Some upheld, recommendations

Summary

Mr C complained about a cafe premises near his property. The complaint included issues relating to the operation of a kitchen in the basement of the cafe and the placing of seating and tables outside the front of the cafe.

In relation to the operation of a basement kitchen, Mr C stated that the council failed to enforce building standards within a reasonable period of time after becoming aware of the fact that the cafe was operating a kitchen in the basement. We found that the council had made efforts over a period of time to get the cafe owner to comply and remove the basement kitchen, however, the cafe owner did not comply. Given the period of time that had passed it was clear that negotiations were not successful. We noted that the council have discretion regarding whether or not they will take enforcement action. However, we considered that the council should have taken a proactive approach and confirmed if the current situation was acceptable to them and why, or take suitable enforcement action within a reasonable period of time. Therefore, we upheld this aspect of Mr C's complaint.

Mr C also complained about a failure on the part of the council to address health and safety breaches in relation to the café's kitchen. We considered that the council are required to make their decision regarding the existence of the basement kitchen clear before it could be determined if the council required to seek further compliance with the health and safety matters raised. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to the seating and tables, Mr C complained that the cafe had not applied for planning permission for outdoor seating and the council had failed to address this within a reasonable period of time. We found that the cafe owner had signed The Street Cafe Annual Agreement that stated that planning permission must be obtained. We noted that the council were aware of the fact that this had not been obtained. We considered that the council should have confirmed that they were content to accept the current position and explain why they did not consider planning permission was required or what steps would be taken to ensure compliance. Therefore, we upheld this aspect of Mr C's complaint.

Mr C also considered that the cafe had breached the Street Cafe Annual Agreement in relation to several other areas. The council stated that the breaches were minor and they accepted them. We found that it was not reasonable for the council to make a determination on these matters until they had decided whether or not they accepted the seating outside the cafe without planning permission being obtained. 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 clarify whether or not they intend to take enforcement action or exercise discretion in relation to a breach of the Street Café Annual Agreement and in relation to the creation and operation of a basement kitchen. The council should also apologise for taking a view on breaches of the Street Café Annual Agreement when it was not reasonable to do so until they had clarified their position on another breach relating to a lack of planning permission. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• The council should clarify whether or not (i) they intend to take enforcement action in relation to a breach of clause eighth of the Street Café Annual Agreement or (ii) exercise discretion and accept the current position without planning permission, and provide reasons for doing so. The council should clarify (i) whether or not they intend to take enforcement action in relation to the creation and operation of a basement kitchen or (ii) exercise their discretion and accept the current position without building regulation requirements and explain their reason for doing so.

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

• Where the council have been unsuccessful in asking a customer to comply with planning or building regulation requirements they should establish on a case by case basis a timescale in which they should reach a decision on whether or not they intend to take enforcement action or exercise their discretion in accepting the current position and provide reasons for doing so.
• Ensure there is a reporting mechanism within Development and Regeneration Services so that information can be shared about complaints received and breaches identified that impact on the decisions made by other departments.

Summary

Mrs C's child (Child A) was injured by another child while at school. Mrs C said that she was not contacted until around two hours after the incident and complained that the school failed to act in an appropriate and reasonable manner. Mrs C was also unhappy that the school had recorded Child A as being a participant in a fight rather than being assaulted and that the level of support provided to Child A after their return to school was unreasonable.

In their responses to Mrs C, the council indicated that the priority after the incident was to establish what had happened. Their responses were unclear, however, in terms of whether they understood Child A to have been displaying signs of a head injury after the incident. The council stated that the school followed NHS advice on head injuries and provided us with a copy of this. However, we noted that there was no direct reference to the NHS advice in staff statements, incident reports or the council's response to Mrs C. In their response to Mrs C, the council acknowledged that they should have handled things differently and did not contact her soon enough. They also stated that they had a new procedure in place in respect of head injuries at school. However, the evidence we reviewed showed a confused account of events and, as a result, we upheld this aspect of Mrs C's complaint.

