Some upheld, recommendations

Summary

Ms C complained about the care and treatment her father (Mr A) received at University Hospital Crosshouse. Mr A had cancer and was suffering from jaundice, requiring him to have bile drained from his body. Mr A had an Endoscopic Retrograde Cholangiopancreatography (ERCP) procedure (a procedure that examines the pancreatic and bile ducts) to try and drain the bile. After this he developed sepsis (a blood infection) and died in the hospital several days later.

We took independent medical advice from a consultant in gastroenterology and an intensive care consultant. We found that an ERCP procedure was the recommended and appropriate treatment to attempt to drain the bile and relieve Mr A's jaundice. Whilst we found that it was reasonable for staff to have carried out this treatment, we found that the procedure was unsuccessful as a result of the invasion of the cancer. The resulting undrained bile had led to Mr A developing sepsis, which is a recognised complication of this procedure. We also found that, although there were some delays in carrying out investigations, including the ERCP procedure, these delays were not unreasonable and did not affect Mr A's outcome. We noted that the surgical team could have recognised the deterioration in Mr A's condition more quickly, however, we found that this did not affect his outcome and found his overall medical management was acceptable. Taking account of the evidence and the independent advice we received from both advisers, we considered that, on the whole, the care and treatment Mr A received was reasonable and we did not uphold this complaint.

Ms C also complained that hospital staff had failed to communicate adequately with her and her family about the seriousness of Mr A's clinical condition and prognosis. We found that there should have been better communication with Mr A's family regarding the risks of an ERCP procedure and also regarding the severity of his illness and prognosis, in particular, when Mr A's condition deteriorated after the ERCP procedure. The board acknowledged that there were shortcomings in their communication with Mr A's family, for which they had apologised. They said that they had taken action to address these failings and we asked the board to provide us with evidence of this. We upheld this aspect of Ms C's complaint but, in light of the action the board had said they had taken, we did not make any further recommendations on this issue.

The gastroenterology consultant who we took advice from on this case commented that there were shortcomings in the level of detail and clarity of documented discussions with Mr A about his diagnosis and its management. We made a recommendation for action in relation to this.

Recommendations

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

• Discussions with a patient should be clearly documented with the relevant amount of clarity and detail.

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 complained about the support her child (child A) received from the Child and Adolescent Mental Health Service (CAMHS). During a period of absence of child A's regular therapist, child A was transferred to a new therapist who was not trained in the approach that the first therapist had used. The second therapist then left the service, and Ms C was told that, if child A wished to wait for the first therapist to return, they would need to be discharged in the meantime. Ms C also complained that CAMHS did not provide support to child A in response to a recent traumatic event, or in relation to a decision about child A's future schooling.

In response to Ms C's complaint, senior members of staff met with her, and it was agreed that child A would remain a patient with CAMHS, but that support would be provided by phone to Ms C until the first therapist returned. The board sent a written response to Ms C's complaint five months after this meeting, which confirmed these arrangements and apologised for the tone of a phone call with the CAMHS team leader. Ms C was not satisfied with the response, or the board's handling of her complaint, and she brought her complaint to us.

We took independent advice from a psychologist. In relation to the proposal to discharge child A while waiting for the first therapist to return, we found that staff acted reasonably, and so we did not uphold this complaint. However, we noted that it would have been helpful for them to have discussed Ms C's concerns and explored alternative options to discharge at an earlier stage, as we found that this was only done in response to her complaint.

We found that, whilst it was appropriate for the therapist not to raise the subject of a traumatic event with child A, they should have raised this with Ms C separately in order to explore the issues and offer indirect support. We also found that, although CAMHS was not responsible for the schooling decision, they had agreed to provide an assessment to support this decision and that there was an unreasonable delay in providing this. We upheld these aspects of Ms C's complaint.

Whilst the board had already apologised for the delayed complaint response, we were critical that Ms C was not kept updated during this delay, and that the board's response did not address key points of her complaint. We upheld this part of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for:
• not providing support in response to the recent traumatic event
• not completing the agreed assessment in time
• failing to update her regularly during their complaint investigation
• not responding to all of her points of complaint.
• 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:

• Where a recent traumatic event is reported in relation to a child currently under the care of CAMHS, the therapist should seek to provide support, for example by raising the issue separately with the parent/carer.
• Agreed assessments should be carried out timeously.

