Some upheld, recommendations

Summary

Mrs C complained about the care and treatment she received during two admissions to Galloway Community Hospital. Mrs C was admitted with abdominal pain and she was suspected to have sepsis (blood infection). We took independent advice from a consultant in acute medicine. We found that during Mrs C's first admission, there was a delay in administering her antibiotics and that she should have been given intravenous fluids (fluid through a drip). We also found that during both admissions there was an unreasonable delay in investigating and establishing the source of her underlying infection. We upheld this aspect of Mrs C's complaint.

Mrs C also complained about the follow-up care she received from the board in response to her ongoing abdominal pain. We took independent advice from a consultant colorectal surgeon (a specialist in conditions of the colon, rectum or anus). We found that reasonable steps were taken to investigate Mrs C's condition and she was given appropriate advice that surgery would not be appropriate treatment for her. We did not uphold this aspect of Mrs C's complaint. However, we gave feedback to the board about the potential benefit of offering out-patient follow-up for patients with complex and unresolved conditions like Mrs C.

Finally, Mrs C complained about the board's handling of her complaint. We found that there was a failure to update Mrs C during the board's investigation, which the board had acknowledged and apologised for. We also found that the board failed to investigate and respond to all aspects of Mrs C's complaint. Therefore, we upheld this aspect of Mrs C's complaint and we made further recommendations in relation to this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the unreasonable failings in her care and treatment and 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:

• When a patient is suspected to have sepsis, they should receive appropriate treatment, including the prompt administration of antibiotics.
• If a patient's diagnosis is unclear, there should be a system in place so medical staff can seek advice or a prompt review from a consultant.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found at www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs.

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 that he was unreasonably billed by Clear Business Water (CBW), despite having paid his water bills regularly. He also complained about the way CBW had pursued payment of the disputed amount.

We found that Mr C's accounts had previously been inaccurately recorded by another water provider. However, we found that CBW had explained the reason for the outstanding sum and that Mr C had used the water that payment was being requested for. We did not uphold this aspect of the complaint.

In relation to CBW's debt collection process, we found that it was confusing and unreasonable and therefore upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings identified in this case. The apology should meet the standards set out in the SPSO guidelines on apologyavailable at www.spso.org.uk/leaflets-and-guidance.
• Review a good will gesture, showing consideration has been given to all the service failures identified in our decision.

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

• CBW need to ensure correspondence sent out by Universal Debt Collection accurately identifies the relationship between the two organisations and sets out clearly and accurately what the debt recovery process is.
• CBW need a written debt recovery procedure, which sets out clearly the timescales and actions they will take when pursuing payment. This should include a clear explanation of when an account will be passed to external agencies for recovery.

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 his withdrawal from his course. The issues we investigated related to an unreasonable failure to advise Mr C of why he was withdrawn from the course in the letter issued by the Progression and Awards Board; an unreasonable failure to advise Mr C that his appeal against the decision of the Progression and Awards Board should have been made on the grounds set out under the university's regulations on appeals; an unreasonable delay in providing Mr C with feedback following a transfer event; and also an unreasonable failure to contact Mr C when he did not attend monthly progression meetings with his director of studies, when the director of studies had supported his application for an interruption of studies.

We upheld the first complaint on the basis that the university failed to document and advise Mr C of why he had been withdrawn from the course. We considered that Mr C should have been made aware of the reasons so that he could base his appeal on this decision.