In respect of the school recording the incident as a fight, we considered this reasonable. We found that the school accepted that Child A had been assaulted and made clear that the reference to a fight was in relation to what lead up to the assault. The account recorded by the school was based on multiple accounts of what happened. In addition to this, we saw nothing in the evidence provided to us that indicated that the school held the view that Child A was partially or wholly at fault for the way the incident escalated. Finally, the council indicated that they were happy for additional information Mrs C wanted to record to be appended, if appropriate. We concluded that the school and council provided a reasonable justification for why the incident was recorded this way and did not uphold this aspect of Mrs C's complaint.

In relation to the support Child A received after their return to school, we found that the school had made appropriate arrangements and that Child A did not take up everything that was offered. We acknowledged that a laptop had not been made immediately available for Child A but noted that this was addressed in a phone call with Mrs C and one was provided the next day. Finally, we considered that a risk assessment had been completed and reviewed appropriately. Therefore, we did not uphold this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for not taking reasonable action following reports that Child A had sustained a head injury, clearly acknowledging where there has been fault. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsand-guidance.

Summary

Mr C complained that the partnership failed to handle his complaint properly and that they had not responded to his concerns about his child.

We found Mr C had made his complaint prior to 1 April 2017. This means that his complaint should have been progressed under the old social work complaints procedure with a Complaint Review Committee hearing as the final stage in the process. Although Mr C had evidence that he had requested that his complaint be escalated, this had not happened. We found that the partnership had incorrectly signposted Mr C to us (as per the new social work complaints procedure introduced from 1 April 2017). Therefore, we upheld this aspect of Mr  C's complaint.

We were unable to consider Mr C's second complaint as it had to have gone through the appropriate complaint process.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to handle his complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsand-guidance.

In relation to complaints handling, we recommended:

• The partnership should allow Mr C to progress his complaint through the process that was in place prior to 1 April 2017.

Summary

Mr C complained about the treatment he received from the board for pain in his thigh. Mr C said that he attended Perth Royal Infirmary and Ninewells Hospital over nearly a three year period for treatment for his condition and was seen by three different consultant vascular surgeons (a specialist in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels). Mr C said he was not satisfied with the treatment suggested by the consultants and was subsequently seen and assessed by a surgeon at a private hospital, who carried out treatment which cured the pain in Mr C's thigh.

We took independent medical advice from a consultant vascular surgeon. We found that Mr C's treatment by the board was reasonable and found no failings in the treatment offered. Therefore, we did not uphold this part of Mr C's complaint.

Mr C also complained that the board failed to provide him with an adequate response to his complaint. We found that aspects of the board's response to Mr C's complaint did not appear to match with the evidence in the medical record and the response also failed to answer all Mr C's questions at the end of his letter of complaint. Therefore, we upheld this part of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure in complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance

In relation to complaints handling, we recommended:

• Responses to complaints should take into account the evidence in the medical records and address all the issues raised, in accordance with the NHS Scotland Complaints Handling Procedure.

Summary

Mr C complained that his wife (Mrs A) had undergone open heart surgery at Edinburgh Royal Infirmary when she had been due to undergo a less invasive procedure. Following surgery, Mrs A was transferred to another hospital where she died shortly afterwards. Mr C said that his wife suffered from dementia and could not have understood the decision to change the procedure or have provided informed consent. Mr C noted he had welfare power of attorney and accompanied his wife to all her appointments. Mr C said that he had not been informed about the change of procedure. Mr C also complained that Mrs A was unreasonably discharged to another hospital. Mr C felt that Mrs A would have survived if she had been treated differently.

We took independent medical advice from a consultant cardiothoracic surgeon (a specialist who operates on the heart, lungs and other chest organs). We found that Mrs A's procedure was changed after an appropriate assessment of the risks of both types of surgical procedure and that it was reasonable to proceed with open heart surgery. There was no evidence that Mrs A's chances of survival were compromised by this decision. We also found that an assessment had been carried out which found that Mrs A had a mild memory impairment, however, medical staff were satisfied that she had the capacity to understand and consent to the change in procedure. We considered that this was reasonable. Therefore, we did not uphold these aspects of Mr C's complaint.

