Some upheld, recommendations

Summary

Mr C's application for a blue badge was refused by the council. At the end of the appeals process Mr C raised detailed concerns about the assessment and the application of the guidelines. The council responded to the complaint by re-stating the decision to refuse the blue badge and addressing various other points raised with respect to the process. Mr C was unhappy with the response and brought his complaint to us. Mr C complained that the council failed to demonstrate that they took into account the information he provided in relation to his appeals and that they failed to address the specific points raised in his complaint.

We found that the correspondence between the council and Mr C showed that the council had taken into account Mr C's information, and supporting evidence, when considering his appeals. Therefore, we did not uphold this complaint. We did, however, provide feedback to the council that further explanation for decision to refuse applications, with specific reference to relevant guidelines, may help clarify their decision making.

In regards to the councils complaints handling, we found that their response to Mr C's complaint failed to address any of the points that he had raised with respect to the assessment process or inconsistencies in application of the guidelines to his circumstances. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Mr C with a further response that appropriately addresses the complaints raised in his letter.

In relation to complaints handling, we recommended:

• Council staff should be reminded of the complaints handling procedure and the importance of ensuring people are directed to register their concerns as complaints where appropriate.

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 to the council about the smell coming from local industrial premises. After monitoring the situation, the council identified a statutory nuisance and issued an abatement notice to the owners of the company concerned. The company did not meet their original compliance date, however, a couple of months later the council confirmed that the problem of odour had been satisfactorily addressed and that as no recent complaints had been made, the company had complied with the notice.

Mr C disagreed that the odour had been addressed and continued to make complaints. He complained to the council about their failure to deal reasonably with his concerns. The council felt that no statutory nuisance remained and that no further complaints had been made. Mr C complained to us that he was unhappy with the council's reply to his complaint and that it contained incorrect information.

We took independent advice from a chartered environmental health officer. We found that the council had taken reasonable action in responding to Mr C's complaints by carrying out full investigations, issuing the correct notices, monitoring the action taken and keeping Mr C updated on the process. While the council subsequently took the view that the statutory nuisance had been remedied, Mr C continued to complain. However, assessment after Mr C's further complaints led the council to confirm that the level of odour was acceptable. Therefore, we did not find the council's response to Mr C's complaint to be unreasonable and did not uphold this aspect of Mr C's complaint. However, in writing to him, the council had said that no further complaints were made after they confirmed the nuisance had abated. This was incorrect in that Mr C maintained his complaints. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for providing him with incorrect 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 made several complaints to the housing association about the noise levels in his flat. Sound tests were carried out, which showed that the sound levels did not meet the required standards. The association agreed to carry out sound insulation to Mr C's floor and walls, if Mr C moved out of the flat during the works. Mr C was reluctant to do this, as he suffers from agoraphobia (a fear of being outside). Mr C also wanted the association to use specific materials for the works. Following some months of negotiation, the details of the works were agreed. The association agreed that Mr C could stay in the flat during part of the works, and that he would move out on a daily basis during other parts, being escorted to and from temporary accommodation by their staff each day. The association also agreed to use the specific materials that Mr C requested.

The works were undertaken over a three month period. Mr C was dissatisfied with the results, and he complained that the association did not use the agreed materials. He was also unhappy with the amount of time taken to complete the works, and was not satisfied with the work carried out in the kitchen recess, which had reduced the space available. He felt that the association had discriminated against him by requiring him to leave the flat unnecessarily and he said that his neighbour had received preferential treatment because works on their flat were carried out within a quicker timeframe, and they were not required to move out.

The association did not uphold Mr C's complaint at first, but when he provided photos and video evidence with his complaint to us, they agreed to carry out more investigations, including taking samples from Mr C's walls. They found that their usual materials had been used, instead of the different materials agreed, and they agreed to redo this work.

