Some upheld, recommendations

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs A). She complained that when Mrs A had been admitted to Queen Elizabeth University Hospital with shortness of breath and chest pain, she was not provided with proper care. Ms C also complained that Mrs A was inappropriately discharged from the hospital, as three weeks after Mrs A's admission, she was diagnosed with interstitial lung disease (thickening of the tissue between the air sacs of the lungs).

During our investigation, we took independent advice from a consultant physician and found that whilst appropriate tests were carried out when Mrs A was in hospital, there was a delay in her chest x-ray being formally reported. The adviser said that had the chest x-ray been reported sooner, the clinician may have arranged further investigations which could have led to an earlier diagnosis of interstitial lung disease. We therefore upheld this aspect of Ms C's complaint. However, we found that the decision to discharge Mrs A had been reasonable as there was nothing to suggest at that time that she had serious health problems.

Recommendations

What we asked the organisation to do in this case:

• The board should apologise to Mrs A.

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

• The board should ensure that formal reports should be more readily available, particularly for acute or unscheduled patients.

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 at Crosshouse Hospital. Mrs A had been a patient there for 12 days when she was discharged home. Mrs A was readmitted to the hospital later the same day and died shortly thereafter.

We obtained independent medical advice and we found that although Mrs A was in an orthopaedic ward during her admission, she should have been admitted to a medical or rheumatology ward, or transferred to one as soon as possible after her admission. There was also a lack of a senior review of Mrs A by a consultant and a failure of early input from rheumatology, general medicine and microbiology. We found that the choice of antibiotics prescribed to Mrs A was a deficiency in her treatment, although we found no evidence that the antibiotics contributed to her decline. Furthermore, we found that there was a failure to act promptly on test results that showed Mrs A had E.coli. We also found that there were failures in communication with Mr C and Mrs A. While we found failings in Mrs A's treatment, we accepted that there were certain features that had masked the serious nature of her illness and that there was no significant error to blame for Mrs A's outcome. Given the failings identified, we upheld this part of Mr C's complaint.

Mr C was also dissatisfied that despite a post-mortem being carried out, Mrs A's death was recorded as unascertained. We found it was reasonable to record Mrs A's death as being unascertained given the advice we received that a post-mortem does not always provide a definite cause of death. We did not uphold this part of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should issue a written apology to Mr C for the failings in the care and treatment provided to Mrs A.

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

• The board should ensure that staff reflect on and learn from the findings of this investigation. In particular there should be reflection on the admission to an inappropriate ward, the antibiotic medication prescribed, the lack of early input from appropriate departments, the lack of senior review by a consultant, the lack of prompt action on test results and the poor communication.

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 made a number of complaints to us about the way the university had handled complaints he had made to them. He complained about the way in which the university had handled his complaint about two members of staff, but we found that the investigation into this matter had been reasonable and did not uphold this aspect of his complaint. He also said that the university had failed to investigate this complaint in the scheduled time. We found that many of the delays had been outwith the university's control and that, where extensions for the investigation to be completed had been sought, this had been done in line with the university's complaints procedure. On balance, we did not uphold this aspect of Mr C's complaint.

Mr C complained that the university had unreasonably stated that he was unwilling to accept a proposed solution. He also complained that they had unreasonably consulted with a member of staff about whom he had complained. We found that it had been reasonable for the university to state that he was not willing to accept a proposed solution and that there was nothing to prevent the member of staff from being involved in his complaint. We did not uphold these aspects of Mr C's complaint. Mr C complained that the university had erroneously blocked him from registering for classes because there was a marker on his record that he was going through conduct proceedings. We upheld this aspect of Mr C's complaint and found that the university had already apologised to him for this.

Mr C complained to us that the university had failed to investigate complaints about both the student conduct committee and the university senate. We found that the responses issued to Mr C about these issues had been reasonable and we did not uphold these aspects of his complaint. Mr C also complained about the actions of a member of staff at the university. Although the member of staff had referred to the wrong sections of the university's complaints procedure in responses to Mr C, we found that this had been due to human error and found no evidence that the member of staff had intentionally mislead him. There was no evidence that the member of staff had bullied or harassed Mr C or had forced him to withdraw his complaints. We did not uphold this aspect of Mr C's complaint. Mr C complained that the university did not have a clear procedure for appointing a complaints investigator. We found that the action that they had taken in Mr C's case had been reasonable and we did not uphold this aspect of his complaint.

Recommendations

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

• The university should ensure that students are not erroneously blocked from registering for classes because of service indicators against their name.

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 (Miss A). Miss A has epilepsy and was studying at the college. Ms C complained that the college did not provide Miss A with adequate support, despite this being requested. Miss A had enlisted the support of an epilepsy specialist nurse who wrote to the college explaining Miss A's memory difficulties and the medication she needed to take. She had highlighted the need for her to have paper copies of notes so that she could revise at home, and confirmed that she would need extra time to copy details. Ms C complained that the college put no support in place to help Miss A compensate for her memory issues, and she was given no additional time to copy information down.

