Some upheld, recommendations

Summary

Miss C, an advocacy worker, complained on behalf of Mr and Mrs A about the care and treatment their late daughter (Miss A) received during an admission to Dumfries and Galloway Royal Infirmary. Miss A, who was severely disabled, was admitted with breathing and swallowing difficulties, but she became increasingly unwell and died two weeks later. Mr and Mrs A complained about various aspects of her medical and nursing care. They also complained that staff failed to reasonably communicate with them, and they raised concerns about the way in which the board handled their complaint.

We took independent advice from a nursing adviser and one of our medical advisers, who is a consultant physician. We were advised that a reasonable standard of medical care was provided to Miss A and that her death could not have been prevented. We, therefore, did not uphold this aspect of the complaint. However, we noted that one of the recorded causes of death was not appropriate, which the board had already acknowledged, and we asked them to bring this to the attention of the relevant member of staff. We considered that most of the nursing care provided to Miss A was also of a reasonable standard, but we identified a failure in respect of her bowel management. Miss A required her bowels to be manually evacuated and this task unreasonably continued to fall to Mr and Mrs A during her admission. The board's manual evacuation, or digital removal of faeces (DRF), policy was not fit for purpose and staff failed to seek specialist advice to allow them to carry out this task. We upheld this aspect of the complaint.

We also found deficiencies in the recorded level of communication between staff and Mr and Mrs A. In particular, we noted that medical staff did not have a sensitive discussion with them regarding the fact that Miss A was approaching the end of her life. This lack of discussion regarding the severity of the situation left them to attribute the deterioration of her health to a lack of appropriate care and thus added to their distress. We upheld this aspect of the complaint. We also upheld the complaint regarding the way in which the board handled Mr and Mrs A's complaint to them. They unreasonably delayed in responding and, having met with Mr and Mrs A, they failed to follow this up with a full response showing that all the issues raised had been fully investigated.

Recommendations

We recommended that the board:

• bring this decision to the attention of the member of staff who certified Miss A's death in order that they can learn from the identified discrepancy;
• review their policy for manual evacuation/DRF, taking account of any appropriate national guidance in this area;
• bring this case to the attention of relevant staff with a view to improving future communication with patients and their families/carers, particularly around end-of-life care;
• review their handling of this case with a view to making improvements and ensuring compliance with their statutory responsibilities, as set out in the Can I Help You? guidance; and
• apologise to Mr and Mrs A for the failings this investigation has highlighted.

Summary

Mrs C complained to the board about how her elderly aunt (Miss A) had been cared for in University Hospital Ayr. Mrs C complained to us that Miss A was not given a bed with rails, that hospital staff did not monitor Miss A's movements, and that they did not respond in a reasonable time to Miss A falling in her ward. Miss A died shortly after the fall. Mrs C also complained about the delay in the board investigating and responding to her complaint.

We looked at the board's file on Mrs C's complaint and at Miss A's medical records. We also took independent advice from two of our advisers, one specialising in nursing, the other in general medicine. We found that when Miss A was admitted to hospital, an assessment was made that she needed bedrails. However, on the night Miss A fell, the bedrails on one side of her bed were not in use, apparently at her request. This change was not recorded by hospital staff, and is significant because they should, when making decisions like lowering the bedrails, have borne in mind that Miss A had delirium.

We found that staff failed to follow a procedure, called the bedrails algorithm, for dealing with the lowering of bedrails, which meant that Miss A was not supervised at the time she fell. Without bedrails, an alternative should have been put in place, such as close monitoring, to compensate for the lowering of the bedrails on one side. We concluded that staff did not take sufficient account of Miss A's delirium and risk of falls in providing care to her. We upheld these aspects of Mrs C's complaint. However, we did not find evidence that staff failed to respond immediately when Miss A fell.

We found, and the board acknowledged, that there was a significant delay in responding to Mrs C's complaint. We also found that updates to Mrs C were not in line with the national NHS complaints guidance. We upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• remind relevant nursing staff of the bedrails algorithm;
• provide us with details of the actions taken to ensure there has been learning from this complaint; and
• remind all staff involved in dealing with Mrs C's complaint of the national NHS complaints guidance, and of the importance of updating complainants in reasonable time.