We took independent advice from an equalities adviser. As the association had failed to use the agreed materials, we upheld this part of Mr C's complaint. We did not consider the time taken for the works to be completed was unreasonable, as the work had to be undertaken in phases because Mr C was still living in the flat. We did not uphold this part of Mr C's complaint. We found Mr C did not object to the kitchen wall being modified as part of the work and he would have been aware that this work was planned. Therefore, we did not uphold this part of his complaint. We found that Mr C had agreed to move out while the association completed works to the floors, but they had also asked him to move out while they completed some of the works to the walls. We found that the association did not have clear records of why they asked Mr C to leave during the works to the walls, and that their overall record-keeping regarding reasonable adjustments was poor. However, on the whole we considered that the association had taken their equalities obligations into account, as they had made a number of adjustments in view of Mr C's disability. 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 failing to use the agreed specifications for the works. 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 a customer discloses a disability, there should be a clear record of this and the reasonable adjustments agreed (including any changes to the agreement).

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, who is an advocacy and support worker, complained on behalf of her client (Mr A). Mr A had an operation at Ninewells Hospital and continued to suffer pain for over a year after the operation. Ms C complained that:

Mr A suffered unreasonable pain after his operation;

Mr A had to wait an unreasonable amount of time to be assessed about his pain management;

the board took an unreasonable length of time to establish the source of Mr A's pain;

the board provided an unreasonable treatment pathway for Mr A's chronic pain; and

the board unreasonably failed to tell Mr A that he could have obtained alternative treatment outwith their area.

We took independent advice from consultants in surgery, anaesthetics and pain management. We found that Mr A did have to wait too long for a referral to the pain clinic, where there were further delays in him being seen. We upheld Ms C's complaint that Mr A had to wait an unreasonable amount of time to be assessed about his pain management.

We found that Mr A did suffer from pain after his operation, but that the care and treatment he had been given had been reasonable. We also found that the approach used to assess Mr A's pain was the correct approach, though it did take time. We found that Mr A's treatment options within the board had not been exhausted. We, therefore, did not uphold any of the other aspects of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the delays in him being seen by the pain clinic. 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:

• Action should be taken to ensure that patients are seen in a timely manner.

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 and Mrs C complained that midwives at Gilbert Bain Hospital failed to recognise that Mrs C had hyponatraemia (low blood sodium levels). Mrs C was given advice to drink more fluids, which made her condition more severe. Mr and Mrs C also complained that the board failed to handle their complaint and the review into Mrs C's care appropriately. In particular, they considered the review wrongly concluded Mrs C had a condition called syndrome of inappropriate antidiuretic hormone production (SIADH - the excessive secretion of antidiuretic hormone resulting in, among other things, water retention and dilution of the blood) when she actually had hyponatraemia. Mr and Mrs C considered the board failed to identify appropriate learning from the review and share it with them.

The board accepted that Mrs C was given inappropriate advice to drink fluids by midwives. However, they said it was unreasonable to expect midwives to have recognised she had SIADH, as it is very rare. The board considered they had undertaken a thorough review of Mr and Mrs C's care and complaint. They explained they had taken learning from it forward by training staff on recognising SIADH.

During our investigation we took independent medical advice from a midwife and from a consultant in general medicine.

The midwife adviser considered that the midwives carried out appropriate observations and tests in light of Mrs C's symptoms. They considered the advice given to Mrs C to drink more fluids was reasonable in light of those symptoms. Therefore, we did not uphold this aspect of the complaint.

The midwife adviser considered that the board undertook an appropriate review into Mrs C's care. However, there was a delay in sharing the action plan with Mr and Mrs C. The general medicine adviser considered it was reasonable that the board diagnosed Mrs C with SIADH following the review. They explained that Mrs C had hyponatraemia, which can have many causes, one of which is SIADH. However, given hyponatraemia is much more common than SIADH, the general medicine adviser considered the board should have trained staff on recognising and treating hyponatraemia as well as SIADH. In light of the failings we found in identifying learning from the review and in sharing it with Mr and Mrs C, we upheld this aspect of the complaint. We made recommendations in light of our findings.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for failing to appropriately identify the learning from their case and share it with them at the time. 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:

