Some upheld, recommendations

Summary

Mr C, an advocacy and support worker, complained to us on behalf of his client (Ms A). Mr C complained that the council had unreasonably failed to respond to Ms A's complaints of anti-social behaviour. He also complained that the council failed to assess Ms A's housing application in line with their obligations.

We found that the council had responded appropriately to Ms A's complaints about anti-social behaviour, and that their responses to her complaints were in accordance with their policy. As such, we did not uphold this aspect of Mr C's complaint.

Regarding the housing application, Ms A was unhappy with the housing award that the council had given her and felt that she qualified for a different award. Mr C wrote to the council on Ms A's behalf to appeal the outcome of the award. In this letter, Mr C provided detailed evidence from Ms A which Ms A considered to be proof that she met the criteria for a different housing award. The council treated Mr C's letter as a complaint and provided a stage two complaints response. We found that the council had incorrectly treated Mr C's letter as a complaint, rather than an appeal against Ms A's housing application. Whilst Mr C had addressed his letter to the incorrect recipient at the council, we found that the council had not communicated clearly with Ms A or Mr C, which had led to confusion. We found that the council did consider a later appeal submitted by Ms A, however at this time they did not take into account the contents of Mr C's earlier letter. Given that the council had not considered all of the relevant information with respect to the appeal, we upheld Mr C's complaint about Ms A's housing application.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for failing to take into account all relevant information as part of the appeal of her housing application. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff should take into account relevant information when considering appeals in housing matters.

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's daughter (Miss A) accepted a tenancy from the council. She recalled having been advised that a garden area was for her sole use. When she approached her neighbours over their use of the garden area they told her that they had access and use rights to the area. Miss A sought clarification from the council about this. The council confirmed that the neighbours had some rights to access and use the garden area. Mr C complained to the council that this was contrary to what his daughter had been told when she was offered the tenancy. He further complained that the time the council had taken to clarify matters had been unreasonable. The council told Mr C that their recollection was that Miss A had been aware that there was no certainty over the use of the garden area when she accepted the tenancy and that they had apologised for the unreasonable delay in providing clarification. Mr C was unhappy with the council's response and he raised his complaints with us.

We found that there was no clear, objective evidence of what Miss A was told before she accepted the tenancy and, consequently, we did not uphold the first aspect of Mr C's complaint. However, we found that the time taken to provide clarification had been unreasonable, and we also found no evidence that an apology had been given to Miss A. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and Miss A for the delay in clarifying rights in relation to garden areas at Miss A's tenancy. The apology should meet the standards set out in the SPSO guidelines on apology available at 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

The funeral service for Mrs C's late mother (Mrs A) was delayed due to earlier services over-running. However, Mrs C said that Mrs A's family and the other people attending the funeral were not pro-actively made aware of the delay and that they were not advised that there was nowhere sheltered for them to sit whilst they waited after they vacated their cars. The council responded to Mrs C's complaints about these matters, but did not accept that they bore any responsibility for the delay or that any further action by them was required.

Mrs C brought her complaints to us. She complained that the council did not act reasonably to minimise the delay to the funeral, that they did not advise the family or the other people attending the funeral of the likelihood of a delay and that they did not respond reasonably to her complaints.

We found that the council could not have acted to minimise the delay once it emerged, so we did not uphold this part of the complaint. However, we agreed that several actions that the council had proposed in their response to us could reduce the likelihood of similar delays occurring in the future.

We found that the council did not act reasonably in communicating the circumstances to Mrs A's family or the other people attending the funeral, and so we upheld these aspects of Mrs C's complaint.

