Some upheld, recommendations

Summary

Mr C passed the first part of his course, but his grades were not high enough for automatic progression to honours. The university invited Mr C to a Progress Committee Meeting (PCM) to determine whether he would be granted conditional entry to honours. Mr C did not attend the PCM. The university offered to reschedule it but in the meantime they became concerned that Mr C was not well enough to attend the PCM and/or classes. They arranged a meeting to discuss this, and a referral to occupational health for assessment. Occupational health confirmed Mr C was fit to study. The PCM was held soon after this and did not grant conditional entry to honours. Mr C appealed against this decision, but the university did not uphold his appeal. Mr C also asked to be allowed to attend lectures while the appeal was being considered, but the university did not allow this. Mr C complained about the university’s handling of the PCM and appeal process, and also that the university failed to take into account his disabilities and mitigating circumstances. He also complained about the university’s handling of his complaints.

The university said Mr C had been given ample opportunity to present his case for the PCM and appeal, including multiple extensions to enable him to request documents under freedom of information (FOI) legislation. The university said Mr C’s mitigating circumstances were taken into account, but Mr C did not notify them of a disability until after the PCM. He had also still not provided any medical evidence for this, although the disabilities adviser contacted him to request this. The university considered that they responded to Mr C’s fourteen complaints in accordance with their procedures.

After investigating Mr C’s complaints, we found he was given a reasonable opportunity to present his case to the PCM and appeal. Although Mr C did not receive all the documents he requested under the FOI process, the university did grant significant extensions, and we considered that he had a reasonable opportunity to make his case. We also found Mr C had no automatic entitlement to attend lectures while his appeal was being considered, and there was no evidence the university acted improperly in deciding not to allow this. We found Mr C did not comply with the university’s requirements for registering a disability, and so the university did not act unreasonably by not taking this into account in the PCM and appeal. However, we found that the university should have explained more clearly to Mr C when they decided not to investigate part of one of his complaints (which was being considered in the appeal process instead). We were also critical that the university did not follow the relevant procedure for managing unacceptable behaviour when deciding not to respond to further complaints from Mr C (in particular, failing to give Mr C a formal warning, and failing to make arrangements to review this decision, or for Mr C to appeal it).

Recommendations

We recommended that the university:

• issue a written apology to Mr C for the failings our investigation found;
• remind complaints handling staff of the need to provide a full and proportionate response to complaints, including explaining the reasons for the decision; and
• revise the procedure for managing unacceptable behaviour in line with the model Complaints Handling Procedure.

Summary

Miss C complained that the council failed to properly investigate when she complained to them that she had been knocked off her bicycle by a council employee who opened his van door directly into her path. She complained that the driver did not stop to make sure she was unhurt. She said he said that she should have rung her bell and he then left in his van. She also complained to our office about the significant length of time it had taken the council to respond to her complaint. The council eventually wrote to Miss C to advise that they were unable to trace the van or driver from the details Miss C had provided and could not, therefore, accept any liability for the incident.

Although the issue of liability in an accident like this can only be determined by the courts, we did look into the background of the case in order to establish whether or not the council's investigations into the incident were reasonable, and whether they had dealt with Miss C's complaint appropriately.

We found that the council did conduct an investigation to identify the van and driver involved but, on the basis of the limited information provided by Miss C, they were unable to identify the vehicle or driver. We found their investigations to be reasonable. However, we noted that the council initially failed completely to respond to Miss C's complaint and, when they did contact her, this was through the claims process rather than the complaints process. We noted that the council did not respond to the questions Miss C raised in her complaint even after prompting by our office. It was not until we had begun our investigation that the council finally wrote to Miss C to answer her questions and to provide information about how to complain to our office. As a result of these failings, and the significant delay in responding to her complaint (around 15 months), we upheld this aspect of the complaint. We recommended to the council that they review their procedures, in light of our findings, in order to ensure that complaints are directed to the relevant team for response.

Recommendations

We recommended that the council:

• review the process they follow, in light of the circumstances of this case, when identifying and acknowledging complaints to ensure that in future, complaints such as these are passed to the appropriate service for response in line with their complaints procedure, and let us know when this review is complete.

Summary

Mr C complained that the council failed to provide his father, who was a resident in a sheltered housing complex, with a reduction in his rent as they indicated they would, in recognition of the additional disturbance caused to him by works being carried out at the sheltered housing complex. He was of the view that they failed to take appropriate steps to address the disturbance caused by these works and failed to deal appropriately, and within a reasonable time frame, with the request for rent reduction.