• Reviews should be transparent and any learning should be shared with all those involved in the adverse event, including patients.
• The board should provide a reasonable standard of care to patients with hyponatraemia, whatever its underlying cause, with adequate staff training in place to support this.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Ms C, who is a patient adviser, complained on behalf of her client (Mrs A) about the care and treatment provided to Mrs A at the Royal Infirmary of Edinburgh. Mrs A attended hospital for a planned coronary artery bypass graft (a surgical procedure used to treat coronary heart disease). After a week of in-patient care, medical staff were satisfied that Mrs A had recovered well and was fit to be discharged. Mrs A became unwell shortly following discharge and was re-admitted to a different hospital with an infection. Ms C raised a number of concerns on behalf of Mrs A, who felt that the care provided by the board was inadequate.

Firstly, Ms C complained that staff failed to monitor Mrs A's condition appropriately. We took advice from a cardiac surgery adviser and a nursing adviser. We found that appropriate monitoring did take place during Mrs A's recovery from surgery and that appropriate records of this were maintained. We did not uphold this part of the complaint.

Ms C also raised concern that staff did not listen to and document concerns raised by Mrs A, and did not keep appropriate records of attempted blood tests. We found no evidence in the records that staff did not listen to and document Mrs A's concerns about her health. We were also satisfied that the medical and nursing records were maintained to a reasonable standard. We did not uphold this aspect of the complaint.

Finally, Ms C complained that Mrs A was inappropriately discharged home with an infection. Ms C raised concern that Mrs A was left waiting for a number of hours in the discharge lounge whilst her condition deteriorated and that staff then failed to readmit her to the ward. We found no evidence from the records of the admission that Mrs A had an infection prior to discharge. However, the advice we received highlighted that Mrs A remained in atrial fibrillation (fast irregular heartbeat) on the day of discharge, and that medical staff should have discussed this, and any potential issues that might ensue, with Mrs A prior to discharge. We found no evidence that Mrs A or her husband had reported that her condition was deteriorating whilst she was in the discharge lounge. However, we noted that the board had advised that the senior charge nurse responsible for the discharge lounge had reminded their team that patients who became unwell should be returned to the ward and they were satisfied that the correct procedure would be followed in future.

We were unable to conclude that the complication Mrs A experienced following discharge was as a result of unreasonable care and treatment from staff at the Royal Infirmary of Edinburgh. However, we upheld the complaint and made recommendations because there was no evidence that staff discussed atrial fibrillation with Mrs A prior to discharge.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for failing to discuss atrial fibrillation, and what she should do if she became more unwell, with her prior to discharge. 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 a patient is in atrial fibrillation, but is otherwise ready for discharge, staff should inform the patient of any complications atrial fibrillation might present, what to do if they become more unwell, and confirm with the patient that they feel ready for discharge. This discussion should be documented in the patient's 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

Mrs C complained about the care and treatment her father (Mr A) received from the board at Caithness General Hospital. Mrs C complained that the board unreasonably failed to take into account her father's dementia, unreasonably failed to establish that Mrs C held a welfare power of attorney in respect of her father and unreasonably failed to obtain appropriate consent for a gastroscopy procedure (an examination of the inside of the gullet, stomach and the first part of the small intestine).

We took independent advice from a nurse and from a consultant in acute medicine. Based on the information in Mr A's records and the advice we received, we considered that the board did not unreasonably fail to take into account Mr A's dementia while he was in hospital and we did not uphold this part of the complaint. However, we were concerned that some documents relating to this were not completed by hospital staff and so we made a recommendation regarding this.

On the issue of welfare power of attorney, we found that attempts should have been made to establish if Mr A had a welfare power of attorney within 24 hours of admission. We found that this had taken the board three days and that this was an unreasonably long time for this to take. We upheld this aspect of the complaint.