We also upheld the second complaint. This was on the basis that Mr C appealed against the decision of the school panel on the grounds that they had not applied their policy on student non-engagement properly. However, the decision to withdraw Mr C had been made by a different body, the Progression and Awards Board, and that body had the authority to make decisions regarding progress. Appeals to the Progression and Awards Board require to be raised on different grounds according to the university's regulations. We did not uphold this complaint on the basis that information about the second transfer event had been given to Mr C within a reasonable period of time. We also did not uphold the fourth complaint. Whilst there was a lack of evidence to demonstrate what communication the director of studies had with Mr C, on balance it was concluded that as a holder of a Tier 4 visa, the onus was on Mr C to meet the terms of Tier 4 visa requirements regarding university engagement.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to advise why he was withdrawn from the course; failing to advise Mr C that his appeal against the decision of the progression and awards board should have been made on the progression and awards board appeal form on the grounds set out under the University Senate Regulations 13 Student Appeals s13.3.2, and; rejecting Mr C's appeal due to non-engagement when the progression and awards board had no authority to remove him from the course on the basis of non-engagement. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• The Progression and Awards Board should clearly explain why Mr C was withdrawn from the course. Mr C should then be entitled to issue an appeal against this decision, should he choose to do so, in accordance with the university's regulations.

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 water damage to her property due to works carried out by the council as part of a Flood Prevention Scheme (FPS). Ms C said that the council failed to investigate the effect of the water damage and remedy these issues. Ms C also complained about vibrations from a nearby road, the quality of the council's communication with her about these issues and their response to her complaint.

We found that the council did conduct a suitable investigation into the effect of water damage to Ms C's property. They investigated concerns about sediment in a burn and took action to remedy this. They continued to monitor both the water flow and level and conducted annual inspection of the burn. No further problems had been identified since the gabion mattresses (a cage or box filled with rocks or other material for use in landscaping, road building etc) were installed and we considered that the council's investigation and remedial action had been reasonable. Therefore, we did not uphold these aspects of Ms C's complaints.

In relation to the vibrations from the nearby road, we noted that the council repaired the road, but when Ms C raised continued concerns, no further inspection was conducted. We considered that the council should have attended the road and/or met with Ms C to establish any outstanding issues. Therefore, we upheld this aspect of Ms C's complaint.

In relation to complaints handling, we found that the council's response to Ms C's complaint was appropriate and responded to the issues raised within the timescales set out in their complaint handling procedure. We did not uphold this aspect of Ms C's complaint.

Finally, we found that the council did not respond to two letters Ms C sent raising her concerns. Therefore, 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 respond to her letters. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Contact Ms C to establish if the road issue remains a problem to her. If it does, they should then conduct an investigation and advise Ms C of their findings.

Summary

Mr C complained that the council failed to follow a number of social work procedures. Mr C and his wife (Mrs C) had been foster carers; however, following a child protection investigation (CPI) regarding one of the children they cared for, an investigation was carried out and Mr and Mrs C were deregistered as foster carers. Mr C complained that the council failed to follow procedures in relation to the CPI and the deregistration.

We took independent advice from a social worker. We found that, in relation to the CPI procedures, it was unclear as to whether one or two social workers should conduct interviews with children. We also found that the National Guidance for Child Protection in Scotland was not followed as Mr and Mrs C were not provided with information about the concern at the earliest possibility. There was also not a clear record regarding the risks and benefits of moving the children from the placement. We further found that the CPI took too long to conclude, and that the council did not ensure that Mr and Mrs C were aware of their ability to access independent support and advice throughout the investigation. We upheld this aspect of Mr C's complaint.

In relation to the deregistration, we found that the council had reasonably followed procedures and we did not uphold this aspect of Mr C's complaint. However, we noted that the foster carer agreement documents had not been reviewed or updated throughout Mr and Mrs C's time as foster carers, and we made a recommendation to the council on this matter.

Finally, Mr C complained about the council's handling of his complaint. We found that the council had failed to deal with his complaint in a reasonable manner as timescales were not met, and at various points Mr C was given incorrect information about the complaints process. We upheld this aspect of Mr C's complaint. Given that the council had stated that they were updating the foster carer agreements with a section on complaints, we asked for evidence of this being approved and implemented, but did not make any further recommendations on complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to reasonably follow procedures in relation to the child protection investigation; and for failing to reasonably follow procedures in relation to complaints handling. The apology should comply with the SPSO guidelines on making an apology, available at: www.spso.org.uk/leaflets-and-guidance.

