland Complaints Handling Procedure. On balance, we upheld this aspect of the complaint but noted that the board had already apologised for this failing.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C that an inhaler review was not performed during the admission or planned. 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:

• Where a patient suffers repeat significant disabling breathlessness attributable to chronic obstructive pulmonary disease, inhaler assessment and medication review should be undertaken or planned.

In relation to complaints handling, we recommended:

• Where a complaint response cannot be provided within 20 working days, the person making the complaint should be updated on the reason for the delay and be given a revised timescale for completion. Delays in investigation should be minimised.

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 clinical and nursing care and treatment given to his late mother (Mrs A) while she was a patient at Royal Alexandra Hospital. Mr C also complained that there was a failure to notify him of Mrs A's deteriorating condition.

We took independent advice from a nurse and a consultant physician. We found that falls assessments were not undertaken as they should have been and that Mrs A had not been provided with the walking frame that she required. We also found that Mr C was alerted neither to Mrs A's deteriorating condition nor to her fall and the injuries she suffered as a result. Similarly, Mr C appeared not to have been told of Mrs A's low sodium which was likely to have contributed to her fall and agitation. Therefore, we upheld these aspects of Mr C's complaint.

In relation to clinical treatment, we found the care to be reasonable. We did not uphold this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to alert him to Mrs A's deteriorating condition and to her fall and injuries, as well as the failure to advise of her poor 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:

• Where a fall occurs, relatives should be alerted in a timely way. Similarly, they should be informed where a poor prognosis is anticipated.
• Medical staff require to communicate effectively with ward staff about the seriousness and risk of common metabolic problems.

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.