Mr A had more than one gastroscopy and Mrs C's complaint was that the board had not obtained appropriate consent for the first gastroscopy. We found that it was reasonable for staff to conclude that Mr A had sufficient capacity to give his consent for his first gastroscopy procedure and that appropriate consent was obtained. We, therefore, did not uphold this part of Mrs C's complaint. However, we were concerned about the consent process for Mr A's second gastroscopy and we found that an adult with incapacity form (completed for patients deemed not to have capacity to consent) should have been completed and that the procedure should have been discussed with Mrs C. We also found that the board's response to Mrs C's complaint was inadequate. We, therefore, made recommendations on these matters.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C, Mr A and their family for the failings in establishing if Mr A had welfare power of attorney, the failings in record-keeping and the complaints handling failures. 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:

• Patients' Admission/Care Records and Treatment Escalation Plans should be completed fully and accurately.
• In cases such as this, staff should establish if patients have a welfare power of attorney in a timely manner.
• In cases such as this, staff should obtain appropriate consent for patients' surgical procedures.

In relation to complaints handling, we recommended:

• Information in internal investigations of complaints should be accurately reflected in complaint responses and full explanations of decisions should be provided.

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 the board failed to provide him with clinic appointments within a reasonable timescale. He also raised concern that the board failed to provide him with adequate notice of the cancellation and rescheduling of appointments, and he was unhappy with the board's handling of his complaint.

The board did not provide us with records and correspondence about Mr C's appointments, cancellations and rescheduled appointments. We also found that their own complaints file did not include relevant evidence, such as records of actions taken by staff in relation to Mr C's appointments and the initial handling of his complaint. The board did not explain why they offered Mr C an appointment for nine months after the originally scheduled appointment, and seven and a half months after the first rescheduled appointment that was offered (which Mr C told the board he could not attend). As we did not receive this information from the board, we had to assume that relevant records were not made at the time. We found that the board failed to follow their complaints procedure, as they did not give Mr C a written explanation for delays, updates on progress, or indicate when they expected to be able to reply. In addition, the board failed to send a response to Mr C's second complaint email, apparently due to an administrative error. We upheld all of these aspects of Mr C's complaint.

Mr C also complained that the board did not consult him about his availability for rescheduled appointments. We did not find evidence that the board were required to consult Mr C about his availability for rescheduled appointments, 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 for failing to provide him with adequate notice of the cancellation and rescheduling of appointments, failing to provide rescheduled appointments to him within a reasonable timescale, failing to inform him of the cancellation of a specific appointment, and for handling his complaint unreasonably. 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:

• Relevant staff should be reminded of the process for dealing with cancelled or reduced clinics, and the necessity of keeping records.

In relation to complaints handling, we recommended:

• Staff investigating complaints should obtain the actual evidence, in addition to comments from colleagues on such evidence, and include it in their complaints file.

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 clinical and nursing care and treatment provided to her late husband (Mr A) when he was admitted to the University Hospital Ayr. We took independent advice from a consultant in emergency medicine, a consultant in acute medicine and a nursing adviser.

In relation to the clinical care and treatment provided to Mr A, having considered the available evidence and the advice provided to us we found that, overall, the medical care and treatment Mr A received was reasonable. The advice we received from the consultant in acute medicine was that Mr A's death was not preventable by the time he was admitted to hospital. We did not uphold the complaint. However, whilst the advice we received from the consultant in acute medicine was that cardiac monitoring would not have saved Mr A's life, they considered that the board should have a clear policy regarding which patients require cardiac monitoring. We made a recommendation regarding this.

Regarding the nursing care provided to Mr A, we found that there were gaps in the assessment and monitoring of Mr A and that the board wrongly focussed on anxiety being the cause of Mr A's shortness of breath. We also found that the guidance on using the Modified Early Warning Score (the monitoring of vital signs such as respiratory rate which helps alert clinicians to patients with potential for clinical deterioration or with established critical illness) was not followed, in that Mr A's Modified Early Warning Score was not repeated in line with guidance and there were gaps in the recording of his vital signs which was unreasonable. We further found that Mr A's Modified Early Warning Score should have been repeated on transfer to a new care area. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide a reasonable standard of nursing care and treatment to Mr A. 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:

• There should be clear a policy regarding which patients require cardiac monitoring shared between the emergency department, the critical care unit and the acute medical unit.
• A Modified Early Warning Score should be checked within the recommended time frames. In line with good practice, a Modified Early Warning Score should be checked and documented when a patient is transferred to a new care area.
• When a patient or relative raises concerns about breathlessness, a Modified Early Warning Score should be rechecked and documented.
• Relevant staff should be aware of the importance of Modified Early Warning Score in anticipating deterioration in a patient.