Summary

Mr C complained about the medical treatment and nursing care that his late wife (Mrs C) had received from the board at University Hospital Crosshouse and University Hospital Ayr. Mrs C as admitted to Crosshouse Hospital four times in seven months, as well as being seen at the accident and emergency department on another occasion. She was initially diagnosed with both chest and urinary tract infections. Later, delirium became a significant issue for Mrs C. She was transferred to University Hospital Ayr so that her urology (concerned with the urinary system) symptoms could be investigated. She was discharged when this was completed but was readmitted to Crosshouse Hospital a short time later.

In relation to the medical treatment that Mrs C received, we took independent advice from a consultant physician. We found that the majority of the care that Mrs A had received at Crosshouse Hospital was reasonable. However, the adviser noted some concerns about the way that Mrs C's delirium had been managed, as changes that had been made to her medication could potentially have affected this. The adviser also highlighted concerns about the level of discharge planning that had taken place. On balance, we found that there was enough evidence to uphold Mr C's complaint about the treatment that his wife received at Crosshouse Hospital. The advice stated that the treatment provided at Ayr Hospital was reasonable. There were some concerns about the level of discharge planning that had taken place but, on balance, we did not uphold this part of Mr C's complaint.

After taking independent advice from a nursing adviser, we did not uphold either of Mr C's complaints about the standard of nursing care provided at Crosshouse or Ayr hospitals. We found that the care Mrs C had received was reasonable.

Recommendations

We recommended that the board:

• review how patients with delirium are managed in light of the adviser's comments;
• ensure that effective discharge planning is taking place on the relevant ward at University Hospital Crosshouse;
• ensure that effective discharge planning is taking place on the relevant ward at University Hospital Ayr;
• apologise for the failings identified by this investigation.

Summary

Mr C owns a property that he lets out as holiday accommodation. The property is classed as non-domestic and is, therefore, liable for commercial water charges. In 2010, the property was identified as a gap site (premises that are receiving water services without being charged). Details of the property were passed to Business Stream in order to set up an account. This was done in September 2013 and an invoice was issued to Mr C for water services dating back to 2010.

Mr C complained that the charges had been issued without warning and were unreasonably high. He compared them to charges for a property that he owns in England which has much lower water bills. Despite a number of calls and letters to Business Stream, Mr C did not feel that they had explained their charges in a way that justified the amounts being charged.

We found that industry rules required Business Stream to contact Mr C within five working days of being passed his property’s details. We were critical that it took them three and a half years to set up the account and issue the first invoice. Whilst we acknowledged that there was a large backlog of gap sites at the time and that procedures have since been changed to prevent similar delays, we recognised that Mr C was prevented from making certain decisions in terms of budgeting and choice of supplier as a result of the delay.

We were satisfied that, once Mr C’s account had been set up, Business Stream took care to clearly explain the charges that were being applied.

Recommendations

We recommended that Business Stream:

• refund ten percent of the full water and waste water charges for the property between specified dates in 2010 and 2013.

Summary

In 2010, Mrs C's business was identified as a vacant site (a premises where one occupant has vacated and the next has not opened a water account). Business Stream created an account and charged based on an estimated meter reading. Mrs C was told several times that meter readers had been unable to find her meter as it was under rubble. In 2012, the meter was found and replaced due to its age. The new meter was installed with a reading of zero and was read again in December 2013. Mrs C subsequently received an unexpectedly high bill. She complained about the amount she was charged, arguing that the new meter could not have been installed with a reading of zero as her small business could not have used the volume of water that had been alleged. She also complained about the lack of meter readings carried out by Business Stream and the fact that she had not been notified of the new meter’s installation.

We found that, although the account had been created using an estimated reading, this was recalculated at a later date using appropriate, verifiable, information. High water usage was recorded through the old meter and continued to be recorded through the new meter with no evidence of a shared supply or a leak. Once the issue was identified, the water usage dropped dramatically. We were satisfied that Business Stream charged appropriately based on the meter information. However, we found that they failed to take two meter readings per year as required by industry rules. This meant that Mrs C was denied the opportunity to identify the high water usage and address the problem before high bills were accrued. We were satisfied that Business Stream were under no obligation to forewarn Mrs C of the meter exchange.

