Some upheld, recommendations

Summary

Mr C complained about the council as he felt that they had failed to appropriately investigate reports of anti-social behaviour he and his wife had made about their previous neighbour. He claimed that the council had failed to liaise with Police Scotland over charges brought against the neighbour and that this had led to them failing to take appropriate action against her. However, on investigation we found that the council had followed their procedure for investigating anti-social behaviour. This included liaising with the police and confirming the charges in question, which led them to take appropriate and proportionate action in response. We did not uphold this part of the complaint.

Mr C was also unhappy that the council had provided inaccurate information regarding their allocations policy after he completed a mutual exchange into a new property. He explained that the council had told him that he would not be eligible for a three bedroom property despite having two children of the opposite sex, as they were both under ten years old. However, in the council's recent responses to his complaints, they apologised for providing this information and clarified that, although the law states that a child over ten would be considered overcrowded if sharing a room with a sibling of the opposite sex, the council's policy was more generous, and lowered this threshold to eight. Mr C remained dissatisfied about this, as it had led him to wait two years living in overcrowded conditions until his eldest child's tenth birthday before submitting a housing application. He felt that his housing application should be backdated two years as a result. We upheld this complaint and agreed that backdating of the application would be a reasonable resolution in the circumstances.

Finally, Mr C wished to complain about the council's handling of his complaints as he felt there had been delays. However, on investigation we found that the council had taken sufficient steps to keep Mr C updated and that the time taken to respond was not excessive, given the depth and complexity of his complaints to them.

Recommendations

What we asked the organisation to do in this case:

• The council should backdate Mr C's housing application by two years.

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 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. Mr C considered that the works carried out at his home had not been done to a reasonable standard and also complained that the council had not handled his complaint about this appropriately.

After investigating Mr C's concerns about the oversight of the programme of works, we did not uphold his 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 Mr C's property, they took an active co-ordination role to work towards resolving these. However, we found that in responding to Mr 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 Mr C's complaint and made recommendations to the council.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr 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 should be 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

Mr C complained that the council had carried out works to improve access to a site they owned at the same time as considering planning applications for the site. He was concerned that the works to facilitate access suggested that consent would be granted and, as such, prejudiced the planning applications. He was also unhappy with the consistency of the explanations he had received from the council about the access improvements.

We noted that the council had planned these works for some time prior to the submission of any planning applications, but the works had been delayed and were only initiated around the time of the submission of the applications. We noted that the council were carrying out the access improvements to improve the marketability of the site. We found no evidence to indicate that carrying out the access improvements was in any way unreasonable or inappropriate, nor did we find any evidence that it had prejudiced the planning applications. Indeed, during the course of our investigations, one of the applications was refused consent by the council. For this reason, we did not uphold this aspect of Mr C's complaint.

However, the council failed to provide us with any evidence to refute Mr C's claims that the information provided by the council during the course of his discussions with council officers and elected members was inconsistent and inaccurate. As we did not have any evidence to show that the council were consistent in their advice and information, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide him with consistent information and explanations for the work carried out. The apology should meet the standards set out in the 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.

Summary

Mr C attended A&E at the Royal Infirmary of Edinburgh on two occasions. The first occasion was for constipation and increasing back pain. Mr C's second attendance was due to concern that he may have deep veinous thrombosis (a blood clot in a vein).

Mr C complained that when he attended A&E, the board failed to provide him with reasonable nursing and medical care. He also complained about the way the board dealt with his complaint. In reply, the board said that Mr C had been treated in accordance with his symptoms and with national and local guidance. However, they apologised to Mr C for the delay in responding to his complaint.

We took independent nursing and emergency medicine advice. We found that on his first attendance, Mr C was examined in a reasonable way and had been checked for any symptoms requiring urgent admission or imaging. None were present. We found that on his second attendance, the doctor failed to conduct a Wells test (a test to ascertain the risk of blood clot) and that the neurological examination of Mr C's lower limbs was not thorough or to a high standard. In light of these failings, we upheld the complaint and recommended that the board issue an apology to Mr C.

Although the board had taken steps to address Mr C's complaint, they took 120 days to reply. The board's timeframe for responding to complaints is 20 days. We therefore upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the delay in dealing with his complaint;
• emphasise to staff involved the necessity of adhering to timescales in line with the complaints policy; and
• apologise to Mr C for the failure to conduct a Wells test and carry out a thorough neurological examination of Mr C's lower limbs.

Summary

Mrs C complained about the care and treatment that was provided to her late niece (Miss A) by Hairmyres Hospital and Wishaw General Hospital. Miss A had been referred to the board by her GP due to gynaecological problems she had been suffering with. The GP referral was downgraded from urgent to routine by the board. Miss A attended the board's out-of-hours service at Hairmyres Hospital on two occasions between the date of the GP referral and her gynaecology appointment.

Miss A was seen at the gynaecology department at Wishaw General Hospital within the timescales for a routine appointment and, following examination, arrangements were made for day surgery investigations. A number of weeks before the arranged date for surgery, Mrs C became increasingly worried about Miss A's health and took her to Wishaw General Hospital, where she was admitted. Miss A was subsequently diagnosed with cervical cancer.