We further found that the council had not responded reasonably to Mrs C's complaints. We found that they had not responded in line with their complaints procedure and that they had included contradictory information in their responses to Mrs C. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C that they:
• did not act reasonably to advise her family or other mourners of the likelihood of a delay to Mrs A's funeral service
• did not respond to her complaints in line with their complaints procedure
• provided her with contradictory information within and between complaints responses.
• The apologies 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:

• The council should:
• implement a system to ensure that, when a service is booked, an advisory note will be issued automatically to the funeral director or person making the booking regarding the length of service and what is expected of the funeral directors and celebrants with regard to timeous running of services and what the consequences may be if a service overruns
• give further practical and sensitive consideration to installing a light system in the service chapel, which will be visible to officiants but not mourners, and which will be operated by crematorium staff, to advise the officiant of the time left for the service to be completed.Advise an appropriate point of contact immediately when likely delays to funeral services emerge.
• Advise an appropriate point of contact immediately when likely delays to funeral services emerge.
• Additional seats should be installed outside of the crematorium. This should ensure that, if delays occur, those waiting do not have to stand whilst waiting for entry to the crematorium.
• Information should be provided to arriving mourners when there are delays to services beginning, or when sheltered waiting areas cannot be accessed at the crematorium.

In relation to complaints handling, we recommended:

• Complaints responses should not contain contradictory information.

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 council's Scottish Welfare Fund team had taken an unreasonable length of time to fulfil a community care grant award for removal costs. Mr C said that, as a result, he incurred additional rent charges due to not being able to move into his new property and not receiving housing benefit for that new property until he was a resident there. He was also unhappy with delays in the council responding to his complaint and not being kept updated on the progress of his complaint.

We noted that the council processed his community care grant application well within the statutory timescales. The council uses a particular removal firm to fulfil awards and, after an award is made, informs the firm and leaves them and the applicant to liaise about the details of the removal. We found nothing in the Scottish Welfare Fund regulations or statutory guidance to suggest that this arrangement was not allowable. We also noted that the council contacted the removal firm for an update after a reasonable length of time. The firm informed the council that they had issues contacting the applicant but were able to make arrangements soon afterwards. Overall, we did not find any evidence of maladministration during the application process or in the council's method of fulfilment. Therefore, we did not uphold this aspect of Mr C's complaint.

However, we did find that the council took an unreasonable length of time to respond to Mr C's complaint. We also found that they did not keep him updated and that they missed their own timescales that they laid out to him. Although there was an apology in their response to him, we did not consider that it was adequate or that their response fully explained the reasons for the delays. Therefore, we upheld this aspect of Mr C's complaint and instructed the council to provide Mr C with a fuller explanation and an apology for the delays.

Recommendations

What we asked the organisation to do in this case:

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

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 his housing association's response to reports of anti-social behaviour and their response to his request for a repair.

We found that the association had spoken to neighbours and the caretaker to gather more information on Mr C's reports of anti-social behaviour. We also found that the association had appropriately informed Mr C of the outcome of their investigations. However, we were critical that they did not contact Police Scotland to find out what information they held, as Mr C had passed on a police incident number. We upheld this aspect of Mr C's complaint.

We found that the repair request was actioned appropriately and we did not uphold that aspect of the complaint.

Recommendations

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

• The association should gather all available evidence to inform their response to reports of anti-social behaviour, including records from Police Scotland if necessary.

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 given to his grandmother (Mrs A), both at home and at Monklands Hospital, in the days prior to her death. He said that while Mrs A was at home, staff changed her opiate-based medication. He believed that Mrs A suffered withdrawal symptoms causing her to fall and he was unhappy that she had been persuaded to go to hospital when she had a long-standing wish to remain at home. He said that there was confusion after Mrs A's admittance and that her family were not kept informed of either her whereabouts or her condition. Mr C said that when the family were reunited with Mrs A, she was very distressed and wanted to go home. He said that the family were not told about Mrs A needing an ECG (electrocardiogram - a test to check the heart's rhythm), which caused her further distress. Following this ECG, and at the end of visiting time, Mrs A's family were asked to leave. Mrs A's condition deteriorated rapidly and she died. Mr C complained that he was not advised of the seriousness of his grandmother's condition and that her resuscitation status should have been discussed. He said the family were totally unprepared for her death and he was upset that Mrs A had died alone.

