Some upheld, recommendations

Summary

C complained that the council failed to respond reasonably to their enquiries. A planning application was submitted by a business located close to C’s home. C contacted the council’s planning service asking a number of questions in relation to the proposed development. There followed a protracted correspondence during which C tried to obtain answers to their questions. The council treated some of C’s questions as objections to the planning application and C was advised that they would receive no response to these points. Some of C’s outstanding questions were eventually answered after C involved their local councillor, but a number remained unanswered.

Generally, we did not consider that C’s enquiries could be viewed as objections to the planning application. We noted the council’s comments about resourcing and the need to focus on core business but found no reasonable explanation as to why the enquiries could not have been dealt with sooner. We considered there to have been a clear and unreasonable delay to their response to C’s enquiries. Therefore, we upheld this part of C’s complaint.

With regard to the procedural aspects of the complaint handling, we found that the council had responded to C’s complaint reasonably. Therefore, we did not uphold this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably respond to enquiries made by C regarding the planning process. The apology should meet the standards set out in the SPSO guidelines on apology at www.spso.org.uk/information-leaflets.
• Invite C to submit any outstanding questions they may have with a view to investigating these and providing C with a written response.

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

• The council should review how they handle enquiries from members of the public to ensure that general enquiries are responded to, or that individuals are appropriately signposted to relevant national guidance in good time.

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

C complained about the standard of medical treatment provided to their late spouse (A) by the board following diagnosis and treatment of upper tract urothelial cancer (a type of kidney cancer). A’s condition deteriorated and they died. C complained that clinicians failed to, amongst other things, communicate with them in a reasonable way about treatment options and take reasonable action in response to A’s clinical condition.

We took independent advice from a urology specialist (concerning the male and female urinary tract, and the male reproductive organs) and a renal specialist (concerning the kidneys). We found that A’s cancer had likely been more aggressive than originally suspected. However, given the information available at the time, the option of treatment offered to A had been a reasonable approach. We also found that the board had failed to adequately document that all treatment options had been discussed with A, and that a specialist renal cancer nurse should have been available to the family sooner. We found that had A’s treatment been carried out sooner (and in line with cancer waiting time standards), it may have improved their health outcomes. For these reasons, we upheld this aspect of C’s complaint.

C also complained that during a hospital admission the board had failed to reasonably manage the removal of A’s nephrostomy tube (a catheter inserted through the skin and into the kidney) causing them to suffer an arterial trauma (or bleed). We found that bleeding is a recognised complication of such a procedure and there was no evidence to indicate any failings in the removal of the tube. We did not uphold this aspect of C’s complaint.

C further complained that when A’s condition deteriorated following dialysis, unit staff advised the family to take A home, or to take them to the emergency department themselves. C also complained that there had been no end-of-life plan in place for A. We found that there was insufficient evidence to determine what advice had initially been offered to the family by unit staff. However, we found that the process around the decision-making to admit A for ward care had been appropriate, and although there had been no end-of-life plan in place, the ‘wait and see’ approach to treatment had been reasonable in this case. Therefore, on balance, we did not uphold this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The board should ensure all discussions between patients and clinicians are clearly documented in line with required standards.
• The board should give consideration to the use of specialist renal cancer nurses in supporting patient diagnosis/patient management from an early stage.
• The board should review urgent suspicion of cancer referrals to address treatment waiting times, ensuring that there are appropriate mechanisms in place to monitor progress from diagnosis to definitive treatment.

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

C’s parent (A) lived in a nursing home and had been shielding during the COVD-19 pandemic. A was later admitted to hospital and was placed in a green pathway (a ward for COVID-negative patients) ward in preparation for emergency surgery. Following surgery and a few days in the High Dependency Unit, A was transferred to another ward which C was advised was a red pathway ward (a ward for COVID-positive patients). A was discharged over a week later.

C complained to the board about A’s transfer to a red pathway ward and had not been satisfied with the explanation the board provided. C also complained about the standard of nursing care, the decision to discharge A, and that the board failed to arrange follow-up care for A following their discharge.

We took independent advice from a nurse and a consultant geriatrician (specialist in medicine of the elderly). We found that, while the decision to transfer A to a red pathway ward had been reasonable and appropriate in the specific circumstances, the board had not reasonably explained the decision to C. Therefore, we upheld this part of C’s complaint.