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

• It should be clear whether one or two social workers will conduct Child Protection Investigation interviews.
• Actions taken with regards to allegations made in placements should be in line with the National Guidance for Child Protection in Scotland.
• A clear record should be maintained clarifying both the risks and benefits of ending a placement following an allegation, before a decision is taken.
• CPI's should be completed within a reasonable timeframe.
• The council should ensure that foster carers are made aware of their ability to have access to independent support and advice following an allegation.
• The contents of fostering agreements should be reviewed at intervals by the authorities and any proposed changes or additions explained and discussed with carers.

Summary

Ms C complained that the council unreasonably failed to carry out parenting capacity assessments to establish whether Ms C was able to look after her child (Child A). Ms C also complained that the council failed to carry out reasonable assessments to inform decisions about Child A's care.

We took independent advice from a social work adviser. We found that decisions made regarding the parenting assessments were reasonable. Therefore, we did not uphold this aspect of the complaint. However, we noted that changes to the planned actions in relation to these assessments should have been discussed and recorded with 'Looked After Child' (LAC) review minutes, with the reasons recorded as to why the plan had changed.

We found that while the assessments of Child A's parents were reasonable, based on the information available, the kinship carer assessment was unreasonably delayed, which was a key assessment to inform future decisions about Child A's care. It was also found that not all LAC reviews were appropriately documented or carried out in a reasonable timescale. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the delay in the kinship carer assessment and the statutory LAC reviews being carried out. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets.

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

• A kinship care assessment should commence within three days of the placement and be concluded within 12 weeks.
• LAC reviews should be held within six weeks of the placement, then a further review three months from that date and then every six months thereafter.

Summary

Mr C is a kinship carer and he approached the council to apply for kinship care allowance. The council approved his application to the date of application; however, they did not agree to backdate his payment to the date that the Scottish Government introduced a change to the eligibility for kinship care assistance. The council explained they were not required to backdate the payment as the Scottish Government did not legislate on the matter and only issued guidance, therefore they had discretion as to whether to follow that guidance. Mr C complained that the council unreasonably failed to follow national guidance when considering his request to backdate kinship care payments and that they failed to provide the appropriate information about entitlement to kinship care assistance in line with their obligations.

We found that while the council are required to consider the guidance, they do have discretion as to whether they apply it as it is not statutory legislation. We found that the council failed to provide contemporaneous evidence which they based their decision on to not backdate Mr C's application for kinship care assistance. The council only provided retrospective accounts of how those decisions were made. We considered that decisions about whether to follow Scottish Government guidance should be carefully documented and in this case it was not. We upheld this aspect of the complaint on the basis that the council failed to clearly record the rationale for their decision.

However, our investigation found that the council provided appropriate information about entitlement to kinship care assistance in line with their obligations when the Scottish Government introduced changes to the legislation. We did not uphold this aspect of the complaint.

Recommendations

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

• The council's policy about whether they should follow Scottish Government guidance on kinship care allowances should be considered for decision at an appropriate senior level, eg at Council Committee or by whichever means the council make such policy decisions.

What we asked the organisation to do in this case:

• Following the review of their policy on whether to follow Scottish Government guidance, the council should reconsider requests for kinship care assistance to be backdated.

Summary

Mr C complained on behalf of his partner (Ms A) who had been diagnosed with lung cancer. She also suffered from other illnesses.

Ms A had experienced shortness of breath and fatigue. It was established that she had anaemia and was referred to St John's Hospital for a blood transfusion by the oncology team at another hospital. When Ms A arrived at St John's Hospital there were no beds and before being transferred to the Medical Assessment Unit (MAU) she spent seven hours on a temporary bed in the corridor. She was eventually transferred to MAU and was given a blood transfusion later that night. Later, she was moved to an observation ward and the next day she was discharged home.

