Some upheld, recommendations

Summary

Mr C complained that the council failed to take enforcement action about a neighbour's replacement UPVC windows, which were a breach of planning control. He also complained that the council had failed to take action about the amenity of the same property, due to construction works at the property. Mr C was also unhappy with how his complaint was handled. In particular, he did not feel all the information he provided was fully considered by the council before they responded to his complaint.

The council said that the initial concerns raised about the replacement UPVC windows were not submitted through the appropriate enforcement complaint process. Therefore, they were not investigated as a breach of planning control at that time. The council said that they had investigated Mr C's concerns about the condition of the site but did not consider that there was a level of harm to amenity to justify taking formal action. Mr C was unhappy with this response and brought his complaint to us.

We took independent advice from a planning adviser. The planning adviser considered that the council should have investigated the replacement UPVC windows as a breach of planning control, even though it was not raised through their enforcement complaint process. Therefore, we upheld this aspect of Mr C's complaint.

In relation to the amenity of the property, we found that the council had taken reasonable steps to investigate the complaint about the condition of the site and to assess the harm caused to amenity. Therefore, we did not uphold this aspect of Mr C's complaint.

Finally, we did not uphold Mr C's concern about the council's complaints handling, as we considered that they had taken reasonable steps to address his concerns.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not investigating the breach of planning control.The apology should meet the standards set out in the SPSO guidelines on apology available at: https://www.spso.org.uk/leaflets-and-guidance.

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

• Allegations of a breach of planning control should always be properly recorded and investigated, in line with the relevant planning 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

Mrs C complained that she had been experiencing issues with the heating system in her home for a considerable length of time and that the actions taken by the housing association to resolve the situation were inadequate. Mrs C complained to the association on four occasions in a two year period as at times the heating system was not providing hot water or heating, or at other times was providing uncontrollable heat. The association responded within timescales to her reports of faults, however the repairs carried out did not resolve the issues. Mrs C's final complaint was escalated to senior management and the entire heating system was replaced. The association acknowledged that it had taken too long to fix the problem and upheld her complaint. Mrs C remained dissatisfied and brought her complaint to us.

Whilst we acknowledged that there were elements of the response to the faults that were outwith the association's control, we considered that the responsibility for managing the issues and co-ordinating a response ultimately lay with the association. We acknowledged that during the process the association had provided good customer service; providing an alternative heating supply, installing an electric shower, offering a good will payment and reimbursing Mrs C for her extra energy costs. However, on balance, we upheld this part of the complaint as we found that it had taken the association too long on the whole to fix the problem.

Mrs C also complained about the response she had received from the association to her complaints. We found that the association had provided a reasonable explanation regarding the actions taken to resolve the heating system issues, mitigated the financial impact of the problem and apologised to Mrs C. We did note that the association failed to signpost Mrs C to the next stage of the complaints process on a number of occassions. However, on balance, we did not uphold this part of Mrs C's complaint.

Recommendations

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

• Update their repairs policy to have a process for considering escalating repairs where issues have recurred three times or more.

In relation to complaints handling, we recommended:

• Provide information about how to escalate complaints at the end of every complaint response and stage.

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, who is an MSP, complained on behalf of his constituent (Ms B) about the support provided to her child (Child A). Child A had a number of developmental and behavioural disabilities and had attended mainstream education facilities while in primary school. However, shortly after their transition to secondary education, they started experiencing difficulties and stopped attending school. Ms B applied for self-directed support (SDS, a package that allows individuals to choose how they receive their social care and support) for Child A and an assessment took place. The SDS budget was approved but Ms A did not receive a payment for a considerable amount of time. Mr C complained about the time taken for the SDS assessment to be completed and payment to be made. He also complained about the general level of support provided by the partnership during the period that Child A was out of education.

We took independent advice from a social worker. We found that the time taken to carry out the assessment was significantly outwith the timeframe detailed in the partnership's best practice guide and we did not consider that they provided a reasonable explanation for why this happened. We also found that there appeared to be confusion about the role of the financial assessment within the SDS process and that this had caused unreasonable delays. Therefore, we upheld this aspect of Mr C's complaint.