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) about a number of failings by the university. During her final year at university, both of Miss A's parents were admitted to hospital unexpectedly. Miss A approached her dissertation supervisor to advise of this and the information was also passed to Miss A's academic mentor. Neither the supervisor nor the mentor advised Miss A of the university's process for having mitigating circumstances taken into account. Miss A was dissatisfied with her final degree classification and, particularly, the mark awarded for her dissertation. Following advice on the university's website, she approached her mentor to seek information about appealing these decisions. The mentor told Miss A that she could not make a complaint or an appeal at that time, but that she could graduate and then appeal her degree classification. The mentor called Miss A shortly before the scheduled graduation to advise her that the information they had given her had been incorrect. A number of complaints and an appeal were then submitted, however, Miss A said that the mentor encouraged her to drop her appeal. In considering the appeal, the university identified that a number of procedural errors had occurred. The university decided that there were mitigating circumstances that had affected Miss A's final year but that they could not measure the impact this had on her academic performance, as only her dissertation had been affected. Mrs C then brought a complaint to us.

Mrs C complained that:

the university did not provide reasonable academic support to Miss A during her studies;

the university did not correctly signpost Miss A to the appropriate processes when she approached her dissertation supervisor with mitigating circumstances;

the university provided Miss A with inaccurate information regarding complaints and appeals;

Miss A's academic mentor inappropriately encouraged her to withdraw her appeal on the evening before, and the morning of, her year group's graduation;

the university did not consider Miss A's appeal in line with university procedures;

the university did not respond reasonably to the complaints lodged on Miss A's behalf; and

the university's conclusions on Miss A's appeal were unreasonable.

We found that the university had accepted that they had not provided reasonable academic support to Miss A during her studies and that they had not correctly signposted her to the appropriate processes when she approached her dissertation supervisor with mitigating circumstances. They also acknowledged that they had provided Miss A with inaccurate information regarding complaints and appeals and did not consider her appeal in line with relevant procedures. Therefore, we upheld these four complaints. Although the university identified these failures, they did not apologise to Miss A. Therefore, we also upheld Mrs C's complaint that the university did not respond reasonably to complaints lodged on Miss A's behalf.

In terms of the university's conclusions on Miss A's appeal, the university said that there was no evidence that the mitigating circumstances had impacted any area of her studies except her dissertation. However, they could not explain their reasoning for this. We considered that the university did not provide a reasonable explanation for this decision and, therefore, we upheld this complaint.

Finally, we found no evidence that the mentor had inappropriately encouraged Miss A to withdraw her appeal during phone conversations shortly before her year group's graduation ceremony. Therefore, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss A for:
• the lack of academic mentoring provided to her during her studies;
• not alerting her to concerns about her work and well-being that were shared between the supervisor and the mentor;
• not reasonably signposting her to the university's mitigating circumstances process;
• not considering her appeal in line with the university procedures;
• not apologising for the failings identified by their consideration of her appeal; and
• not providing a reasonable explanation for their conclusion that they are unable to measure the impact of her mitigating circumstances on her dissertation.
• The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Provide Miss C with the opportunity to have her appeal considered by separate mitigating circumstances and examination committees, with membership in line with relevant procedures.
• Provide Miss C with a reasonable explanation for their conclusion that they are unable to measure the impact of her mitigating circumstances on her dissertation.

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

• The university should review the responsibilities of supervisors and mentors to ensure that they include clearly advising and signposting students to appropriate support functions or processes.

In relation to complaints handling, we recommended:

• The university should take steps to ensure that any failings that are identified in appeal considerations are formally apologised for.

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.