Some upheld, recommendations

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.

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 on her home 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 oversight of the programme of works, we did not uphold her complaint about this. We found that the council had used a managing agent to oversee the programme of works and that 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.

We did, however, uphold Mrs C's complaint about the way the council had handled her complaint. We found that the council accepted that Mrs C's initial complaint had not been dealt with appropriately in terms of their complaints handling procedure. We also found that Mrs C had not received a response to her complaint within the prescribed timescales and that, while she had been contacted about the delay, a revised timescale was not offered. This was not in line with the council's complaints handling procedure. We made recommendations to address these issues.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in complaints handling. 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.

Summary

Mrs C complained about the care and treatment that was provided to her following her admission to Ninewells Hospital for induction of labour. Mrs C complained that the midwifery care around her induction, labour and birth was unreasonable. She also complained about the way the board handled her complaints.

During the birth, Mrs C's baby became stuck after delivery of the head due to shoulder dystocia (where one of the shoulders becomes trapped behind the mother's pubic bone) and additional help had to be called to assist the midwife who was attending to her. The baby was delivered following this, but died a few days after the birth.

After Mrs C raised her complaints with the board, they carried out a local adverse event review and also had an external review conducted by a senior midwife from another NHS board area. These reviews identified some failings with regards to aspects of Mrs C's care. However, it was found that these failings did not affect the outcome, which was considered to be unavoidable.

After taking independent advice from a midwife, we upheld Mrs C's complaint about the induction of her labour. We found that there had been delays which affected her access to pain relief and that there had been poor communication. We did not make any recommendations relating to this as these failings had already been addressed by the board.

We also upheld Mrs C's complaint about her care during labour. We found that the board had already identified issues, including the way that examinations were carried out to monitor Mrs C's progress. The advice we received highlighted further concerns about monitoring of blood pressure and listening to and recording Mrs C's preferences during labour. We made recommendations to address these matters.

We did not uphold Mrs C's complaint about the care that was provided to her during the birth of her baby. The advice we received was that this care was timely and that the shoulder dystocia could not have been identified earlier or avoided.

We upheld Mrs C's complaint about the way her complaint was handled by the board. We found that the timescale for completing the investigation of her complaint had not been met and that Mrs C had not been kept updated during the process. We made a recommendation in relation to this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide reasonable care during induction and labour, and for failing to handle her complaint reasonably. 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 be listened to. Their preferences and concerns should be responded to. Clear and accurate records of this should be kept.
• Blood pressure should be recorded in line with national 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 underwent a pubovaginal sling procedure (a surgical procedure used to manage urinary incontinence) and a cystoscopy (a bladder examination using a narrow tube-like telescopic camera) to address her stress incontinence. She was reviewed a few months later, and she reported a loss of sensation and significant distress about the appearance of her scars. She was referred to plastic surgery to see if anything could be done about the scarring.

Mrs C complained to the board about her treatment, and one month later she was advised that her complaint had been forwarded for investigation. Five months later Mrs C wrote to the board to raise concerns about the long wait for a response to her complaint. Upon receiving Mrs C's letter, the board discovered that her complaint had inadvertently been closed five months previously. Some weeks later, the board phoned Mrs C to explain that the complaint had been inadvertently closed and to discuss Mrs C's concerns about the delay in responding and her concerns about her treatment. The board then referred Mrs C to a different consultant urologist, and agreed that they would look into why the complaint had been closed. They also suggested that they would arrange an external review of the case, and they said that they would update Mrs C when they had further information. Despite phoning several times over a period of a further four months, Mrs C heard nothing from the board about her complaint. When she did manage to speak to the board again Mrs C asked to be sent a letter with the findings of the board's investigations. Mrs C did not receive a letter, and she then brought her complaints to us.

Mrs C complained to us about the medical treatment she received and the board's handling of her complaint. We took independent advice from a urologist. We found that the treatment that had been carried out was reasonable, and that it had achieved the outcome of restoring continence, even though there were some problems with loss of sensation. We found that Mrs C's scarring was considered to lie within the bounds of what can be seen following the types of surgery she had underwent. We did not uphold Mrs C's complaint about her treatment.

We were highly critical of the board's complaints handling. We found that there were delays, and that some of the board's communication with Mrs C about her complaint was misleading. We found that the board failed to investigate her complaint as agreed. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for closing Mrs C's complaint in error, for including misleading information in their communication with Mrs C and for failing to investigate her complaint as agreed. This apology should comply with SPSO guidelines on apology, available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complaints handling staff should ensure that complaints are not closed unless there is clear evidence that this is the correct course of action.
• Key staff should receive refresher training in complaints handling, in particular in relation to managing the expectations of complainants.