The college provided evidence that a significant amount of support had been provided, with records showing 29 additional support sessions over a nine-month period. A learning needs assessment had also been arranged, with details of recommendations circulated to academic staff associated with Miss A's course. We did not find sufficient evidence of a failure to provide agreed support, so did not uphold this complaint.

Ms C also complained that the college unreasonably failed to comply with the terms of their Equality and Diversity Policy. The college did not specifically address this aspect of Ms C's complaint in their response to her or to this office in the course of our investigation. We highlighted this as a point for future improvement in their complaints handling. However, we found no evidence that they had failed to comply with the terms of their Equality and Diversity Policy, and did not uphold this complaint.

Ms C complained that the college's response to a letter she had sent was unreasonable. After Ms C's initial complaint, the college issued their response stating that Ms C had the right to bring her complaint to this office, but also asking her to contact them again if there were aspects of her complaint she felt had not been fully addressed. She wrote asking for more information and gave a number of specific examples of Miss A's concerns about lack of support. The college responded, declining to investigate or comment further. We found that the college had provided poor customer service, and noted that their complaints policy did not reflect the model complaints handling procedure (CHP) for further education institutions in Scotland. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• The college should apologise for the failure to consider Ms C's letter and respond accordingly.

In relation to complaints handling, we recommended:

• The college should revise their complaints policy to ensure it complies with the model CHP.

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 home was flooded and the flood was reported to Scottish Water, who subsequently carried out an investigation. The investigation concluded that the flood was caused by severe rainfall and that Scottish Water were not responsible. Mr C was unhappy with the investigation and raised a number of questions, including why his neighbour's properties were not flooded. He was unhappy that Scottish Water did not offer a clean-up service and that they refused to install non return valves (NRVs), which he believed would prevent future flooding. Scottish Water advised that they would not recommend installing NRVs as they could not be certain that they would not pass the flooding onto a neighbouring property. Mr C subsequently installed NRVs at his own cost.

Mr C complained to us that Scottish Water unreasonably failed to offer a clean-up service, unreasonably failed to thoroughly investigate the cause of the flood and unreasonably refused to compensate him for the cost of the NRVs. Scottish Water said they did offer assistance when Mr C reported the flooding and that Mr C did not request a clean-up service. We found that Scottish Water should have been more explicit when asking Mr C if there was anything they could help with and therefore we upheld this aspect of the complaint. We found that Scottish Water properly investigated the flooding in line with national guidelines and that they were not required to reimburse Mr C for the cost of installing NRVs at his property. We did not uphold these two aspects of the complaint.

Recommendations

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

• All members of the Sewer Response Team should explicitly offer a clean-up service to customers when they report internal flooding.

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 (Miss A). He said that the council had unreasonably failed to comply with its policy on restraint and physical intervention. He also complained that the council were unreasonably using a restraint and physical intervention policy which is not specific for children. Miss A was unhappy with how staff at her daughter's school had responded to an incident involving her daughter.

In investigating the complaint, we received information from Miss A and the council about the incident, including statements from the staff involved and Miss A's daughter. The council also provided copies of their policies relating to behaviour management and physical restraint in schools.

We found that the council's policies mentioned three stages of good practice to deal with a critical incident at a school and the potential need for physical intervention. We found that the act of restraint used towards Miss A's daughter was appropriate given the council's policy. However, there is a clear emphasis in the policy on avoiding or de-escalating a potential incident in the first place and we found that the council did not act reasonably in line with their policy to stop the incident taking place.

We also found that there was a failure to document if Miss A's daughter was injured following the restraint, as is required by the council's policy. The council acknowledged that the preventative measures could have been better used and said that they have provided further training for the staff involved. We have asked for evidence of this training. We upheld this aspect of the complaint.

The council agreed that the restraint and physical intervention policy is generic but stated it was applicable in any situation where challenging behaviour occurs. We found that, whilst the policy could be more child-specific, it does refer to risk-benefit assessments and care/education plans which will be specific to an individual's situation. We felt this would allow the impact of the policy to be child-specific when implemented and we therefore did not consider the existing policy to be unreasonable. We did not uphold this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss A for failing to reasonably comply with procedures, and for the distress caused to both Miss A and her daughter. 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

Miss C complained that the council failed to follow their policies and procedures before raising court proceedings to recover rent arrears. She also complained that they failed to follow policies and procedures in relation to recovery of council tax arrears. Miss C has a history of depression, stress and anxiety and has had spells when she has been well enough to work, as well as periods when she has been in receipt of benefits due to ill health. She pointed out that she had always notified the council of any change in her employment.

We found that the council had followed their policies and procedures in relation to recovery of rent arrears. It appeared that the council had correctly identified her as vulnerable and had taken steps to ensure that her arrears did not get out of hand, in line with their protocol. We did not uphold this complaint.

In relation to the council tax arrears, the council had instructed sheriff officers to recover council tax arrears dating back almost 20 years. Miss C accepted that she owed council tax, but she questioned how the council could pursue her for debts dating so far back. The council advised that the Department of Work and Pensions (DWP) had not notified them when her direct deductions (deductions taken from benefit payments in order to repay debts) ceased, and that the debt had remained on hold until the council's debt recovery team recently carried out a review of all historical debts. The council accepted that there had been administrative failings in dealing with her historical debts. We considered that poor communication had led to an opportunity to share information being missed. Had there been better communication between departments, it may have been picked up sooner that she was no longer in receipt of benefits and was therefore not having direct deductions taken by DWP.