In relation to complaints handling, we recommended:

• Where a complaint response takes longer than 20 days, the complainant should be kept updated on progress.
• Complaints should be responded to in full.

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 attended a course at the college. There were verbal interactions between Mr C and his tutor over the course of two tutorials. Subsequently, the college suspended Mr C and instituted a disciplinary process against him. The disciplinary process made no findings against Mr C. Mr C complained about the actions of his tutor, which were also investigated by the college.

In investigating Mr C's complaints, we reviewed the material Mr C and the college provided, as well as the relevant policies. Mr C made four complaints about the college, of which we upheld three.

Mr C complained that the college's tutor acted unprofessionally towards him at the tutorials. We found that there were opposing views on what occurred at the two tutorials. We considered there was insufficient evidence to conclude that the tutor acted unprofessionally, and did not uphold this complaint.

Mr C said that at the first tutorial he was not provided with written material on yellow paper (as required under his personal learning support plan). The college acknowledged this was not provided, and we upheld Mr C's complaint in this regard.

Mr C raised a number of concerns about the way the college brought and handled the disciplinary investigation against him. We had concerns about delays in the disciplinary process, the procedure followed, and the decision to immediately suspend Mr C. Therefore, we upheld Mr C's complaint on this point.

Mr C said the college's complaints process was unreasonable. We found that while the college had taken interviews as part of this process, their investigating officer did not consider transcripts previously obtained during the disciplinary process. We considered that this evidence should have been taken into account. We upheld Mr C's complaint in this respect.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in the disciplinary process and the failings in the complaints process. 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 aware of the requirements of the student disciplinary procedure.

In relation to complaints handling, we recommended:

• Complaints investigation staff should consider the transcripts of disciplinary processes as evidence when dealing with 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

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs A). Mrs A was referred by her GP to hospital as she had an umbilical hernia. She had tests involving her chest, abdomen and pelvis which led to a suspicion of cancer, and a letter was sent to her GP advising that at the same time as her hernia was repaired, a biopsy would be taken. After these procedures, Mrs A was advised that it was likely that she had cancer. She was reviewed at a subsequent appointment where it was confirmed that she had advanced malignant disease.

Ms C complained about the way in which Mrs A had been told about her diagnosis and that she had not been given full information about the surgical procedures she was to undergo. She also said that the board had delayed in reaching a diagnosis and delayed in responding after Ms C made these complaints to them.

We found that Mrs A had been alone when her diagnosis was given to her and that no effort had been made to try to contact her husband before she was given bad news. We found little evidence that the procedures and the risks had been fully explained to Mrs A, despite the fact that she had signed the consent form as having understood. We upheld these aspects of the complaint. Although Mrs A felt that there had been a delay in diagnosing her, we found no evidence of this. She was seen within a month of referral, and tests were carried out in a timely way. We did not uphold this aspect of the complaint. However, we did find that when the board came to consider Ms C's complaints, they took too long, so we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should send Mrs A a formal letter apologising for failing to attempt to involve her husband or another supporter when she was given bad news.
• The board should send Mrs A a formal letter apologising for failing to discuss the risks of surgery with her.
• The board should send Mrs A a formal letter apologising for the delays in responding to her complaint.

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

• The board should ensure as far as possible that when patients are receiving bad news, they are personally supported by a friend or family member.
• The board should ensure that prior to elective surgery, a full explanation is given to the patient including information about the risks entailed. This conversation should be documented.

In relation to complaints handling, we recommended:

• The board should complaints should be responded to within the stated timeframes. Where this is not possible, the complainant should be updated.

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 of concerns about the service he received from Scottish Water. Mr C lived in a property which is not served by a typical mains water supply, but instead involves a private pump system drawing water from a Scottish Water storage tank. Mr C experienced issues with this system and replaced his pump with a new one. When this did not resolve the supply issue, Scottish Water agreed to investigate the problem. We found that Scottish Water provided Mr C with an alternative supply of water throughout their investigation, and after almost three weeks the source of the supply issue was identified. Scottish Water replaced the pump Mr C had installed with a different kind, which restored the system to its original design. After a short delay in commissioning this pump, the supply issue was resolved.