We found that the council had offered Mr C's father a decant to another property for the period of the major renovation works but he had refused this offer. They paid a disturbance allowance to all residents in recognition of the works, and arranged for new residents facilities and alternative eating arrangements when the lounge was closed and the in-house meals service was terminated. Following Mr C's complaint to the council, they also agreed to make a further payment for the additional level of disruption. We found that they had taken into account the disturbance caused to Mr C's father and made appropriate offers to recognise this. However, we also noted the council's suggestion that a waiver or reduction of Mr C's father's rent for this period was being seriously considered. We felt that the council's correspondence did not clearly highlight that this was a possibility and not a likelihood. In addition, it took the council almost seven months to reach a decision on this point, by which time, Mr C's father had died. As a result of the lack of clarity in their communication, and the significant delay in reaching their decision on the rent reduction, we upheld this aspect of the complaint and recommended that the council write to Mr C to apologise for the failings identified.

Recommendations

We recommended that the council:

• apologise to Mr C for the lack of clarity in their consideration of the possibility of a rent reduction/abatement and for the significant delay in reaching a decision on additional disturbance payments.

Summary

Ms C complained that when she had taken up her tenancy, her flat had been suffering from water ingress. She said the association had been aware of this problem prior to the allocation of the property. She also complained that although it had been agreed that she should not pay rent until the problem was resolved, she had been forced to pay, with only a small reduction in rent offered by the association. Throughout her tenancy, the association had failed to return her calls and had failed to attend appointments without explanation, causing her inconvenience and unnecessary expense.

Our investigation found the association had responded reasonably to Ms C's complaint of water ingress. There was also no evidence that the association were aware of the problem prior to allocation. We also found there was no evidence of any agreement that Ms C should withhold her rent, or evidence that she had formally informed the association that this was her intention. We did find that the association, whilst acknowledging the poor communication with Ms C, had failed to demonstrate they had taken action to improve their responsiveness to residents, so we upheld Ms C's complaint about their communication.

Recommendations

We recommended that the association:

• provide evidence of the implementation of the association's communications improvement project; and
• apologise to Ms C for the failure to communicate appropriately with her.

Summary

Mr C's daughter (Ms A) was an in-patient at the Royal Edinburgh Hospital's Child and Adolescent Mental Health Services In-Patient Unit. He raised a number of concerns about the care she received as an in-patient and also the steps taken around her trial return home.

Mr C was unhappy that Ms A had been left unobserved for a period of time that allowed her to self-harm whilst an in-patient, with the level of nursing care that was to be provided for the home trial, and also with the nursing care that his daughter then received at home. As part of our investigation we took independent medical advice from an experienced mental health nurse. Looking at Mr C's complaint about Ms A's care whilst an in-patient, our adviser outlined the importance of taking an effective approach to risk, but said he could not confirm that had happened in this case. The adviser explained that staff had a difficult balancing act in using the least restrictive means necessary when providing care and he said there may have been a phased plan to have reduced observation of Ms A. Although, for that reason, we could not say it had been unreasonable to have reduced Ms A's observation in the unit, we shared the adviser's concerns about the record-keeping and the fact that we could not identify the board's rationale for their actions. Although we did not uphold that specific complaint, we took this into account with our subsequent recommendations.

Mr C also complained that the transition plan for Ms A's trial return home lacked detail and was prepared hurriedly. Our advice largely reflected Mr C's concerns about the plan's lack of detail and we upheld Mr C's complaint. We also upheld his complaints about the lack of clarity regarding the planned level of nursing for Ms A's first day home, and about the nursing care that was ultimately received (the nurse had arrived at Mr C's house considerably later than had been arranged, in which time Ms A had taken action that may otherwise have been avoided). We made five recommendations in total.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified in our report;
• remind staff of the importance of logging incidents - including near misses - on the relevant system in line with their policy;
• take steps to ensure that future transition care planning is done effectively to minimise the risks and maximise recovery for the individual;
• take steps to ensure that future transition care planning is communicated adequately to all relevant stakeholders; and
• remind staff of the importance of accurate record-keeping, in line with the relevant Nursing and Midwifery Council guidance.

Summary

Mrs C complained about the treatment received by her late father (Mr A) during two admissions to Hairmyres Hospital and at an interim out-patient appointment. During his first admission, Mr A was diagnosed with cirrhosis of the liver (scarring of the liver). He was then seen by a nurse specialist in an out-patient clinic. He was re-admitted via A&E two days later and was treated for sepsis, but his condition declined rapidly and he died the following day.