We also found that the standard of nursing care and decision to discharge A was reasonable. The board also made the relevant referrals to the appropriate community services after A’s discharge. Therefore, we did not uphold these aspects of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not explaining the rationale behind the transfer of A to a red pathway ward. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

C complained that social work failed to reasonably assess A’s needs following a hospital admission, in relation to whether they required 24-hour care, and C’s concerns that social work ignored clinical opinions.

We took independent advice from a social worker. We considered that it was reasonable for social work to have concluded initially that A did not technically meet the criteria for residential care and was functionally fit to be discharged home with a support package. While we noted that the opinions of others were taken into account in arriving at this conclusion, we considered that there was a failure to fully examine the emotional impact on A of potentially being discharged. The council had already acknowledged that there could have been more detailed discussion with A’s GP and further exploration of the views of a specialist nurse from the psychiatry team, which we agreed with. We also considered that some wording used in the social work assessment to describe A’s reactions could have been perceived to lack empathy and compassion. We upheld this complaint.

A suffered a stroke three days after the initial social work assessment was concluded. They were in temporary accommodation at the time, awaiting further assessment. It was subsequently agreed that A required 24-hour care. They remained in the temporary facility until their transfer to a care home, but died a month later. C complained that a delay in social work re-assessing A delayed their transfer to a care home, which meant the transfer took place during lockdown when the family were unable to support A with the move. The council advised that A was re-assessed in a timely manner once a care home vacancy became available. We considered that it was reasonable for the assessment to be updated once a vacancy arose and were satisfied that the delay was due to a lack of available places and not due to a failing on the part of social work. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to give enough weight to the emotional impact on A of potentially being discharged and for the wording used to describe A’s reactions. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Appropriate weight should be given to the emotional impact of discharge on clients. Social workers should be aware of the impact of language used and where it may be perceived to lack empathy and compassion.

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

C complained about the council’s handling of a planning application. Planning consent was approved for a development that was contrary to the Local Development Plan. Whilst C acknowledged that the Planning Committee were entitled to approve the development, they considered that, in doing so, the Committee failed to explain what material considerations had contributed to the decision to go against the Local Development Plan and approve the application. C also complained that a pre-determination hearing should have been held, but was not.

C raised their concerns in a complaint to the council. They said that it took many months of repeated attempts to obtain a response from the council and, when the council did respond, C did not consider that their concerns had been addressed.

We took independent advice from a planning specialist. There was no question that the Planning Committee had the authority to approve developments that were contrary to the Local Development Plan, as long as there were relevant material considerations, or justifiable reasons for doing so. We acknowledged the council’s position that the report of handling for the application set out the material considerations that had to be taken into account when determining the application and that this information was available to the Planning Committee when reaching their decision. However, the report of handling presented the material considerations with reference to the Local Development Plan and explained in detail why the Planning Officer considered the proposed development went against the Local Development Plan and why they recommended the application be refused. We found that there was a clear unexplained “leap” from the Planning Officer’s recommendation to refuse, to the Committee’s decision to approve. We considered that there should have been a clear record of the reasons for approving the planning application in the minutes of the Committee meeting and in the decision notice. We were critical of the council for failing to record the reasoning behind the Planning Committee’s decision. Therefore, we upheld this aspect of C's complaint.

We were satisfied that the decision on whether to hold a pre-determination hearing was a discretionary decision for the council to make. We found no evidence to suggest that their decision not to hold a pre-determination hearing was unreasonable. Therefore, we did not uphold this aspect of C's complaint.

With regard to the council’s handling of C’s complaint, we found that there were excessive delays to the council’s response, despite C chasing them on a number of occasions. We were critical of the council’s delays and their failure to consider C’s correspondence through their complaints procedure. We were also critical of the fact that, when the council issued their response, they failed to address the main points of C’s complaint. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the poor handling of their complaint and provide a full response to their initial enquiry as to the Planning Committee’s reasons for approving the application contrary to the Planning Officer’s recommendation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• That the council consider how they may take steps to clarify complaints to ensure that they are progressed through the correct channel.
• That the council share this decision with members of the Planning Committee and remind them of the need to properly document the reasons for their decisions.

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

C, a representative of an organisation that provides support to planning application objectors, complained on behalf of an objecting neighbour (A). C raised a number of concerns about the council’s handling of a retrospective planning application. An unauthorised development had been reported to the council’s planning enforcement team. The retrospective planning application was approved, subject to conditions. C complained that the council failed to reasonably assess the risk of flooding at the site, that they failed to follow correct procedure for the scale of the development and failed to take into account an objection submitted by the Scottish Environment Protection Agency (SEPA).