In relation to the general support provided by the partnership, we considered that their actions had been reasonable. The partnership acknowledged that more support would have been beneficial but explained that they could not have envisaged that Child A would have remained out of school for so long. We found that the actions carried out to support Ms B and try to get Child A back into education were reasonable based on the circumstances and available information at the time. Therefore, we did not uphold this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms B for the delay in carrying out the SDS process and releasing payment. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Reflect on the timescales detailed in the Best Practice Guide and review whether effective processes are in place to monitor whether these timescales are being met.
• Ensure that the role of the financial assessment within the SDS process is clearly understood by all relevant staff and applicants.

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 NHS National Services Scotland’s practitioner services division (PSD) had changed his Community Heath Index (CHI – a ten digit number that identifies a patient in the NHS in Scotland) number without his permission. PSD had given Mr C a new CHI number in order that his results from a national screening programme could be recorded on the relevant database. Mr C was unhappy with this and complained that he did not want to be part of the national screening programme. He asked that the new CHI number was deleted. PSD agreed to do this.

We found that, ideally, PSD should have discussed the matter with Mr C before they changed his CHI number. We also found that PSD had apologised to Mr C for any distress or upset that had been caused. However, Mr C’s complaint was that PSD unreasonably made changes to his CHI number without his permission. We found that PSD were not required to seek Mr C’s permission to make changes to the CHI number. Therefore, we did not uphold this complaint.

Mr C also complained that PSD had failed to ensure that correct information was applied to the new CHI number. He said that PSD had entered a previous GP practice on his record. However, the evidence that PSD sent us showed that the correct details had been recorded for Mr C. There was no evidence that incorrect information had been recorded and we did not uphold this aspect of his complaint.

Finally, Mr C complained that PSD’s response to his complaint had been inaccurate. We found that part of the response had been inaccurate and we upheld this aspect of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that the response to his complaint included inaccurate information. The apology should meet the standards set out in the SPSO guidelines on apology available at https://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

Mr C complained on behalf of his late wife (Mrs A). Mrs A attended the Emergency Department (ED) at the Royal Infirmary of Edinburgh. When she attended she was unable to walk and required a wheelchair. Mr C said that Mrs A waited for nearly four hours before she was seen by a doctor, during which time her requests for pain relief were ignored. He complained that the care and treatment given to Mrs A in the ED was unreasonable. He also complained that the board gave incorrect or inaccurate information when they responded to his complaint about this.

We took independent advice from a consultant in emergency medicine. We found that in the ED Mrs A had been appropriately examined, that many aspects of her care were reasonable and that she was appropriately discharged. However, we found that she was not assessed, and reassessed, for her pain as she should have been. We found that she was given two paracetamol three hours after arriving, and then oral morphine an hour and a half later. However, we found that this delay was unreasonable and contrary to the Royal College of Emergency Medicine guidelines. We upheld this part of Mr C's complaint.

We found no evidence that the board had provided Mr C with incorrect or inaccurate information, and so 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 that Mrs A's pain was not promptly assessed/reassessed and for the delay in providing pain relief.

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

• The Royal College of Emergency Medicine guidelines (management of pain in adults 2014) should be implemented.

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 attended an antenatal screening which tested for Down's syndrome before the birth of her child (Child A) and it was determined that she was at low risk to have a child with this condition. Following the birth, Child A was diagnosed with Down's syndrome. Ms C said that the board's communication with her about Down's syndrome, before and after the birth was unreasonable.

During the pregnancy, an ultrasound scan confirmed Child A had a hole in their heart. Child A died a few months after birth and Ms C complained that the board had unreasonably failed to diagnose, discuss and treat Child A's heart condition and breathing problems.

We took independent advice from a midwife and consultants in cardiology, emergency medicine and neonatology. We found that, before the birth of Child A, Ms C was given reasonable information about the Down's symdrome screening process but after their diagnosis there was little evidence of what had been said and discussed. There was no record of the conversation telling Ms C about Child A's diagnosis and the immediate plan for them. We upheld this aspect of Ms C's complaint.