Mr C felt that Scottish Water was responsible for his pump failing in the first place and complained that there was an unreasonable delay in Scottish Water reinstating his water supply. We took independent advice from a chartered engineer who has experience in the water industry. The adviser noted that the pump was owned by Mr C and was his responsibility. They did not find evidence that Scottish Water was responsible for the pump failing and said that Scottish Water was not obliged to replace the pump, but did so in good faith. The adviser considered that there were good reasons for the delay in investigating the cause of the supply issue and did not consider that the delay in commissioning the new pump was unreasonable. We did not uphold this complaint.

Mr C complained that Scottish Water unreasonably contaminated his water supply during their investigation of the supply issue. Scottish Water acknowledged that, during the investigation, an operative failed to follow correct water hygiene practice, which resulted in the contamination of Mr C's water supply. Scottish Water said that an apology was offered to Mr C at the time and they confirmed that the operative's training record showed that training in water hygiene and operating processes was up to date. The adviser found that once Scottish Water became aware of the incident, it followed the expected procedures and appropriately escalated the issue. The adviser noted that Scottish Water took and analysed three sets of samples, flushed the system between each sample, and provided bottled water to Mr C property in the meantime. In view of the failing, the adviser said that they would have expected the operative to have undergone further training and reassessment. On balance, we upheld this aspect of Mr C's complaint.

Mr C also raised concern that Scottish Water staff failed to appropriately communicate with him regarding the supply and contamination issues. We did not find evidence of significant delays in staff returning Mr C's calls or failing to call him back when this had been agreed. Based on the evidence available, we were unable to conclude that the communication maintained was unreasonable. While we did not uphold this complaint, we considered that Scottish Water's record-keeping of phone conversations with Mr C could have been better.

We also considered how Scottish Water handled Mr C's complaint. We were critical that Scottish Water's complaint response had not addressed all of the main issues that Mr C raised in his complaint and we upheld this aspect of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the contamination incident, and for the complaints handling shortcomings. This apology should comply with SPSO guidance on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Operatives should carry out their work in accordance with the Hygiene Code of Practice and Scottish Water Distribution, Operation and Maintenance Strategy procedures.

In relation to complaints handling, we recommended:

• Staff should appropriately respond to the points of concern within customers' complaints. Staff should ensure that each aspect of the correspondence is addressed.

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 us about the council's involvement in statutory notice works that had been carried out to his property over four years. Mr C had several concerns, including the tendering process for the contractors, the communication with owners about the works, the management of the works, the decision to charge all owners in equal shares, and the billing and debt recovery process. Mr C also complained that the council had failed to respond reasonably to his complaints and that they had not answered all of his questions regarding an independent review that was carried out of the statutory notice projects.

Our investigation found that the council had appropriately and reasonably followed their policies and guidance with regard to the issues about which Mr C complained. However, we found that they had failed to respond in full to the first of Mr C's three formal complaints. Therefore we upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the council:

• apologise for failing to respond in full to Mr C's first formal complaint.

Summary

Mr C, who is a council tenant, complained to the council about a number of issues regarding his new property. He complained that the council failed to ensure that his property was made available in an appropriate standard of repair and that they failed to follow their housing allocations policy. Mr C also complained that he was provided with incorrect information about his entitlement to a decoration grant and about his utilities contract. He also said that he was provided with wrong information about anti-social behaviour complaints from a previous tenant, dog fouling and the council's handling of his complaint. Mr C was dissatisfied with the response from the council. He felt that the council did not properly investigate his complaints and that they failed to offer remedies to his upheld complaints. Mr C brought his complaints to us.

We found that the council failed to follow their housing allocation policy as they did not offer Mr C a 'settling in visit' after he moved into his new property and that they failed to ensure that Mr C had the opportunity to choose his own energy provider. We upheld these complaints and recommended the council provide Mr C with a written apology for these failings. We found that the council have already taken steps to ensure that tenants are better informed about their arrangements with their energy providers and we have asked the council to provide us with an update on their improvements. We found no failing in the council's actions regarding the standard of repair in Mr C's property and the decoration grant. We found that the council acted appropriately regarding Mr C's complaints about dog fouling and the information provided to him about the previous tenant's complaints of anti-social behaviour. We also found the council's handling of Mr C's complaint to be reasonable. We did not uphold these complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to follow their housing allocations policy by ensuring that a 'settling in visit' was arranged. Further apologise for failing to inform Mr C about their arrangements with the energy provider for the property. 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

Ms C complained to the council about a decision taken to refer a concern about her child (child A) to the social work department. The referral occurred after the head teacher of child A's primary school became aware of an incident that was considered to be a potential welfare concern to the child. The head teacher separately called Ms C and child A's father (Mr B) and asked them both to attend a meeting. A meeting was not arranged and the head teacher then decided to refer the concern to social work. The reasons given for this decision were that the incident gave rise to a potential welfare concern to child A and that the parents refused to attend a meeting.