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 a solicitor, complained on behalf of his client (Mrs B) about the care and treatment provided to Mrs B's late brother (Mr A) during three admissions to Monklands Hospital in the months leading up to his death. Mr A suffered from alcohol liver disease and hepatic encephalopathy (a deterioration of brain function due to liver failure). Mr C complained that the medical care and treatment provided to Mr A was not of a reasonable standard, that the nursing care was unreasonable, that the communication with the family was poor and that the board failed to adequately investigate and respond to complaints.

Regarding medical care and treatment, the family were particularly concerned that Mr A had been discharged following his second admission when they felt he was not medically fit to be discharged. We took independent advice from a consultant physician and from a senior nurse. We found that Mr A's fitness was appropriately assessed at that time. We also found that, while on the whole Mr A received a reasonable standard of care and treatment, there were some failings in medical care and record-keeping. Specifically, we noted that a final discharge summary was not completed following Mr A's first admission, and that the actual date of discharge was not clear from the notes. We also found that, when Mr A suffered a fall overnight, he was not reviewed by a doctor until the following afternoon. The advice we received was that this review should have happened in the morning. We were also critical that, when this review did take place, the doctor who reviewed Mr A failed to document this assessment. The family had also expressed concerns about Mr A's weight loss and the board had said that this was due to deliberate fluid loss. Whilst we found that deliberate fluid loss was a factor, we considered that there was also a nutritional element that should have been acted upon sooner. In light of these failings, we upheld Mr C's complaint about medical care and treatment.

Mr C raised several concerns about the nursing care and treatment provided to Mr A. We identified that nursing staff had failed to make medical staff aware of a vomiting episode on the morning of Mr A's discharge following his second admission which, had it been shared, may have influenced the medical staff's thinking when assessing Mr A's fitness for discharge. However, we found that this appeared to be an isolated failing, which the board had already acknowledged and apologised for. The family had also been concerned that an appropriate package of home care was not in place for Mr A following his second discharge. We found that adequate arrangements were made, and we noted that responsibility for the delivery of these arrangements lay with social services and not the board. We did not uphold Mr C's complaint about nursing care.

In terms of communication, we found inconsistencies and a lack of clarity in the information conveyed to the family about the seriousness of Mr A's condition. We found that the language used may not have helped the family to fully understand that Mr A's illness was terminal. The family had also raised concerns that their repeated requests to speak to another consultant were not actioned. The board had noted that these requests did not appear to have been passed on, and they had agreed to implement a process to document requests for meetings with medical staff in the future. Overall, we concluded that the communication with the family was not of a reasonable standard and we upheld this complaint.

In relation to complaints handling, we considered that the board could have responded in more detail and could have provided clearer explanations in some instances. However, given the complexity of the complaint and the significant number of issues raised, we were satisfied that, on the whole, the board's response was reasonable and proportionate, and that considerable time and effort had been spent attempting to address the family's concerns. On balance, 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 A's family for the identified failings in relation to medical care and treatment, medical record-keeping and communication.

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

• Patient discharge dates should be clearly recorded in the clinical notes.
• Medical reviews should take place within a reasonable timeframe following patient falls.
• Medical reviews should be documented in patient records.
• Medical staff should ensure they remain aware of patients' nutritional status and take appropriate action to address any identified malnutrition.
• Consistent information should be provided, and clear language should be used, when communicating with patients and their relatives regarding the patient's condition and prognosis.

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 provided to her late husband (Mr A) at Raigmore Hospital over a number of months leading up to his death. In particular, she said that his medical care was poor. Mrs C said that, despite his many illnesses and poor prognosis, Mr A underwent surgery which may have extended his life but that this was at the expense of his quality of life. She also raised concerns about the nursing care provided to Mr A and complained that the communication with herself and Mr A about his illnesses was not clear.

We took independent advice from a consultant surgeon and from a nurse. We found that Mr A's medical care and treatment had been in keeping with standard practice in Scotland. We found that his care had been fully discussed with him and that he had agreed to the treatments he was given. Accordingly, we did not uphold this aspect of Mrs C's complaint. Similarly, we did not uphold Mrs C's complaint about poor communication as there was evidence to show that matters had been fully discussed with Mr A and Mrs C. However, we found that Mr A's nursing care had not been reasonable as we found that the notes kept were poor and were not completed in accordance with the Nursing and Midwifery Council code. We upheld this part of the complaint.

Recommendations

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

• Documentation should be completed as required in accordance with the Nursing and Midwifery Council code.

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.