We found that although the officers involved in collecting Miss C's rent were aware of her depression and appeared to recognise her vulnerability, those pursuing her for council tax arrears failed to take her vulnerability into account. In terms of their policy, the council had discretion in relation to recovering the arrears, taking into account her vulnerability. We noted that they had certain write-off powers, but they satisfied us that these were not applicable in these particular circumstances. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to note that she was no longer having direct deductions taken by DWP, leading to a build-up of council tax arrears dating back many years. Further apologise to Miss C for failing to identify her as vulnerable when recovering council tax arrears from her. These apologies should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.
• Review the way they treated Miss C in relation to their policies and her vulnerability, with a view to writing off some or all of the council tax arrears. They must explain their reasons for their decision in clear, jargon-free language.

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

• Communication between relevant departments, particularly with regard to vulnerable tenants, should be improved.

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 the home care package provided to her father. Although her complaint had been upheld by a Complaint Review Committee (CRC), Ms C was unhappy that several of the outcomes she had requested had been deemed to be outwith the CRC's remit. Ms C said they remained unanswered and that, as she had completed the social work complaints process, the council were refusing to discuss the matter further.

We found that CRCs have a broad remit and that there were no obvious grounds for ruling the outcomes Ms C requested as outwith the competence of the committee. We also found that one of the outcomes Ms C sought related to the provision of care to her father by an outside agency. Whilst the CRC was correct to state that they could not give directions to such an organisation, Ms C had been repeatedly promised by the council that this support would be progressed. It was unreasonable for the council not to have followed up on this, given that the CRC stated it could not reach a decision on it. We upheld Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Explain, with reference to the appropriate guidance, why the CRC was unable to comment on some of the requested outcomes.
• Provide a clear explanation of why support from the external agency has not been progressed and give a timescale for delivery, if appropriate.

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

• Staff should ensure that care users and their families are provided with regular and accurate updates and advice on accessing care from third party providers.

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 contractors working on land opposite his home created a new site entrance and works compound, despite him have received assurance from the council during the planning process that the existing site access would be preserved. The council advised this on the basis that the planning application did not show plans for a new entrance. Revised plans showing the new access arrangements were then submitted, subsequent to this complaint, and the council deemed the new access permitted development, not requiring planning permission.

We took independent advice from an planning adviser, who found that the new access and compound were classified as permitted development. We, therefore, concluded that the council did not act unreasonably in allowing the contractors to take this action, and we did not uphold this aspect of complaint.

Mr C also complained about the way in which the council responded to his concerns. As he had received an assurance from the council that the existing access arrangements would be preserved, we considered that he was justified in raising concerns when this changed. However, the council initially advised him that the planning process could not consider matters of construction, which the planning adviser disagreed with. The council then noted that they had no obligation under the planning process to provide Mr C with an individual response to his representations. They did not explain to him that the deviation from the submitted plans was permissible under permitted development rights, despite confirming this to the applicant shortly thereafter. We considered that the council failed in their duty to respond reasonably to valid concerns raised by a member of the public and we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to respond reasonably to his concerns.

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

• Ensure that enquiries, such as those submitted by Mr C, are passed promptly to relevant members of staff to fully consider and respond to accurately and in sufficient 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

Mr and Mrs C were living in temporary accommodation while they were on the council's housing list for permanent accommodation. When a first floor flat was offered, Mrs C contacted the council to discuss the offer. Mrs C's health condition had deteriorated and she had started to experience difficulty with climbing stairs. As this was new information to the council, they required Mrs C to provide further information about this from a medical professional. Mrs C complained that the council required her to provide a letter from her GP, which would cost her £25. Mrs C said she believed the council's policy states that they will obtain further information about a medical condition if it is required.

The council responded to the complaint and advised that Mrs C was not requested to specifically go to her GP, but to obtain information from a medical professional. The council contacted the GP to request a refund of the £25 but this was refused.

Mrs C also complained that the council did not keep her properly informed of what was happening next regarding the property offer. She told us she knew she was required to accept the first offer of housing made to her, yet she knew she could not accept the first offer as it was on the first floor. The council confirmed with Mr and Mrs C that the first floor property was no longer appropriate and they would remain on the housing list for a permanent property with ground floor accommodation.

Our investigation found the council's policy does clearly state that if they require further information from a medical professional, they would request this information. We could not establish whether Mrs C was in fact asked to specifically contact her GP, or to contact a medical professional. We upheld this complaint, however we could not recommend a refund of £25 due to not being able to establish what was said.

Our investigation also found the council did keep Mr and Mrs C informed of the next steps. The council wrote to Mr and Mrs C and confirmed the housing offer would be withdrawn because it was no longer suitable and they would remain on the housing list for more appropriate accommodation. We found the council's level of communication to be clear and reasonable. Therefore we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for not clearly explaining that they should request the information they required from a medical professional. 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.