Recommendations

We recommended that Business Stream:

• calculate the company's average daily consumption from the 7 January 2014 meter reading onward and retrospectively apply this to the company's account from 9 October 2010 (six months after the account was created) to 17 December 2013 (the date of the last delayed meter reading).

Summary

Mr C had several wage deduction punishments imposed by the prison for different offences. Mr C complained that the prison inappropriately applied these punishments consecutively (so that the wage deductions were applied one after the other and continued for several months) instead of concurrently (such that each day of wage deduction counted towards all of the current punishments). He said that the prison guidance required punishments to be applied concurrently, unless they were specifically recorded as consecutive.

An Internal Complaints Committee (ICC) was held, which agreed with Mr C's interpretation of the guidance and ordered a review of Mr C’s wage deductions. However, the review did not take place, and Mr C complained about this. A second ICC was held which disagreed with the first decision and found that Mr C’s wages deductions were being applied correctly.

After investigating Mr C’s complaints we found that the guidance on this issue was unclear, and that the Scottish Prison Service (SPS) was interpreting this differently in relation to wages and other kinds of punishments. Although we considered either interpretation would be reasonable, we were critical that the SPS was using two inconsistent interpretations at the same time. However, in Mr C’s case, we found that the approach taken was permitted by the rules and guidance, and Mr C had been treated consistently with other prisoners in a similar situation. Therefore, we found that the application of the wage deduction punishments was reasonable and we did not uphold this aspect of Mr C's complaint.

However, we found that it was unreasonable that the recommendation of the first ICC was not carried out (due to an administrative error), and that Mr C was not given any apology for this. We were also critical that Mr C was given two inconsistent ICC decisions, as the ICC is the final stage for a prison complaint and care should be taken to ensure the decision is robust. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the SPS:

• apologise to Mr C for the failings our investigation identified;
• review their guidance on consecutive and concurrent punishments to ensure that there is a clear and consistent approach followed by all prisons;
• bring our findings on the two inconsistent ICC decisions to the attention of ICC members to prevent this situation recurring; and
• demonstrate to us that adequate steps have been taken to ensure ICC recommendations are implemented timeously (once they have been endorsed by the Governor).

Summary

Ms C, a council tenant, was unhappy with the steps the council had taken as her landlord. Her property had required a substantial repair the day after she moved in and, from the outset, she did not think it met the required standard of repair. Ms C was also unhappy with the amount of compensation they offered her following this, the fact that they did not provide her with alternative living and storage arrangements while works were being done, and also with the time taken for subsequent repairs.

The council said that, when they did their normal inspection of the property before allocating it to Ms C, there had been no clear signs pointing to the problem. However, a historic repair they had done had been inadequate – it led to the additional repair then being needed. Therefore, on balance, we considered the evidence available indicated that the council had not provided a flat that met the required standard of repair when Ms C moved in. We upheld this complaint.

Our role in considering Ms C’s compensation claim was limited to the council’s administrative handling of it. The evidence indicated that the council had offered Ms C the amount she had asked for. She said she would have asked for more had she known it would have been offset against her council tax arrears, but the council's guidance did explain that would happen. In addition, the form she signed included a declaration that Ms C had read and understood this guidance. However, the evidence also indicated that the council did not adjust Ms C’s award for depreciation or the lack of documentation, which they said they would do. The council had increased their offer following her additional contact and we did not uphold this complaint.

Ms C’s lease said the council could require her to move temporarily for necessary repairs, but not that they had to move her for all repairs. They had offered alternative accommodation following the initial issue and during more recent repairs. There was no evidence that the council had to offer storage. Accordingly, we did not uphold this complaint. Finally, the evidence indicated that the council’s subsequent repairs had taken longer than they should have done, and they acknowledged that their historic repair should have gone further than it did. Although the flat was not actually Ms C’s home at that point, their delay in properly repairing the underlying problem materially affected her once it was her home. We upheld this complaint and made three recommendations.

Recommendations

We recommended that the council:

• apologise to Ms C for the failings identified;
• check that there are no outstanding repairs at Ms C’s property for which they are responsible; and
• review this matter for any possible areas for improvement (for example, consider ensuring repairs are recorded from the date they are reported so they can be tracked appropriately).