We reviewed the relevant planning documents and sought independent advice from a planning adviser. We found that there was a failure to seek a flood risk assessment, particularly in light of the concerns raised by SEPA, the fact the development was on a listed flood plain and the Planning Officer had identified a risk of flooding as a reason for recommending refusal of the application. As such, we upheld complaint C’s complaint about the failure to request a flood risk assessment.

In respect of C’s concerns about the council’s consideration of SEPA’s consultation response, we found that the content of SEPA’s response was accurately summarised in the Planning Officer’s report to the Planning Committee. We did not uphold this aspect of C’s complaint.

Our final consideration was whether the council failed to refer the planning application to Scottish Ministers. We concluded that the council should have treated SEPA’s response as an objection to the planning application and that this should have led to the application being referred to Scottish Ministers. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the issues highlighted in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• That the council offer to meet with A to discuss ways of establishing to what extent the development may have contributed to an increase in flooding on their property and what action the council can take to mitigate this.

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

• The council should review their standard working practice of not requiring technical assessments in cases where they anticipate refusing an application due to the cost that would be incurred by the applicant.

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

C complained about the care and treatment that they received in relation to their mental health from the board over the course of just over a year. C was also concerned about the treatment that they received from a psychiatric consultant including consideration of referring C to a different health board and dealing with complexities in the case, such as C’s parent being employed by the board. We took advice from an independent psychiatric nursing adviser. We found that the overall standard of treatment provided to C was reasonable and did not uphold this complaint.

C was also concerned that the board unreasonably delayed the organisation of community mental health care to them due to concerns over safety and risk. Although C was ultimately referred to the specific community mental health team outwith the area that they had requested from early in the process, we found that the board’s regard for the potential risks of such an arrangement were reasonable and that, overall, there was no unreasonable delay due to the board’s action and that the standard of care provided was reasonable. We did not uphold this complaint.

C was further concerned that the psychiatric consultant did not reasonably record their assessment and reasoning of decisions to hospitalise C, to prescribe medicine to C or to refer C to a psychologist. We found that record keeping over the relevant period had been reasonable and that, taking all of the available evidence, the psychiatric consultant had reasonably recorded their assessments and reasoning regarding C’s treatment. We did not uphold this complaint.

C was concerned about delays in the board responding to complaints about their care and treatment, the board’s inability to explain the reasons for those delays and the board’s failure to provide a copy of a response to an elected representative as C had requested. While the board had accepted some of these failures during their consideration of the complaints submitted or while responding to our enquiries we also concluded that, contrary to the board’s views, the reason for these delays were confusion within the board and a lack of clear responsibility for responding to the complaints. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Re-iterate their apologies to C for the unreasonable delays in responding to the complaints and their unreasonable failure to provide a copy of their response to their MSP as they had requested. Apologise to C that they did not provide reasonable explanations for the delays in responding to the complaints. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Establish a clear hierarchy of responsibility for complaint responses and a system of escalation to senior management for circumstances where complaints have not been responded to within three times the length of a timescale in the Complaints Handling Procedure, or Complaints and Feedback Team follow up messages do not result in action to progress 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

C’s adult child (A) had spent time in hospital due to abdominal pain, following which complaints had been raised and promises made that action would be taken to prevent any recurrence. A few years later, A spent time in hospital again as a result of abdominal pain and swelling, bruising to the legs and breathing issues. During the admission, A required cardiopulmonary resuscitation (where the heart and/or breathing is re-started if it stops) and died in hospital. A post-mortem examination established that A had rheumatoid arthritis-related constrictive pericarditis (a condition that causes the flexible sac that surrounds the heart to become stiff, preventing the heart from functioning properly).

C raised a number of concerns regarding the clinical investigations carried out into A’s symptoms, the time taken to reach a diagnosis and the quality of clinical nursing care provided. C complained about the standard of communication from the board’s staff and expressed their concern that the improvements that had been promised previously had not been implemented by the board.

We took advice from an independent nursing adviser. We found that multiple, relevant, investigations were carried out to establish the cause of A’s symptoms, appropriate specialist advice was sought, a reasonable treatment plan was followed and that the true nature of A’s heart condition was not detectable, despite the appropriate investigations having been carried out. Given this, we found that the medical care and treatment provided to A had been of a reasonable standard. We did not uphold this aspect of the complaint.