In relation to the hospital transfer, we found that this was unreasonable given Mrs  A's condition. We upheld this aspect of Mr C's complaint. However, we could not determine that Mrs A would have survived if this had not taken place.

In relation to the board's communication with Mr C and his family, we found that Mrs A had been in hospital for over a week prior to the procedure due to a chest infection and that Mr C had been present every day. We considered that the board should have discussed Mrs A's care when Mr C was present. Therefore, we upheld this aspect of Mr C's complaint. We noted that the board had acknowledged and apologised for this failing.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for unreasonably deciding to transfer Mrs A to another hospital before she had sufficiently recovered from surgery. 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:

• Review their policies and procedures for patient transfer to ensure that distance travelled is taken into account as part of the decision.

Summary

Mrs C complained about the medical and nursing care and treatment her late mother (Mrs A) received when she was admitted to Lorn and Islands Hospital. She also complained about the communication with her family and that the board had failed to handle her complaint in a reasonable way.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nursing adviser. We found that it was difficult to provide an overall view about the medical care and treatment given to Mrs A due to the length and complexity of her admission. However, we found there had been a delay in diagnosing Mrs A's delirium and that she had a urine infection. We also found that the death certificate process was handled insensitively. Therefore, we upheld this aspect of Mrs C's complaint.

In relation to the nursing care given to Mrs A, we found no failings on the part of nursing staff regarding Mrs A's dehydration, dietary intake and her personal care. Therefore, we did not uphold this aspect of Mrs C's complaint.

In relation to communication, we found that the nursing communication was reasonable. However, we found that there was a delay in medical staff communicating the results of a CT scan and the overall assessment of Mrs A's health to Mrs C. Therefore, we upheld this aspect of Mrs C's complaint.

Finally, in relation to complaint handling, we found that the board had failed to comply with their complaints handling procedure and we upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in clinical care, communication and complaint handling. 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:

• Staff should be aware of the potential for elderly patients to have delirium. Staff should be careful and sensitive with the death certification process and junior doctors should have senior supervision of this process as set out in national guidance.
• Families or carers should be involved in identifying delirium. Results of CT scans and the overall assessment of a patient's health should be communicated timeously to families.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the complaints handling process.

Summary

Ms C complained about the care and treatment she received at the GP out-of-hours service at Gartnavel General Hospital when she attended with a rash and bruising on her legs. We took independent advice from a GP. We found that the examination carried out within the out-of-hours service was reasonable and it was reasonable that Ms C was referred to the Immediate Assessment Unit (IAU) rather than A&E. We did not uphold this aspect of Ms C's complaint.

Ms C also complained about the care and treatment she received within the IAU at Queen Elizabeth University Hospital. We took independent advice from a consultant in acute medicine. While most of the care and treatment that Ms C received was appropriate, we found that it was unreasonable that Ms C was not assessed for signs of bleeding when an initial low platelet (cells that help blood clot) result became available. 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 the failure to carry out an assessment for signs of bleeding when the initial low platelet result became available. 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:

• Patients with a low platelet count should be assessed for signs of bleeding.

Summary

Mr C attended the Western Infirmary Hospital a number of years ago when he was experiencing dizziness and migraines. Mr C was referred for an MRI scan to investigate his condition further. Several years later, Mr C was diagnosed with a schwannoma (a tumour on the nerve tissue). His original MRI scan images were reviewed and he was told that the tumour had been visible at that time.

Mr C complained that there was a failure to investigate the tumour when he first attended hospital as it had been visible in his MRI scan. We took independent advice from a consultant neuroradiologist (a radiologist who specialises in the use of radioactive substances, x-rays and scanning devices for the diagnosis and treatment of diseases of the nervous system). We found that in retrospect, the tumour was visible in the original MRI scan. However, as it was small and not clearly defined, we found it was reasonable that it was not identified at that time. We found that even if the tumour had been identified then, it was reasonable for it not to have been reported as it was only borderline abnormal. We also found that Mr C did not yet have any sign of a neck tumour or any symptoms relating to it. We did not uphold this aspect of the complaint.