In relation to Child A's heart condition and breathing problems, we confirmed that there are limitations in the antenatal screening process, with screening identifying only half the number of heart defects. We found that Child A's heart and breathing problems had been reasonably diagnosed and treated but that there were also lung problems which could have not been predicted. We did not uphold this aspect of Ms C's complaint.

Recommendations

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

• Full records require to be maintained and available for a clinical audit trail and scrutiny.

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 care and treatment provided to his late mother (Mrs A) at Monklands Hospital. In particular, he complained that Mrs A had been inappropriately discharged. He also complained that the board's communication about Mrs A's positive Methicillin-resistant Staphylococcus aureus (MRSA, a strain of antibiotic-resistant bacteria) result was unreasonable.

We took independent advice from a consultant in acute medicine and a nurse. Regarding Mrs A's discharge, we found that she had been fit for discharge and that the discharge planning for her had been reasonable. We also found that Mrs A's nutritional care had been reasonable. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to the communication about the positive MRSA result, we found that the level of communication with Mr C and his family had been unreasonable and that the board had failed to follow their policy for the control and management of patients colonised or infected with MRSA. We also noted that the board had accepted and apologised for the breakdown in communication in relation to the MRSA result. We upheld this aspect of Mr C's complaint.

Recommendations

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

• The policy for the control and management of patients colonised or infected with MRSA should be adhered to. In particular, the patient/relative should be informed about a positive result, given a copy of a MRSA patient information leaflet and that this should be documented in the medical records.

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 care and treatment provided to him at the Queen Elizabeth University Hospital. Mr C had suffered visual disturbance and had attended the Emergency Department (ED). He was assessed and discharged as there were no abnormal findings. The following day, Mr C attended the ED again as he again was suffering from visual disturbance, and also had some leg numbness. Clinical examination was again normal and he was discharged. Later that day, Mr C attended the ED again with new symptoms of facial muscle weakness. He was admitted for further investigation and was found to have suffered a stroke. Mr C complained that it took three attendances for him to be diagnosed and he felt that if he had been given treatment on his first attendance the visual loss which he subsequently suffered would have been prevented.

We took independent advice from a consultant in emergency medicine and from a consultant stroke physician. We found that, whilst the overall standard of Mr C's care and treatment was reasonable, on his second attendance the possibility of transient ischaemic attack (a ‘mini stroke’ caused by temporary disruption of blood supply to the brain) should have been considered. We, therefore, upheld this aspect of Mr C's complaint.

Mr C also complained that he had not received appropriate follow-up. We found that follow-up was of a reasonable standard and, therefore, did not uphold this aspect of Mr C's complaint.

Finally, Mr C complained that the board failed to respond to his complaint in a timely manner. We found that the board had taken well over 20 working days to respond to his complaint, and had failed to keep him updated about the delays. 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 the failure to consider the possibility that he had suffered a transient ischaemic attack. 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:

• In similar circumstances, a differential diagnosis of transient ischaemic attack should be considered.

In relation to complaints handling, we recommended:

• Where a complaint response takes more than 20 working days, the board should explain the reasons for the delay and agree a new 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

Ms C, an advocacy worker, complained on behalf of her client (Mrs B). Mrs B was concerned about the care and treatment her husband (Mr A) received during his admission to Queen Elizabeth Hospital. Mr A had suffered a broken neck in an accident and he was being treated with a neck brace. Ms C's main concern related to Mr A swallowing his dental plate and explained that this was not discovered for almost two weeks even though Mr A had a sore throat and difficulties swallowing. Ms C also complained about the nursing care and that there was inadequate communication with Mr A's family. In particular, when his condition deteriorated and he was thought to have sepsis (a blood infection). Finally, Ms C complained that the board's handling of the complaint was unreasonable and that no significant clinical incident review was carried out.