He complained to the board who acknowledged failures in communication but said that Mrs A's deterioration and death had not been anticipated. They explained the reasons why her resuscitation status had not been discussed and added that since Mr C's complaint, Mrs A's case had been discussed with staff and changes had been made to avoid a repetition of the situation for other patients under the board's care in future. Mr C remained dissatisfied and complained to us.

We took independent advice from a nursing adviser and from a consultant geriatrician. We found that the opiate-based medication Mrs A had been prescribed at home for her pain could have side effects, particularly leading to the increased risk of a fall. Her medication had been given a detailed review and changed in view of her presenting symptoms. While Mrs A's fall required her to be admitted to hospital, we found that this was more likely due to her slow heart rate and swollen legs rather than to her change in medication. We did not uphold the aspect of Mr C's complaint regarding changes to Mrs A's medication.

We found that Mrs A's resuscitation status was not discussed with her or her family at the hospital, although there was evidence that they had been ready to talk about it. We upheld Mr C's complaints about the failure to discuss resuscitation status and keep the family updated, and the failure to reasonably take account of Mrs A's wishes regarding this. However, we found that there was no indication that Mrs A was close to death, and that she was being actively treated for her slow heart rate which is considered to be a reversible condition. As such, we did not uphold Mr C's complaint about the board failing to recognise deterioration in Mrs A's condition.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to listen to the family when they were ready to talk about resuscitation. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff should be reminded to inform family members about what is happening to their relatives.

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 his late wife (Mrs A) received from the board at Monklands Hospital. Mrs A was initially admitted to hospital for seven days, with concerns about her eating and her bowels not moving. She was discharged home for three days and received some medical treatment at home but was then readmitted to hospital. Mrs A died in hospital four weeks later. Mr C also said that the board withheld long-standing medication from his wife and that they failed to reasonably communicate with him during his wife's admission. Mr C explained that his wife had suffered a stroke previously, which impaired her ability to communicate.

We took independent advice from a consultant in general/stroke medicine and geriatrics. We did not consider that the board failed to provide reasonable care and treatment for Mrs A and did not uphold this part of the complaint. However, there were failings in the note-taking by hospital staff and we made a recommendation to address this.

The evidence suggested that Mrs A's medication was not prescribed for her during her second admission and that there was no clearly documented decision for this. We found that, as it was a long-standing medication and Mr C would have been well placed to judge the effect of this being withdrawn, the cessation of the medication should have been discussed with Mr C. We upheld this part of the complaint. We also considered that the board failed to reasonably communicate with Mr C during his wife's admission and we upheld this part of the complaint. We asked the board to provide evidence of the remedial action they said they had already taken in both of these areas.

Recommendations

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

• Staff should note details of conversations with patients' family members regarding patients' care and treatment in patients' 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

Miss C complained about the care and treatment provided to her late father (Mr A). Mr A attended the board's out-of-hours service at Monklands Hospital with throat pain and difficulty swallowing. He was seen by an out-of-hours nurse practitioner and an out-of-hours GP. An examination was performed and Mr A was not admitted at that time. Mr A's condition worsened the next day and he was admitted to the hospital where staff identified an abscess in his throat. Over the following days, Mr A had a number of operations and spent time in the intensive care unit (ICU). He was then discharged to the ear, nose and throat (ENT) ward. While on the ENT ward, Mr A suffered a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs) and died.

Miss C complained that the board's staff failed to appropriately admit Mr A to hospital when he attended the out-of-hours service, that they inappropriately discharged him from the ICU to the ENT ward, and that they failed to appropriately monitor him on the ENT ward. The board considered that Mr A had been provided with reasonable care and treatment by the out-of-hours service, and that he had been reasonably discharged from the ICU. However, they acknowledged that there had been some failures in their clinical observation policy on the ENT ward.

After obtaining independent advice from out-of-hours practitioners, we did not uphold Miss C's complaint about Mr A not being admitted to hospital. We found that there was evidence of an appropriate examination being made, and a reasonable basis for concluding that the problems Mr A was experiencing were due to tonsillitis. We found that it was reasonable for staff not to have admitted Mr A to hospital at that time.