Mr C also complained that the board failed to provide an appropriate response to his complaint. We found that their response did not accurately identify all of his concerns or provide a reasonable response to them. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not accurately identifying and providing an appropriate response to all aspects of his complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at: www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complaints responses should accurately identify and provide a reasonable response to all the issues of concern.

Summary

Ms C, an advocacy and support worker, complained on behalf of her client (Mrs  A) about the medical and nursing care and treatment Mrs A received when she was admitted to Aberdeen Royal Infirmary. Ms C also complained about Mrs  A's discharge, delays in receiving a neuropsychology (the study of the relationship between behaviour, emotion, and cognition on the one hand, and brain function on the other) assessment and neurosurgery (surgery on the nervous system, especially the brain and spinal cord) follow-up and that the board had failed to respond to her complaint in a reasonable way.

We took independent advice from a consultant neurosurgeon and a nursing adviser. We found that both the medical and nursing care and treatment given to Mrs A was reasonable. We did not uphold these aspects of Ms C's complaint.

In relation to Mrs A's discharge, we found that Mrs A had been medically fit for discharge and that nursing staff had reasonably managed the discharge planning. However, the board accepted that there had been a failure to provide appropriate information and literature to Mrs A and her family on discharge and had taken action as a result of these failings. We upheld this aspect of Ms C's complaint.

In relation to Mrs A's neuropsychology assessment, we found that there had been a delay in arranging this. We also found that Mrs A was not advised of the progress of her neurosurgery follow-up appointment when the timescale was not met. Therefore, we upheld these aspect of Ms C's complaint.

Finally, we found that the board had failed to comply with their complaints handling procedure and we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for the delay in providing a neuropsychology assessment, failing to update her on her neurosurgery review appointment and for the failings in complaint handling. 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:

• Patients should receive a neuropsychology assessment, as part of post head injury follow-up, in a timely manner.
• Patients waiting on review appointments with the neurosurgery department should be updated on the progress of their appointments.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the complaints process, including that all issues raised in complaints should be addressed.

Summary

Mrs C attended the emergency medicine department at Victoria Hospital with abdominal pain. She was reviewed by medical staff and it was considered that she probably had pain related to possible endometriosis (a condition where the tissue that lines the womb is found outside the womb, such as in the ovaries and fallopian tubes). She was discharged home and advised to see her GP. On the following day, Mrs C was admitted to the surgical admissions ward at the hospital under the care of a general surgery consultant. Blood tests were carried out and she was started on intravenous antibiotics. She was found to be improving and was discharged. Mrs C was readmitted to the hospital just over one month later. An ultrasound scan was carried out and an ovarian cyst was detected. Mrs C subsequently had surgery to remove the cyst.

Mrs C complained that she had not received a reasonable standard of care and treatment when she attended the emergency department. We took independent advice from an emergency medicine consultant. We found that the standard of assessment and treatment she received there had been reasonable. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained about the surgical care and treatment she received when she was admitted to the hospital. We took independent advice from a general surgery consultant. We found that Mrs C should have had a magnetic resonance imaging (MRI) scan or computerised tomography (CT) scan during or shortly after her initial admission. The delay in carrying this out delayed her subsequent surgery. Therefore, we upheld this aspect of Mrs C's complaint.

Mrs C also complained about the medical care and treatment she had received during her admissions. We found that she should have had early medical investigation to establish an underlying cause for her symptoms during or shortly after the initial admission. In addition, although antibiotics were prescribed and given, there was no evidence that the sepsis pathway plan was implemented. Although it had been reasonable to discharge Mrs C from hospital after her first admission, additional investigations should had been carried out whilst she was an in-patient or shortly after her discharge. In particular, she should have had a repeat test to ensure her blood tests were returning to normal. We also upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in carrying out a scan and in diagnosing that she had an ovarian cyst and for the failure to carry out repeat blood tests during or shortly after her first admission to 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 board should ensure that patients receive the appropriate tests.