We took independent advice from a consultant orthopaedic trauma surgeon (a surgeon who diagnoses and treats a wide range of conditions of the musculoskeletal system) and a registered nurse. The board considered that swallowing a dental plate was a very unusual occurrence so it was reasonable this was not suspected by hospital staff. We found that the medical treatment initially received for Mr A's swallowing and eating difficulties was appropriate. However, we found there was an unreasonable delay in referring Mr A to ear, nose and throat and this delayed the discovery of his swallowed dental plate. We upheld this aspect of Ms C's complaint.

In relation to the nursing care received, we found that Mr A was given a reasonable level of personal care and his food input and fluid intake was appropriately monitored by staff. We noted that nursing staff recognised Mr A's difficulties swallowing and eating and made appropriate referrals. Therefore, we did not uphold this aspect of Ms C's complaint.

In relation to communication, we found that communication with Mr A's family was not to the appropriate standard. We upheld this aspect of Ms C's complaint. However, we noted that the board had acknowledged this failing and had apologised to Mrs B.

Finally, we found that the board failed to commmunicate clearly about meeting to discuss the complaint or about the significant clinical review and it's findings. 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 making the referral to ear, nose and throat; and for the failings in their communication about meeting with her and about the significant clinical incident review. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Provide Mr A's family with a copy of the significant clinical incident review.

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

• Ensure there is appropriate communication with patients and/or their families during, and at the conclusion of, significant clinical incident reviews.

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 on behalf of his wife (Mrs A) about the care and treatment she received at the Royal Alexandra Hospital. Mrs A experienced a traumatic birth when problems with the fetal heart occurred and an emergency caesarean section was required. Mr C complained that both the obstetrics (the field of medicine concerned with pregnancy, childbrith and the post-birth period) and midwifery care was unreasonable.

We took independent advice from a consultant obstetrician and from a midwife. We found that consideration could have been given by the obstetric staff to the possibility that the drug terbutaline (medication to stop uterine contractions) could have resulted in improvement in the fetal heart rate. We also noted that there was insufficient evidence to show that a thorough debrief of the birth took place with Mrs A. However, we found that the overall obstetric care during Mrs A's admission was appropriate and that the problems with the fetal heart rate were promptly recognised, with timely action being taken to deliver the baby in line with national guidance. We did not uphold this aspect of Mr C's complaint but made recommendations to the board in light of the failings identified.

In relation to the midwifery care Mrs A received, we found that there was a lack of evidence to show what action had been taken when it was recorded that she was in discomfort when being triaged around the time of admission to hospital. There were also insufficient records to show that Mrs A had been kept informed about the baby's progress while in the special care baby unit; however, we noted that the board had apologised for this failing. We also found that there was poor record-keeping to demonstrate what information had been shared with Mrs A when she was discharged from hospital, particularly in relation to advice regarding self-administration of blood thinning medication and advice regarding breastfeeding given she had experienced problems during her admission. We were also critical of the lack of evidence to show what information had been shared with the community midwifery team at the time of discharge. Finally, we considered that there was no evidence of assessment or support of Mrs A's psychological needs during her admission. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failings in addressing Mrs A’s discomfort and psychological needs, the lack of information given to her, and the community midwives, on discharge and for the failings in record-keeping. The apology should meet the standards set out in the SPSO guidelines on apology available at: https://www.spso.org.uk/leaflets-and-guidance.

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

• Where appropriate for patients in labour, consideration could be given to the administration of terbutaline, in accordance with national guidance.
• In a similar situation patients should be adequately debriefed and this should be properly recorded in the medical notes.
• Patients should be properly advised on any discharge medication and this should be properly documented in the medical notes.
• Midwifery patients should receive appropriate assessment of their needs, including any psychological needs, during admission which should be appropriately planned and documented.
• Midwifery patients should have their pain/discomfort suitably assessed and acted on when in triage.
• In a similar situation midwifery patients should receive detailed information in relation to the care and treatment of their baby and this should be properly recorded in the midwifery notes.
• Midwifery patients and community midwives (on handover) should receive adequate information on their care and treatment on discharge. This should include the discharge plan for women and babies leaving hospital, that each woman has received a copy of Ready Steady Baby, that there has been an effective handover between the hospital and community midwifery staff, and the guidance and support given to women having difficulties breastfeeding.

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.