Some upheld, recommendations

Summary

Mrs C complained about the care and treatment provided to her late mother (Mrs A) by the practice. In particular, she complained that Mrs A had not been seen by a medical professional before antibiotics were prescribed to her, and, futher, that she had not been seen when the antibiotics were subsequently changed.

We took independent advice from an advanced nurse practitioner. We found that a home visit should have been carried out before the antibiotics were prescribed to Mrs A and that, as such a visit did not take place, it was even more important that a review should have been undertaken of Mrs A before her antibiotics were changed. The advice we received was that there was a lack of detail in the clinical records and that it was not clear from the records what symptoms Mrs A had when the decision to change antibiotics was made. We were concerned that the practice had failed to follow guidelines that all older patients suspected of having a urinary tract infection, like Mrs A was, should be seen and fully examined. In light of these failings, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that the practice had inappropriately decided not to undertake a home visit after she had contacted them a number of times. We found that, when the visit was requested, Mrs A had deteriorated and she needed to be seen or arrangements needed to be made for admission to hospital. We also found that, whilst reasonable advice had been given to Mrs C to contact the ambulance service if Mrs A's condition deteriorated, there was a delay in this advice being given to Mrs C. The practice accepted that a home visit should have been carried out. We upheld this aspect of Mrs C's complaint.

Finally, Mrs C complained that the member of staff she was complaining about had responded to her complaint. We found that neither the Scottish Government guidance on complaints handing which was in place at the time of the complaint, or the new NHS Scotland model complaints handling procedure introduced since the complaint was made, specified that the person being complained about should not handle a complaint. In view of this, 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 the failings identified in relation to the clinical treatment provided to Mrs A and for the failure to carry out home visits.

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

• The practice should follow guidelines in relation to diagnosing urinary tract infections in adults aged 65 and over.
• The practice should maintain records in line with relevant guidelines.

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 of her late mother (Mrs A), initially by an out-of-hours doctor and then following an admission to Aberdeen Royal Infirmary. The out-of-hours doctor visited when Mrs A became unwell and diagnosed infection, prescribing antibiotics. Two days later Mrs A was admitted by her GP to a GP unit in a local care home. From there she was admitted to hospital in the early hours of the following morning with sepsis (a blood infection) secondary to pneumonia. After an initial improvement, she deteriorated and died five days later.

Mrs C complained that the out-of-hours doctor should have admitted her mother to hospital. We took independent advice from a GP adviser, who considered that the doctor appropriately assessed Mrs A and treated her in line with relevant guidelines. We were advised that there were no clear signs at the time that might reasonably have led the doctor to suspect a diagnosis of pneumonia and necessity for hospital admission. We accepted this advice and did not uphold the complaint.

Mrs C also complained that the family were told by hospital staff to administer Mrs A's regular medication from her own supply, and also that there was a 12 hour delay in commencing treatment for her presenting condition. We took independent advice from a hospital adviser, who confirmed that it was not good practice to expect relatives to administer medication. However, the board had already acknowledged this and appropriately highlighted the issue to staff. The adviser noted that the medication was appropriately recorded so no safety issues were apparent. In terms of treating Mrs A's presenting condition, the adviser noted that she had a NEWS score (an aggregate of a patient's 'vital signs' such as temperature, oxygen level, blood pressure, respiratory rate and heart rate which helps alert clinicians to acute illness and deterioration. A NEWS score of five or more is linked to increased likelihood of death or admission to an intensive care unit ) of seven on admission. This elevated score should have prompted early recognition of the severity of the illness and more timely treatment. The adviser considered that a 12 hour delay in commencing antibiotics was unreasonable. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the unreasonable delay in commencing antibiotic treatment following Mrs A's admission. 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 with an elevated NEWS score should be promptly investigated and treated.

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

After the birth of her child at Borders General Hospital, Mrs C made a number of complaints about the procedures involved. She said that there was a failure to obtain properly informed consent for intimate examinations and that the board provided incorrect information about who had acted as a chaperone. She also complained that the board did not ensure that she was anaesthetised by an anaesthetist of sufficient seniority given that she had scoliosis (a musculoskeletal disorder in which there is a sideways curvature of the spine). Mrs C also complained that she and her new born baby were not given reasonable nursing care when she was in hospital.

The board said that they had followed their usual practice of obtaining implied consent to treatment set against a background of the clinical care they had already given. They also said that they had provided the correct name of the chaperone as requested and that Mrs C's spinal injection had been performed by both a consultant and a senior trainee. They were also of the view that Mrs C's nursing care had been reasonable.

We took independent advice from a consultant in obstetrics and gynaecology and a consultant in obstetrics and general anaesthesia. We also took independent nursing advice. We found that implied consent was insufficient for intimate examinations and that consent must be recorded in patients' notes. It was not recorded in Mrs C's notes and, therefore, we upheld this complaint.

Regarding Mrs C's other complaints, we found evidence in the notes to confirm who had acted as chaperone and we found that Mrs C had been given her anaesthetic reasonably by clinicians of appropriate seniority and expertise. We found no evidence of unreasonable nursing care. As such, we did not uphold these aspects of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise for failing to seek formal consent for intimate examinations.

