Some upheld, recommendations

Summary

Mr C said he issued a letter to his solicitor and he requested that it be sent by special delivery. However, Mr C said an officer told him that his letter had been lost and asked him to resubmit it, which he did. Mr C said that it was unreasonable that his original letter was lost and that there had been an unreasonable delay in issuing the letter he resubmitted. He also complained that the prison did not respond appropriately to his complaint.

In response to Mr C's complaint, the Scottish Prison Service (SPS) said it was unacceptable that Mr C's letter was lost. However, when we made enquiries with the SPS, they told us the officer identified by Mr C in his complaint had said he did not tell Mr C that his letter had been lost. Instead, the officer said Mr C approached him to say that a letter he had sent by standard delivery to his solicitor had not arrived. The officer said he advised Mr C to resubmit the letter. There was no other evidence available to support Mr C's position that his original letter had been lost by the prison.

We also looked at whether there had been an unreasonable delay in the SPS issuing Mr C's letter. The evidence available confirmed that the prison deducted the special delivery postage fee from Mr C's account, but his letter did not reach its destination until four days later. The SPS explained that all prisoner mail being sent by recorded or special delivery had to be hand-delivered to the nearest post office by a member of staff. They said it could not always be done on the day the letters were collected from prisoners. In Mr C's case, the SPS explained that his letter was collected on a Friday, taken to the post office after the weekend, before being delivered to its recipient on the Tuesday.

In light of the evidence available, we did not uphold Mr C's complaints. However, we did agree that the prison did not respond appropriately to his complaint. It was apparent that steps were only taken to speak with the officer identified in Mr C's complaint after we made an enquiry to the SPS. We felt this should have been done when Mr C made his complaint to the prison.

Recommendations

We recommended that the SPS:

• share our findings with relevant complaints handling staff and remind them to ensure that, where appropriate, individuals identified in complaints are interviewed.

Summary

Mr C, who is a council tenant, complained to us about two issues regarding reports he had made to the council about the anti-social behaviour of his neighbour. Firstly, he complained that the council failed to follow their policies and procedures by deciding not to investigate his reports. We found that he had been told that his reports did not constitute anti-social behaviour in terms of the relevant legislation, and his case was closed on these grounds. On reviewing the council's anti-social behaviour procedures, it became clear that his complaint should have been passed to the local housing office and investigated through the procedure. This had not been done and, as such, we upheld his complaint.

He also complained that the council had failed to progress repairs to his property to stop smells entering from his neighbour's property. On investigation, it became clear that the council had attempted to progress these works, but Mr C had refused to allow the works to go ahead unless they were done on a Saturday. The council had sent Mr C a letter, clearly stating that Saturdays were outwith their normal working hours and the works would not go ahead until he proposed a suitable time. We found this to be a reasonable response and, as such, did not uphold this part of his complaint.

Recommendations

We recommended that the council:

• apologise to Mr C for the failings identified;
• re-open Mr C's case, and investigate his complaints in line with their stated procedures;
• review their anti-social behaviour procedures to rectify the discrepancies identified in our investigation; and
• provide training to relevant staff on the anti-social behaviour procedures they are required to follow.

Summary

Ms C complained that the council had failed to deal properly with her claim to them for damage to her car, which she believed was due to a pothole. She also complained that they failed to deal with her subsequent complaint in line with their complaints process.

We found that the council had followed their claims process properly, apart from their failure to provide one piece of photographic evidence submitted with the claim to their claims handlers. This photograph was later provided and the council asked their claims handlers to reassess the claim. Having done so, they did not admit liability because the council had met their responsibilities in terms of roads inspections. However, as they had failed to pass the photograph on to their claims handlers, and as this resulted in an increase in the time taken to fully assess the claim, we upheld this aspect of the complaint. We recommended that the council review their procedures to ensure that all evidence is provided to claim handlers and, when photos cannot be accessed, they ask the claimant to provide copies in another format.

We found that, with the exception of a delay in acknowledging the complaint, the council dealt with the complaint in line with their complaints procedure.

Recommendations

We recommended that the council:

• review their claims procedure to ensure that all relevant evidence is provided to their claims handlers and, if photographic evidence cannot be accessed, that they revert to the claimant to obtain copies through other means.

Summary

Mrs C's son (Mr A) went to a school that was not in the council's area. Mr A attended the school seven days a week, coming home only at the end of term. Mrs C wanted the council to pay for transport costs for visits during term time. The council would only pay costs to take Mr A to school at the start of term, and return him home at the end of term. Mrs C complained to us that it was unreasonable of the council to pay only these transport costs, that the council did not include her or Mr A when making the decision, and that the council failed to keep records about the decision. Mrs C was also unhappy with the council's response to her complaint.

It is clear that the situation was very difficult for Mr A and Mrs C. However, we had to explain to Mrs C that complaining to us was not a route to appeal the council's decision. Instead, our role was to determine whether the council acted in line with relevant policy and procedure.