We obtained independent advice from an intensive care specialist regarding Miss C's complaint about the decision to discharge Mr A from the ICU. We found that this decision was consistent with the relevant guidance and adhered to the standards of general practice. Therefore, we did not uphold Miss C's complaint in this regard.

We obtained independent nursing and medical advice regarding the monitoring of Mr A on the ENT ward. We found failings by nursing staff in following the board's clinical observation policy to act on Mr A's deteriorating early warning scores. We found that on one day, Mr A did not receive a dose of medication given to help prevent the development of deep vein thrombosis and pulmonary embolism. However, we did not find that Mr A's outcome would likely have been any different if he had received this medication. On balance, we upheld Miss C's complaint about how Mr A was monitored on the ENT ward.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C and to Mr A's family for the failings in medical and nursing care. The should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff should be aware of, and follow, the board's clinical observation policy, which requires them to act on deterioration when alerted by early warning scores.
• The circumstances of this case should be fully considered for wider learning (for example by discussing the case at a mortality and morbidity meeting).
• Patients should receive appropriate preventative medication for deep vein thrombosis, and this should be reflected in the relevant 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

Miss C complained about the treatment that she received from her dentist, after they removed one of her teeth. She explained that, following the removal, she felt that the wrong tooth had been removed. This led her to attend another dentist, who found a crack in the remaining tooth, meaning this also had to be removed. Miss C was also unhappy with the dentist's handling of her complaint, as it took almost a year to receive a response.

In their response to Miss C's complaint, and in response to our enquiries, the dentist defended their decision to remove the tooth based on the symptoms Miss C presented with. They said that this tooth was loose and the area around it was badly infected, leading them to conclude that this was not saveable and the most likely source of Miss C's pain. We sought independent advice from a dental adviser, who reviewed the records and agreed with this assessment. For this reason, we did not uphold the first complaint.

With regards to the complaints handling, we found that there had been a considerable delay caused by the dentist awaiting an independent expert report they had commissioned in order to respond to Miss C's complaint. During this time, the dentist failed to provide Miss C with regular updates, or to formally agree extensions to the deadline for response, which is not in line with the most recent model complaints handling procedure. For these reasons, we upheld the second part of the complaint. However, we considered that the eventual response was reasonable in its content and conclusions.

Recommendations

In relation to complaints handling, we recommended:

• Adopt the model complaints handling procedure and ensure that all staff are aware of 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 A had a miscarriage and she felt that her appointment for a surgical evacuation of the uterus (SEU) (a procedure sometimes carried out after a miscarriage to ensure that the uterus is fully evacuated and to prevent infection) at Royal Alexandra Hospital was unreasonably delayed, which she felt put her at increased risk of infection or haemorrhage. Ms A also complained that the board had unreasonably failed to provide her with information about support groups and counselling in relation to miscarriage and that the board had unreasonably failed to provide her with details of her scan results when she elected to pursue private treatment at another hospital for the SEU.

We took independent advice from a consultant obstetrician and gynaecologist. We found that earlier treatment would have been desirable to minimise psychological distress to Ms A, but that the time she waited for the SEU was within the National Institute for Health and Care Excellence guidelines. We found that it was likely that the first available appointment was offered to Ms A, and that there was no reason to think that Ms A was at risk of infection or haemorrhage because of the wait. We concluded that the actions of the board were not unreasonable and we did not uphold the complaint.

The adviser noted that there was evidence in the medical records that Ms A had declined information about counselling and support organisations. We did not uphold this complaint.

The adviser said that it was evident from the medical records that the consultant obstetrician had refused to provide information about Ms A's scan results when she requested this information to help with pursuing private treatment for the SEU. Although the still images that were available would not have been helpful for staff at the private hospital, the adviser said that the board could have provided Ms A with copies of scan results or a handwritten letter with little inconvenience. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for failing to provide Ms A with information about her scan results when she decided to pursue private health care.

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.