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

• The board should develop a guideline on consent for intimate examinations and the use of chaperones, with reference to national guidance, including documentation.

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 is the secretary for a business. Mr C complained that Business Stream had failed to notify the business of their increased water usage, that they had failed to properly investigate the cause of the issue and that they did not deal with his complaint in line with their procedures.

We found that, once they had become aware of the high water usage, Business Stream did make appropriate contact with the business to alert them of this. We received evidence of the call that was made to the business, and we also noted that the business received invoices that illustrated high meter readings. We also found that Business Stream took appropriate action in investigating the cause of the leak, in line with their responsibilities, and that they contacted Scottish Water to investigate the issue further when it was appropriate. We did not uphold these aspects of Mr C's complaint.

However, we found that Business Stream did not advise Mr C clearly of his rights to escalate his complaint to stage two of the complaints procedure. We also found that they failed to issue Mr C with a final response to his complaint. We, therefore, upheld this part of Mr C's complaint.

Recommendations

In relation to complaints handling, we recommended:

• Communication regarding a customer's complaint should clearly explain the stage at which the customer's complaint is being handled. Staff should also ensure that customers have received a final response to their complaint before referring them to SPSO.

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 way that the Scottish Prison Service (SPS) managed his prison sentence. Specifically, he complained about a delay in referring him back to the risk management team (RMT) to consider his suitability for progression to less secure conditions. Mr C was not referred back to the RMT until around two months after the planned date. The reason for this was that the RMT required his home leave report but this was not complete, as there had been a delay in the SPS sending it to social work for comment. The SPS explained that this was because Mr C's personal officer chose to wait on the outcome of Mr C's parole hearing, when in fact the home leave report should have been sent six weeks prior to completion of his management plan, which was completed ahead of his parole hearing. The SPS had already acknowledged and apologised for the inappropriate delay in referring Mr C back to the RMT. We agreed that this delay had potentially delayed Mr C's progression to less secure conditions by around two months. We upheld this aspect of the complaint.

Mr C also complained that the SPS failed to respond to his complaint within the timescales laid down in the prison rules. These allow 20 working days for a written response to be issued but, in Mr C's case, the response was delayed by over two weeks beyond this timeframe. We upheld this aspect of the complaint.

Mr C subsequently made an additional complaint directly to the prison governor, via the confidential complaints process. The governor did not investigate the matter as they did not consider the subject of the complaint to be confidential in nature. Mr C complained to us that the governor unreasonably refused to accept his confidential complaint. We noted that this was a matter for the governor's discretion. In any event, we considered that the governor had already arranged to have the subject of the complaint appropriately considered when it was brought to their attention via Mr C's previous (non-confidential) complaint. We did not uphold this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in responding to his complaint.

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

• Home leave reports should be submitted to social work 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 C raised a number concerns about the way that the Scottish Environment Protection Agency (SEPA) regulated a site. As part of the regulations, the site was required to maintain records of the waste materials that were being transferred to and used on the site. Mr C complained that SEPA had failed to ensure that the site maintained appropriate records in accordance with the regulations.

We found that SEPA had been aware of the record-keeping issues at a site inspection and it had been recorded that this should be followed up at the next inspection. We did not find evidence that this had happened at the next inspection and we were critical that SEPA did not take timely action. We also noted that SEPA had written to the site annually to request waste data. We found that when the site operator did not provide this information over a period of consecutive years, SEPA did not take any action to ensure it received the information requested. We upheld the complaint and made a recommendation.

Mr C was also unhappy about the way SEPA investigated his complaint that staff at the site were burying tree bark, which he said was not in accordance with the terms of the site's registration. In response to Mr C's complaint, SEPA said that the volume of buried bark was unlikely to be significant and said that it did not present a risk to health or the environment. For these reasons, SEPA did not consider that it would be appropriate to conduct intrusive site investigations to establish the volume of buried bark or to require the removal of any buried bark. We found that SEPA officers had visited the site after Mr C raised concern about this matter, and we were satisfied that SEPA took appropriate steps to investigate the concern. We did not uphold this complaint.

Recommendations

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

• Where SEPA becomes aware of an establishment's failure to meet the record-keeping obligations of a registered exemption, comply with regulations, and/ or a failure to provide waste returns as required, this should be followed up to ensure that the terms of the registered exemption are being met.

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 lives in a conservation area. An application for planning permission for external alterations to a property neighbouring his was submitted to the council. The proposal was to increase the height of the roof of an existing utility building and associated works to create additional living space. Mr C submitted objections to the proposal. The council produced a report of handling of the application and granted full planning permission subject to conditions. The first of these was that the development had to be implemented in accordance with the approved drawings.

Mr C was concerned that the council's decision had been procedurally flawed and based on inaccurate information. He complained to the council about this. At both stages of the council's complaints procedure the responses stated their conclusions that the decision had been taken properly and on the basis of accurate information. Mr C was dissatisfied with these responses and raised his complaints with us.