We looked at the council's policy and found that they had discretion to pay costs they determined were appropriate. Although Mrs C disagreed with the council's decision, there was no evidence that they had acted outwith their policy. We considered that the council's communication with Mrs C could have been better. However, there was no requirement for the council to include Mrs C and Mr A in the decision-making process. We also found that the council had investigated Mrs C's complaint thoroughly and provided a reasonable response. We did not uphold these aspects of Mrs C's complaint.

The council were aware that, other than letters to Mrs C about their decision on transport costs, there were no records. The council acknowledged that it was best practice to keep records, and they were looking into how they could do this from now on. We concluded that it was good practice to keep records, for example, making even a brief file note of important conversations which relate to the decision-making process. This would ensure there was an audit trail of how and why important decisions were made. We upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the council:

• provide us with a copy of their consideration of, and plan for, record-keeping.

Summary

A developer had demolished a farm steading and begun construction of a new building without getting planning permission. The council served stop and enforcement notices on the developer that required the building works to be stopped, the foundations of the new building to be removed and the steading reconstructed. Some years later, the developer applied for permission to construct a new building on the site and the council granted consent.

Mrs C, a neighbouring property owner, complained that the council had failed to follow through on the original enforcement notice requiring the removal of the foundations and rebuilding of the steading. She said they had unreasonably used the fact that there were existing, though unapproved, foundations as justification for granting consent on the new building. She also raised concerns about the omission of details about the enforcement notice on the planning officer's report, their failure to take into account her concerns about the local water supply, and their failure to deal adequately with her complaint.

We found that the council had acted reasonably, and within their discretion, when taking enforcement action against the developer. We did note that the enforcement notice was inappropriately worded and required works to be carried out which, if enforced, would have effectively granted consent for a new building in an area which, at that time, was against the terms of the local development plan. We noted that the local development plan had changed since then and now allowed for new development in the countryside, and that this was the reason the new application was granted. We also found that the council had taken into account Mrs C's concerns about water supply and had placed conditions on the planning consent requiring that her supply be unaffected by the new development. We did not uphold these elements of her complaint. However, we noted that it would have been good practice for the planning officer's report to have included details of the enforcement notice in the site history section, and we noted some inaccuracies and delays in the council's responses to the complaint. We upheld these elements of the complaint.

Recommendations

We recommended that the council:

• remind staff of the importance of preparing clear and enforceable notices;
• review this case to identify why the existence of the enforcement notice was not included in the planning report and whether there were any procedural reasons for this omission; and
• remind staff of the importance of accurately addressing complaints and dealing with correspondence in line with their complaints procedure.

Summary

Mrs C, who is an advice worker, complained on behalf of Mrs A about the care and treatment she received at Caithness General Hospital in 2004/05 for a lump in her breast. In August 2013, Mrs A had a routine mammogram and was referred for further tests, after which she was diagnosed with breast cancer in the area that had been examined in 2004/05. Mrs A was concerned about the lack of communication by the surgeon in 2004/05 in relation to some test results which indicated an abnormality. She also complained that a procedure for exploring whether there was any sign of malignancy (cancer cells) was not properly performed; that she was wrongly advised that the lump would never be cancerous; and that she should have been kept under continual review.

The board found no failings in the treatment given in 2004/05. However, they acknowledged that there were failings by the surgeon in the record-keeping of one of her procedures, and that there was a lack of evidence that the results of a test which indicated an abnormality (but not malignancy) had been explained to her.

We took independent advice on this case from one of our medical advisers. We found that Mrs A was given appropriate investigations in accordance with national guidance in place at the time. However, we were critical of the poor record-keeping by the surgeon and the failure to explain all of Mrs A's test results. Therefore, we upheld this aspect. We did not identify evidence to support that Mrs A was given misleading information about the lump and, even though there was an abnormality in one of the tests, this was not a reason to keep her under continual review.

Recommendations

We recommended that the board:

• share with the surgeon the importance of ensuring test results are fully explained to patients and provide evidence that informed consent has been obtained where relevant.

Summary

Miss C complained that the board had unreasonably removed her pet from her property and had also failed to gain her consent to search her property.

We took independent advice from one of our mental health advisers. Our investigation found that, in the circumstances, the action taken to arrange for Miss C's pet to go into foster care was reasonable, but that it had not been reasonable to ask her to make a decision about the long-term future of her pet without allowing sufficient time to consider this and give her informed consent.

Our investigation also found that, given the concern about Miss C's welfare and safety at that time, it had been reasonable to search Miss C's home and remove medication. However, the record-keeping was unreasonable.

Recommendations

We recommended that the board:

• apologise for the failings identified in this case;
• ensure that the relevant staff reflect on the adviser's comments on the advisability of seeking permission to remove a pet permanently without allowing time to adequately consider the long-term consequences of such a decision; and
• ensure that the staff involved in Miss C's care review the adviser's comments about the standard of record-keeping and advise us of any action plan arising from this. Also, that consideration be given to putting in place consent and search policies to support the consent form.