Summary

Ms C built a new house. A planning application was submitted for another new house to be built on the neighbouring plot of land. Ms C was not notified of the proposed development and, therefore, missed the opportunity to submit representations. The development was subsequently approved. When she learned of the approval, Ms C wrote to the council outlining her objections which included the close proximity, overlooking and overshadowing of the new house to her home. She also objected to the council’s approval of a late decision to relocate the new house within the site without consulting owners of neighbouring properties.

The council accepted that they had not issued a neighbour notification notice to Ms C before giving consent for the new development. This was because her new house did not yet show on the maps that were used to identify neighbouring properties. However, the council felt that they had met their obligation to advertise details of the development in the local press.

We found that advertising in the local press was insufficient and there was a clear requirement for the council to notify Ms C. We were critical of their failure to do so and sought evidence of the procedural changes they have implemented to avoid similar problems in the future. That said, we were satisfied that the points she raised as objections had been considered by the planning officer before the planning permission was granted. We were also satisfied that the relocation of the property was permissible as a non-material variation to the original plans and that no neighbour notification was required for this.

Recommendations

We recommended that the council:

• issue a written apology to Ms C for failing to properly notify her of the planning application; and
• demonstrate to us that changes to the neighbour notification process have now been implemented to ensure that all neighbours (including recent/new builds) will be notified.

Summary

Mr C complained about the way that his child's school managed a residential trip. Mr C's child has special needs and required medication to be administered by staff during the trip. Mr C was concerned that medication had not been given as instructed and that there was no medication record. Information provided to Mr C by the council during their complaint investigation led him to believe that his child may have been given medication prescribed to another pupil. Mr C also complained that there was a lack of appropriate supervision during a visit to a restaurant. The school later decided that Mr C's child should be excluded from a forthcoming trip. Mr C complained that a medical professional involved in his child's care was not consulted before this decision was reached. Finally, Mr C was unhappy with the way the council had addressed his concerns.

Our investigation found that the school had not kept any record of the medication that was given to pupils during the trip and that they had not retained a copy of Mr C's written instructions detailing timings. Consequently, we upheld Mr C's three complaints regarding medication as the council were unable to provide any evidence that medication had been administered appropriately. Following assessment of the council's complaint responses, we also upheld the complaint that they had not properly addressed his concerns. We found that the council had not responded to all the issues he raised and had not made it clear that they held no medication record.

After considering Mr C's complaints about supervision and consultation with a medical professional, we found that there was no evidence of maladministration on the part of the council. We did not uphold either of these elements of Mr C's complaint.

Recommendations

We recommended that the council:

• issue Mr C and his family with an apology for the failure to keep an accurate record of the medications administered during the school trip;
• provide evidence of how the arrangements for medication on trips have been improved to avoid a recurrence of such failings in future;
• consider whether there are merits in consulting other professionals involved in a pupil’s care when completing person-specific risk assessments;
• apologise to Mr C for failing to address his concerns appropriately in the response to his complaints; and
• ensure that all relevant staff are aware of the need to provide a full response to complaints in line with the complaints handling procedure.

Summary

Ms C's home was included in a housing upgrade programme by the housing association, as part of which there were to be extensive improvements to the kitchen and electrics. Ms C complained that the housing association failed to advise her that as a result, some of her electrical appliances may not work. She also said that they failed to fit a new kitchen worktop as agreed, and that their contractor failed to communicate adequately.

Our investigation found that as part of the works, new electrical circuit breakers were installed. These were extremely sensitive and Ms C's cooker did not work with them. While notice of an electrical upgrade was given to tenants, there was no evidence that the association mentioned that there may be compatibility issues and some electrical equipment may not work. Accordingly, we upheld this part of Ms C's complaint.

However, we did not find evidence to suggest that the association's contractor did not communicate adequately or that the kitchen worktop had not been fitted as agreed. There were issues with a secure wall fixing for the worktop and an alternative solution was found which was properly finished to the association's standards of acceptability.

Recommendations

We recommended that the association:

• make a formal apology for their failure in this matter; and
• confirm that in the future any documentation will make the situation clearer.