Mrs C complained that there was an unreasonable delay by staff at Wishaw General Hospital in diagnosing that Miss A had cancer and that the out-of-hours service at Hairmyres Hospital did not take reasonable action in light of the symptoms that Miss A presented with.

In investigating Mrs C's complaints, we took independent advice from a consultant gynaecologist, an out-of-hours GP and a consultant histopathologist (a consultant in the study of changes in tissues caused by disease).

On the basis of the advice we received, we upheld Mrs C's complaint about the delay in staff diagnosing that Miss A was suffering from cancer. While we found that it was reasonable to downgrade the GP referral to routine on the basis of the information available at that time, the advice we received was that there was insufficient urgency in arranging appropriate investigations after Miss A was seen at the gynaecology department at Wishaw General Hospital. Although we considered that there was an unreasonable delay, the advice we received was that earlier diagnosis would not have affected Miss A's prognosis. We found that the board had already identified some improvements to be made in this area, but we made further recommendations as a result of our findings.

We did not uphold Mrs C's complaint about the out-of-hours service at Hairmyres Hospital as the advice received was that reasonable care and treatment were provided for the symptoms that Miss A reported.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C that appropriate investigations were not urgently arranged for Miss A following her attendance at the gynaecology department at Wishaw General Hospital. This apology should comply with SPSO guidelines on making an apology, found at www.spso.org.uk/leaflets-and-guidance.

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

• Patients with symptoms that are potentially indicative of cervical cancer should be referred for colposcopy (a procedure used to look at the cervix in detail) and seen urgently.

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 level and type of support her adult son (Mr A) was receiving from community support services to help him manage his mental health. Mrs C was especially concerned that there was no proper regime for cover when the regular support worker was on planned or unexpected leave. Our investigation showed that the board's investigation had not properly considered this matter and could not demonstrate that the proper level and type of support had been in place. Whilst Mrs C told us that the arrangements had improved since she complained, we upheld this complaint and made recommendations to ensure future investigations were appropriately robust and that the improved support arrangement was sustained for the future.

Mrs C was also concerned that on one occasion her son had been assessed by the community mental health team because his mental health had been deteriorating, but a decision was taken not to admit him to hospital. Mr A's condition worsened and he later became aggressive and violent towards Mrs C's property, causing her considerable anxiety and distress. The police also became involved and Mr A was admitted to hospital for compulsory treatment. Mrs C considered that Mr A met the criteria for admission when first assessed and that a psychiatrist should have been involved and should have made the decision to admit Mr A at that time. We obtained independent advice from a mental health specialist who concluded that it was not necessary to have a psychiatrist involved in the assessment and that the initial decision not to admit Mr A was reasonable. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to adequately or appropriately investigate her concerns about the level of support Mr A was receiving. This apology should comply with SPSO guidelines on making an apology, found at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• All complaints submitted and accepted by the board should be thoroughly investigated and final responses should include details of investigations undertaken and the outcomes of such investigations. Guidance and standards for good investigations are set out in the SPSO Investigations Toolkit, available at www.valuingcomplaints.org.uk/learning-and-improvement/best-practice-resources/decision-making-tool.

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 treatment she received at the Queen Elizabeth University Hospital during labour. Mrs C's concerns included that during the delivery, she sustained a tear which resulted in significant bowel problems. Mrs C also said the board failed to provide her with appropriate follow-up treatment for her bowel problems.

We obtained independent medical advice on the complaint from a consultant obstetrician and gynaecologist. The adviser explained that Mrs C sustained a third degree perineal tear (a tear which involves the muscles around the anus which contract to provide continence of faeces) during labour. They said that third degree perineal tears were a recognised complication of vaginal birth, and that Mrs C's records suggested that she was informed of the risk of this complication before the birth of her baby. We noted that the board apologised for the added pain and discomfort Mrs C experienced as a result of the tear. We considered this to be reasonable and did not uphold this part of Mrs C's complaint.

The adviser confirmed that Mrs C was appropriately seen in a specialist clinic 11 weeks and 25 weeks after the delivery of her baby daughter and that the treatment she received during the appointments was reasonable. However, it appeared that Mrs C did not receive the planned physiotherapy treatment following her first clinic appointment. We were critical of the board in this regard and upheld this part of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Mrs C with a written apology.

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

• Staff should arrange follow-up physiotherapy treatment for patients in cases such as 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

Mr C, who works for an advocacy and support agency, complained on behalf of his client (Mr A) about the care and treatment that was provided to his late wife (Mrs A) at Queen Elizabeth University Hospital. Mrs A had been referred to the board by her GP after she was diagnosed with Cushing's syndrome (a collection of symptoms caused by high levels of the cortisol hormone in the body). Mrs A attended the hospital and remained there until she died two months later.