Summary

Mrs C complained about the mental health care and treatment provided to her late son, as well as the lack of support for her and her family, the lack of family involvement in the critical incident review (CIR) following her son's death, and the delay in providing her with a copy of the CIR report. Mrs C also complained to the General Medical Council (GMC) about the psychiatrist involved in her son's care. The GMC investigated, and decided to take no action.

We decided not to re-investigate those matters which had already been considered by the GMC. However, we agreed to investigate some issues which had not been looked at by the GMC, including the conduct of a mental health assessment, the support provided to the family, and the complaints about the CIR.

After taking independent mental health advice, we upheld three of Mrs C's complaints. We found that the board unreasonably failed to include Mrs C in the CIR process and that the delay of over six months in providing Mrs C with a copy of the CIR report was unreasonable. However, we accepted that the board had apologised for this delay and taken appropriate steps to improve their CIR process.

We also found the board had not provided reasonable support for Mrs C and her family as carers. While the board had since amended their paperwork to improve involvement of carers at the assessment stage, we did not consider this was sufficient to prevent a recurrence, as the meaningful involvement of a person's relatives should be on-going, rather than completed as a one-off exercise.

In relation to the mental health assessment of April 2011, we found this had been conducted reasonably, and we did not uphold this complaint. However, we were concerned that there had been a delay in arranging a referral to a psychiatrist following this assessment, and we raised our concerns about this with the board.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings our investigation found; and
• advise us how they will ensure on-going carer involvement, in light of our adviser's comments.

Summary

Mr C's father (Mr A) had a complex medical history and was admitted to Aberdeen Royal Infirmary with a suspected heart attack, which was believed to have been caused by an infection in his leg. Surgery to amputate his leg below the knee was delayed to minimise post-operative risks, but carried out two months later. A few weeks after surgery, Mr A's health began to deteriorate, but there was a delay in admitting him to the intensive care unit and he died of a cardiac arrest. Mr C complained that staff failed to provide a reasonable standard of medical and nursing care and treatment, and that there was a failure to admit Mr A to the intensive care unit within a reasonable time. Mr C also complained about the length of time it took the board to respond fully to his complaint.

We took independent advice from a nursing adviser and an adviser who is a specialist in end-of-life care. We found that the medical and nursing treatment provided was reasonable and that there was relatively prompt recognition of Mr A's problems. However, we also found that the delay in admitting Mr A to the intensive care unit was unacceptable. We found that, while it may not have altered the outcome for Mr A, an earlier admittance would have improved his chances of survival. Also, while the board's investigation of the complaint was thorough and comprehensive, the delay in responding was unreasonable, as it caused further distress to Mr C and his family at a difficult time.

Recommendations

We recommended that the board:

• ensure the action plan is implemented in full;
• review their processes to ensure that investigations into complex complaints are completed within a reasonable time and that complainants are regularly updated and told of their right to contact us; and
• apologise for the failures in complaints handling this investigation identified.

Summary

Mrs C, who is an advocacy worker, complained to the board on behalf of her client (Mrs B). Mrs B's mother (Mrs A) had been admitted to Forth Valley Royal Hospital with swallowing difficulties, and there was a problem when a nurse was performing an endoscopy (a procedure where a tube-like instrument is put into the body to look inside). A consultant gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas) was called to continue the procedure and Mrs A's oesophagus was perforated, which meant the procedure had to be cancelled. Mrs A was transferred to the intensive care unit (ICU) and Mrs B complained that Mrs A suffered problems with her catheter, blockages of her NJ tube (nasojejunal tube - a small tube that is passed through the nose and into the small intestine), inappropriate management of her chest drain, and poor communication from staff.

The board maintained that the perforation of the oesophagus was a rare but recognised complication of an endoscopy procedure and that Mrs A was transferred to ICU for close monitoring. They said Mrs A had received appropriate care and treatment, and that it was appropriate for the catheter to have been fitted. They said the blockages in the NJ tube were addressed in a timely manner, and explained that staff dealt appropriately with problems of fluid build-up by managing chest drains correctly.

After taking independent advice from a gastroenterologist adviser and a nursing adviser, we did not uphold the complaint about the care and treatment which Mrs A received. We found that Mrs A had suffered a recognised complication of an endoscopy procedure which was not caused by failings by the staff involved. We were also satisfied that the staff provided Mrs A with appropriate care and treatment in relation to the problems with her catheter, NJ tube and chest drain management. However, we did find that, although communication from the staff to the family was generally good, there was a four-day period after Mrs A's transfer to ICU when senior staff did not provide her family with an update.

Recommendations

We recommended that the board:

• apologise to Mrs A for the failings in communication from ICU staff;
• take steps to ensure the relevant staff are made aware of the importance of communication with relatives, in line with General Medical Council guidance; and
• remind staff who compile draft complaint response letters to ensure that all relevant issues are included.