We found that the board’s monitoring and management of A’s fluid balance and wound care was not of a reasonable standard, and that there were apparent issues in terms of the nursing staff’s engagement with A and their family. We found that the board had failed to provide A with a reasonable standard of nursing care. We upheld this aspect of the complaint.

While we found the board’s communication with C following A’s death was generally reasonable, we found that the board unreasonably failed to apologise to C for not contacting them when A became unresponsive. Given this, and that there were communication failings that the board had accepted, we found that the board had failed to communicate with A’s family appropriately during their admission and following their death. We upheld this aspect of the complaint.

We did not find any evidence that the actions and service improvements promised following C’s earlier complaint were implemented by the board. We also found that if actions were taken, they were not effective, as the board accepted that similar issues had recurred. We found that the evidence the board provided regarding actions taken as a result of their later commitments were from too small a sample of patients and taken over too short a period to adequately demonstrate that issues identified had been addressed. Given this, we found that the board had failed to implement the actions and service improvements promised following C’s earlier complaint. We upheld this aspect of the complaint.

We found that C’s complaint was taken seriously and investigated thoroughly. However, there were delays to starting an investigation into the most recent issues raised by C and to arranging a meeting regarding these. We also found that the board’s communication with regard to the Chief Executive’s attendance at any meeting and how the most recent issues would be taken forward were poor. Given all of the above we found the board failed to handle C’s complaint reasonably. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the issues highlighted. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A’s family for failing to contact them when A became unresponsive. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A’s family for failing to effectively implement the actions and service improvements promised following C’s original complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The board should conduct an audit of the relevant ward's current compliance with their obligations to monitor fluid balance and wound condition to ensure that the improvements that have reportedly been made since C’s complaint are reflected in the nursing care currently provided on the ward.
• The board should conduct two audits of the general quality of nursing care in the relevant ward to demonstrate an improvement in standards over the next six months.
• The board should effectively implement the actions and service improvements promised following C’s original complaint and take action to effectively address issues regarding nursing care, communication, attitude and behaviour.

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 provided her express consent for her pronouns to be used for this publication.

Ms C complained about matters relating to the SPS failing to give Ms C advice and failing to put in place an appropriate procedure for Ms C to obtain certain items. Ms C also complained about the SPS refusing to allow Ms C to wear her own clothing and having the use of certain electrical items. We took independent advice from an adviser who specialises in equal opportunities and diversity.

We found that there were delays in the SPS giving Ms C advice and in putting in place a process to order certain items. We upheld these aspects of Ms C's complaint.

We found it was reasonable that the SPS refused Ms C's request to wear her own clothes and have access to the electrical items. Therefore, we did not uphold these aspects of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the delays in providing her with advice and putting in place a process for her to order items to support her gender identity. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• All relevant SPS staff should be clear about their obligations to transgender prisoners and their policy on accessing, or facilitating access, to items to support their gender identity.

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

C complained about the council's handling of a planning application.

C's neighbour was granted planning consent for an outbuilding in their garden. C noted that this space was to be used for commercial activities and complained that the council failed to comply with their own adopted and emerging Local Development Plan policies when reaching the decision to approve the application. C did not consider that their concerns in this regard had been addressed in the report of handling.

C raised further concerns as to how the approved development would impact the neighbouring properties and the local area. C contended that the council failed to appropriately notify all of the affected neighbours.

When objecting to the development, and in their subsequent complaint to the council, C noted that approving the application would allow the developer, or future owners of the residential property, to conduct other activities that could be disruptive. C did not consider that the council had taken adequate steps to consider this eventuality, or to limit the activities to those listed by the applicant. C raised a complaint with the council, but did not feel that all of their concerns were addressed.

We took independent advice from a planning specialist. We found that the council were largely able to demonstrate that the planning application had been handled reasonably. Therefore, we did not uphold this complaint. However, the report of handling failed to address C's concerns about the potential for other activities taking place at the site in the future. Whilst we were satisfied that the council were entitled to reach the decision that they had, we were critical of them for failing to demonstrate that this issue had been considered prior to consent being granted and we made a recommendation in this regard. We also found that the council failed to address this, and another issue, in their responses to C's complaint. This was particularly concerning given how central these two issues were to C's complaints about their handling of the planning application. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to handle their complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• That the council share this decision with their planning staff.

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.