In investigating Mr C's complaints, we took independent advice from a consultant in acute medicine. On the basis of the advice we received, we upheld Mr C's complaint that the board failed to provide reasonable care and treatment for Mrs A during her admission to the hospital. The advice we received was that when Mrs A's condition deteriorated, this was recognised and responded to in an appropriate manner. However, there were aspects of her care that were unreasonable. In particular, she had recurrent bouts of sepsis which were not adequately investigated and her elevated blood glucose and low potassium levels were not investigated. Mrs A also had a fever of unknown origin and this was not recognised or investigated promptly. In addition, the advice we received was that Mrs A was moved unreasonably on multiple occasions between wards and hospitals. We found that, despite an elevated national early warning score (a system that determines the degree of illness of a patient), Mrs A was transferred to a hospital that was unable to look after a patient who required oxygen, and so she was subsequently transferred back to the Queen Elizabeth University Hospital.

We also upheld Mr C's complaint that the board had failed to communicate with Mr A about his wife's condition during her admission. The advice we received was that there was little evidence in the medical records to demonstrate that Mr A was informed of Mrs A's multiple transfers, or the rationale for these transfers. We considered that the level of communication was unreasonable.

We did not uphold Mr C's complaint that the board had failed to respond fully to Mr A's complaint. We were satisfied that the board had reasonably responded to the issues raised by him in his letter of complaint to them.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to provide Mrs A with appropriate care and treatment. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.
• Apologise for failing to communicate adequately with Mr A. 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:

• Where possible, moving a patient multiple times should be avoided. The rationale for necessary moves should be clearly recorded in the medical records.
• Patients with elevated national early warning scores should not be transferred without further medical review and adequate handover.
• Communication between 'giving' and 'receiving' units regarding a patients needs should include national early earning scores and any requirement for oxygen.
• The handover process should ensure that events that happen overnight, even those perceived as small, are relayed to the day team for action. Abnormal blood results should be appropriately flagged and consideration given to an alert if the same patient has
• Patients with ongoing low potassium levels should be reviewed by appropriate specialist teams.
• Microbiology input and review should be sought for patients with recurrent sepsis.
• Families should be given sufficient opportunities to discuss their concerns and raise questions with clinical staff; especially in situations where the admission is prolonged and complex.

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's son (Mr A) is in long-term foster care. He has ear problems requiring him to attend hospital. Ms C complained that she was not always informed of Mr A's appointments and that, on occasion, appointments for him were cancelled without her knowledge or permission. She said that although she wanted to discuss Mr A's diagnosis and prognosis with his consultant, her request to do so was refused. She further complained that the board refused unreasonably to send her a detailed consent form in advance of the surgery he required.

Ms C made her complaint to the board who confirmed that there had been difficulty in always keeping her informed of Mr A's appointments because of the limitations of their current patient management system and also due to human error. They apologised that this had been the case but said that they had had discussions to improve the system. They said that in the interim they had appointed a member of staff to regularly check the system in order to update Ms C. However, they denied that appointments for Mr A had been cancelled unreasonably or that staff had not been prepared to discuss his care with Ms C. They said that she had been spoken to and given explanatory information about Mr A's condition and about the operation he needed.

We made further enquiries of the board and also sought confirmation of Mr A's status as a looked after child. We obtained independent advice from a medical adviser on the matter of consent. We found that there had been problems in keeping Ms C up to date about Mr A's medical appointments but that, where appointments had been cancelled, cancellations had been made in accordance with the board's procedures. The board had also offered to meet with Ms C to discuss Mr A's diagnosis and prognosis but she had been unable to attend. We found that they had discussed it with her immediately before Mr A's operation and provided her with explanatory documentation. However, they could have given these explanatory leaflets sooner and so we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to always keep her informed of Mr A's appointments.
• Apologise to Ms C for failing to provide her with information that she had requested about Mr A's diagnosis, prognosis and treatment. The apology should comply with SPSO's 'Guidance on Apology', which can be found 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

Mr C complained about the care he received at a prison healthcare centre after he was diagnosed with diabetes. Mr C was concerned that he did not receive appropriate medical care and treatment or support in relation to his diabetes. He also complained that there had been a delay in providing treatment for thrush, and complained that when he was admitted to hospital, staff at the prison health centre had not informed his next of kin. Finally, Mr C felt that his complaint had not been dealt with appropriately.

After taking independent GP advice, we upheld Mr C's complaint about medical care and treatment. While we found that most aspects of his diabetes care and treatment were reasonable, the adviser highlighted two separate days following hospital discharges where Mr C had not received his prescribed medications. We made recommendations to the board to address this.

We found that the board had taken reasonable steps to provide help and support to Mr C for his diabetes and identified no delays in the provision of thrush treatment. Consequently, we did not uphold these elements of Mr C's complaint. We also did not uphold his complaint about the health centre staff failing to inform his next of kin when he was admitted to hospital as we found that this was a matter for the Scottish Prison Service.

Finally, we upheld Mr C's complaint about the board's handling of his complaints as we found that they had not addressed all the issues raised. We made a recommendation to address this failing.

Recommendations

What we asked the organisation to do in this case:

• Apologise in writing to Mr C for failing to give him his prescribed medication on two dates.
• Apologise in writing to Mr C for failing to address one of the concerns of his complaint.

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

• Medications that have been prescribed to a prisoner in hospital should be made available following discharge.

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.