A few days later, Ms A was unwell again and she was admitted to St John's Hospital once more. Again, she spent a number of hours in a corridor before being admitted to the MAU. Mr C complained that these events were unacceptable given Ms A's serious illness. The board recognised that the situation had not been ideal but said that on both occasions the hospital had been extremely busy. They apologised but said that they could not give assurances that the same situation would not occur again. They confirmed that Ms A had been treated in accordance with the cancer treatment helpline advice. They added that St John's Hospital had asked the referring hospital whether the transfusion could be deferred the first time Ms A attended hospital but were told that it could not.

We took independent advice from consultants in general medicine and oncology (cancer). We found that although the board had no control over the number of patients arriving at the same time, it was, nevertheless, unreasonable that a cancer patient like Ms A should have had to wait so long (seven hours each time) before being transferred to MAU. We also found that there was no clinical reason why Ms A should have been given a blood transfusion late at night. For these reasons we upheld the complaint. Although Mr C had also complained about the cancer treatment helpline, this was a national helpline run by another public body and the board could not be held responsible for the policy of another organisation.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for the time required to wait before transferred to MAU. The apology should meet the standards set out in the SPSO guidelines on apologyavailable at www.spso.org.uk/information-leaflets.
• Apologise to Ms A for giving a blood transfusion late at night when there was no urgent requirement to do so. The apologies should meet the standards set out in the SPSO guidelines on apologyavailable at www.spso.org.uk/information-leaflets.

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

• Cancer patients in particular should be admitted to MAU in a timely manner.
• Blood transfusions should be given in line with National Institute for Health and Care in Excellence guidelines.

Summary

Ms C, who works for an advice and support agency, complained on behalf of Mr B about the care and treatment provided to his late wife (Mrs A) at Queen Elizabeth University Hospital. Ms C raised concerns about the medical and nursing care and treatment provided to Mrs A, about the decision to transfer Mrs A to another hospital, and that Mrs A's family were not advised of the transfer.

We took independent advice from a consultant physician/geriatrician (a medical doctor who specialises in medicine of the elderly) and a nursing adviser. We found that the medical treatment provided to Mrs A was reasonable, and did not uphold this aspect of Ms C's complaint.

In relation to nursing care, we found that whilst many aspects were reasonable, there was a failure to swab Mrs A's leg ulcers on admission to the hospital and this was a breach of the board's standard operating procedure on

meticillin-resistant Staphylococcus aureus (MRSA - a type of bacteria that is resistant to several widely used antibiotics). Mrs A's leg ulcers were found to be MRSA positive when she transferred to another hospital. We upheld this aspect of Ms C's complaint. However, we were unable to conclude if this could have been avoided if Mrs A had been swabbed on admission.

We found that the decision to transfer Mrs A to another hospital was unreasonable given Mrs A's condition and we upheld this aspect of Ms C's complaint. However we found that her family were appropriately advised of this and did not uphold the complaint about communication of the transfer.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B for failing to swab Mrs A's leg ulcers for MRSA on admission and unreasonably transferring Mrs A to a different hospital. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• The multidisciplinary team should satisfy themselves that a patient is suitable and fit before being transferred.
• Staff should follow the board's MRSA Standard Operating Procedure.

Summary

Ms C complained about the board's assessment of a referral that was made for her child (Child A) to the child and adolescent mental health services. Ms C considered that it was clear from the referral that Child A had not been appropriately assessed by the GP and that the board had failed to appropriately risk assess the situation based on Child A's history of suicidal ideation and

self-harm. We took advice from a consultant in child and adolescent psychiatry. We found that the assessment and action taken when the board received the referral was reasonable and therefore we did not uphold this aspect of Ms C's complaint.

Ms C also complained about the board's handling of her complaint. We found that there were delays in responding and some information was not provided. We found that this was in part due to the complexity and scope of the investigation, however, we upheld this aspect of Ms C's complaint.

Recommendations

In relation to complaints handling, we recommended:

• As far as possible, complaints should be responded to in a timely manner, and should be responded to in full. Where a complaint is complex or involves more than one service, a process for handling this should be determined from the outset.