We upheld Mr C's complaints that statements in the report were inaccurate (specifically statements that the pitch of the roof 'will match' the main house and that the rooflights will be 'invisible from a public area'); that the approved drawings associated with the application did not contain sufficient written dimensions to ensure that the precise location and scale of what was being proposed was clear; and that the council did not respond reasonably to some of Mr C's complaints. We did not uphold complaints that the evaluation of the application against relevant guidance was unreasonable or that the inadequacies of the report of handling meant that the decision on the application was unreasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that they did not respond reasonably to some of his complaints about the handling of the application.
• Provide Mr C with a direct response to his complaint.
• Amend the approved drawings for the application to ensure the precise location and scale of what was being proposed, and has been approved, is clear.

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

• Relevant council staff should be reminded that statements of fact in reports of handling should be accurate.
• Relevant council staff should be reminded that approved drawings should be adequately dimensioned to ensure the precise location and scale of what is being proposed is clear.

In relation to complaints handling, we recommended:

• Relevant council staff should be reminded that issues raised in complaints should be directly responded to.

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 on behalf of two of their children (Master A and Miss A), who have additional support needs. They complained that the council failed to provide the children with adequate educational support, that they had failed to follow their anti-bullying policy in relation to Master A, and that their investigation of the complaint was unreasonable. They also complained that the head teacher of the children's school had made an inappropriate referral to the social work department.

In response to our enquiry the council provided us with the children's pastoral care notes, the children's wellbeing assessments and plans, and the relevant council policies. We found that the council mostly appeared to have followed their policies when providing the children with educational support but we noted that neither Mr and Mrs C, nor the children, had been consulted in relation to the children's wellbeing assessments and plans, which is in line with council policies. However, we did not consider that this was in itself enough to uphold the complaints.

In relation to the complaint about bullying, it was clear that there was a difference in opinion between the council and Mr and Mrs C. Mr and Mrs C considered that Master A had experienced a number of incidences of bullying, but the council disagreed and had therefore not recorded the events as bullying. In relation to one incident involving another child that had been recorded, we considered that the council had dealt with the matter appropriately and in line with their anti-bullying policy.

We were critical of the way in which the council had investigated this complaint. Mrs C had to chase a response and the council's initial response to her was very brief. We considered that the investigation could have been carried out more clearly and transparently.

In relation to the social work referral we found that contact had been made in an informal way with a view to supporting the family, and we therefore did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for failing to consult with Mr and Mrs C, or Master A, in relation to Master A's wellbeing assessment and plan.
• Apologise for failing to consult with Mr and Mrs C, or Miss A, in relation to Miss A's wellbeing assessment and plan.
• Apologise for the failings in the complaint investigation. All apologies should comply with SPSO guidance on making an apology, available at www.spso.org.uk/leaflets-and-guidance

In relation to complaints handling, we recommended:

• Staff should be confident in identifying and escalating complaints, and should provide details of their investigations when responding to complaints.

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 raised a number of complaints about the council regarding various housing repairs. They complained that the council did not issue an invoice for a repair that was carried out until 18 months later and they felt that this delay was unreasonable. They also complained that the council unreasonably required them to provide receipts as proof of purchase when they were trying to submit an insurance claim for damage caused to their property. They did not think it was reasonable to expect tenants to retain receipts for items that were purchased a number of years ago. They also complained that the council unreasonably delayed in completing a communal repair to the chimney at their property.

The council acknowledged that they delayed in issuing the invoice for the repair and they agreed to cancel it. We upheld this aspect of the complaint.

The council confirmed that they will accept forms of evidence other than receipts when considering an insurance claim. We found that the letter provided with the insurance form does not provide clear information in this regard. We upheld this part of the complaint.

The council explained that the repair to the chimney was categorised as a non-emergency repair and that it therefore had no timescale attached to it. The council confirmed that, at the time of our investigation, the repair order had been sent to the contractor and that they would expect the repair to be completed soon. We found the council's actions to be reasonable and we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for unreasonably delaying in sending them an invoice for a repair. Also apologise for failing to provide clear information on how to submit an insurance claim.

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

• The information provided by the council with insurance claim forms should be reviewed to ensure that customers are aware that other forms of evidence may be accepted if receipts are not available.

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

Summary

Mrs C complained that the council had unreasonably failed to act in line with their responsibilities in overseeing a programme of works that was carried out in the area by a third party company. Mrs C considered that the works carried out at her home had not been done to a reasonable standard and also complained that the council had not handled her complaint about this appropriately.

After investigating Mrs C's concerns about the oversight of the programme of works, we did not uphold her complaint. We found that the council had used a managing agent to oversee the programme of works and there was evidence that a supervisory service was provided by them. While the council had no liability or responsibility for the works, we found that when issues arose at Mrs C's property, they took an active co-ordination role to work towards resolving these. However, we found that in responding to Mrs C's official complaint, the council failed to respond within the 20 working days specified in their complaints handling procedure. Therefore, we upheld this aspect of Mrs C's complaint and made recommendations to the council.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to respond to her concerns or give an appropriate update within the timescales laid out in their complaints handling procedure. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the complaints handling procedure. Any revised timescale should be agreed with the complainant or approved by senior staff in line with the policy and the reasons for this explained to the complainant.

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.