Ms C said that neither she nor Mr B were able to attend a meeting on the date suggested and that the school was unwilling to arrange a meeting at a convenient time. We found that the school's records did not provide a consistent picture in relation to whether child A's parents were willing to attend a meeting. Based on the evidence available, we were unable to establish whether the parents would have attended a meeting on a different date.

We were critical that the record-keeping in relation to this matter was not as complete as it should have been, and records were not kept in accordance with the council's standard circular, 'Protecting Children and Ensuring their Wellbeing'. We made recommendations in relation to this. We concluded that the decision to refer the concern to social work was one that involved the head teacher exercising their professional judgement based on their assessment of the information available at the time. We also found the correct procedure for the referral had broadly been followed. In view of this, we did not uphold this complaint.

Ms C also complained that the school had unreasonably failed to amend information in child A's educational records. We found that Ms C had complained that the record was inaccurate, but we did not consider that Ms C made a clear request for this information to be removed. We concluded that the council had not failed to take appropriate action in relation to this matter. For this reason, we did not uphold this complaint.

Ms C raised concerns about the council's handling of her complaint. We found that Ms C initially submitted an online complaint to the council, but this had not been logged or acknowledged in accordance with the council's procedure which meant that Ms C had to contact a councillor to progress her complaint. The council acknowledged to us that they had not appropriately responded to Ms C's query about a meeting and we concluded that the council had missed a potential opportunity to resolve (at least part of) the complaint at an earlier stage. We also found that the council had not kept appropriate records of their complaint investigation. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Ms C with a written apology for the shortcomings in record-keeping and the complaints handling failings, which should comply with the 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:

• Detailed records should be kept in accordance with the procedures within the council's circular 'Protecting Children and Ensuring their Wellbeing'.

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 unreasonably failed to respond to his concerns of dampness, water leaks and mould, in line with their procedures. He also complained that they failed to respond reasonably after he reported problems with his boiler, and that customer service staff responded unreasonably when he phoned them to report his concerns.

We found that the council did not meet the requirements of their Responsive Repairs Policy in relation to the first two aspects of Mr C's complaint, and we upheld these. We were, however, satisfied that the council acted in line with their customer service standards and complaints procedure in relation to the third aspect of his complaint, and we did not uphold this part.

Recommendations

What we asked the organisation to do in this case:

• The council should provide a written apology which complies with the SPSO guidelines on making an apology.

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 council's handling of a complaints review committee (CRC), in relation to care arrangements for his elderly mother after she was discharged from hospital. Mr C complained that the CRC was unreasonably delayed, and that the council did not take steps to remedy failings identified by the CRC. In addition, Mr C was unhappy with the council's consideration, at a different CRC, of his concerns about an Equality Impact Assessment (EQIA).

We found that the council failed to make arrangements for a CRC as soon as Mr C told them he wanted to progress his complaint to that stage. Therefore, we upheld this part of Mr C's complaint. However, we noted that delays after this point were largely due to Mr C engaging in protracted correspondence with the council, and due to Mr C's choice not to proceed to a CRC for a period of time, but to approach us instead without having been to a CRC.

We found that the council did take steps to remedy failings identified by the CRC, so we did not uphold this part of Mr C's complaint. However, one matter identified by the CRC was not addressed, and we have made a recommendation to remedy this specific issue.

We noted that Mr C disagreed with the council's view about when an EQIA should take place. He wanted an EQIA of contracts and polices within the council, in particular relating to new contracts for dementia care. The council's view was that, as no new policies had been introduced, an EQIA was not necessary. We found that the council considered Mr C's concerns and gave a view based on their reading of their obligations in relation to an EQIA. The council then explained why they did not consider an EQIA to be necessary. In the circumstances, we could not conclude that the council's consideration of Mr C's concerns was unreasonable, and we did not uphold this part of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to progress his complaint to a CRC in a timely manner. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.
• Apologise to Mr C for failing to address one of the findings of the CRC. This apology should comply with SPSO guidelines on making an 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.