Mrs C complained that adequate investigations were not carried out during Mr A's first admission. We obtained independent advice from one of our medical advisers, who considered that Mr A had been appropriately assessed. We did not uphold this complaint. Mrs C also raised concerns that the discharge was not discussed with her family and they were not given information regarding Mr A's new diagnosis. The board agreed that more could have been done and they agreed to discuss this at a forthcoming nurse debrief meeting. However, the adviser noted that this failing still needed to be addressed from a medical point of view. We upheld this complaint.

Mrs C was unhappy that the nurse specialist did not arrange to re-admit Mr A. The adviser said re-admission should have been arranged when results from blood tests taken at the out-patient clinic became available. This did not happen and we upheld this complaint. Mrs C also complained that there was a delay in admitting Mr A when he subsequently attended A&E. The adviser confirmed that Mr A received appropriate treatment during his wait and we did not uphold this complaint. Finally, Mrs C complained of a delay in releasing Mr A's body to the undertaker. We considered that this had been arranged within a reasonable timeframe and we did not uphold this complaint.

Recommendations

We recommended that the board:

• review the communication by medical staff surrounding Mr A's discharge, with a view to making improvements, and report back to us with their findings;
• draw this decision to the attention of the nurse specialist and develop an action plan to address the concern that admission was delayed in this case. They should notify us when this has been done; and
• apologise to Mrs C and her family for the identified delay in arranging to re-admit Mr A to hospital.

Summary

Mrs C complained about the care her late mother (Mrs A) received in Wishaw General Hospital following her hip replacement. Mrs C had been concerned that Mrs A – who had advanced dementia - had become dehydrated while in the hospital, that it had taken too long for her to be discharged and that her urine infection was not treated properly.

Our role was to assess whether the evidence indicated that Mrs A's treatment was reasonable in the circumstances. We took independent medical advice from a geriatrician and a nurse, both of whom felt that clinical staff had been aware of the possibility of dehydration. The medical advice we received was that staff had responded to Mrs C's concerns and had given Mrs A a fluid drip, even though there was no evidence of significant dehydration. Taking everything into account, we did not uphold Mrs C's first complaint.

Both advisers explained that it can take time to make the necessary arrangements to discharge a patient. However, our geriatrician adviser felt that the time taken between the necessary equipment being put in place in Mrs A's home and her being discharged from hospital was too long. We upheld this complaint and made one recommendation. Finally, the medical advice we received explained the difficulty in diagnosing a urinary tract infection. It also outlined the balance to be struck between not over treating somebody with antibiotics and not missing a chance to provide appropriate treatment (the adviser felt that balance had been struck appropriately for Mrs A). While we took account of Mrs C's concerns, we did not uphold her complaint about this.

Recommendations

We recommended that the board:

• remind staff, in circumstances where appropriate arrangements have been made for a patient's discharge, of the importance of taking a proactive approach.

Summary

Mr C was diagnosed with prostate cancer in 2013. A scan showed that the disease also caused obstruction to the right ureter (the tube draining from the kidney into the bladder). Furthermore, it showed inflammation of his lower bowel, and tests were performed in November 2013 and July 2014 to confirm a diagnosis of Crohn's disease (a long-term condition that causes inflammation of the lining of the digestive system). In the meantime, in September 2013, Mr C had a stent (drain) inserted into his kidney to overcome the effects of the blockage. His treatment was carried out at Dumfries and Galloway Royal Infirmary.

Mr C complained about the care and treatment he received from the board. He complained that he was not told formally about the results of his test in November 2013; he was often kept waiting at appointments or for procedures without explanation; he received little treatment for his prostate and bladder problems; he was not given a timely diagnosis of Crohn's disease; administrative arrangements for his discharge from hospital in April 2014 were unreasonable; the board failed to reply to a letter from his GP; and that they failed to handle his complaint reasonably.

We investigated the complaint and took independent advice from consultants in urology (a speciality in medicine that deals with problems of the urinary system and the male reproductive system) and in general and colorectal surgery, and also from a senior nursing professional. We found evidence that Mr C's results had been discussed with him, although there were some shortcomings in communication with him and we made a recommendation to address this. We also found that he had been given an explanation for the delays (unexpected emergencies or appointments running over). We found that his urological treatment had all been appropriate but that some of the communication had been poor. We found that Mr C's diagnosis of Crohn's disease had been given after results and biopsies were known and, while there was a slight delay, his treatment had not been compromised while clinicians concentrated on his other diagnoses. We also established that Mr C's nurse-led discharge was appropriate and staff had been used efficiently to avoid hold-ups. We also found that Mr C's complaint was handled reasonably well. While we did not uphold these complaints, we found that there had been no reply from the board to a letter sent by his GP so we upheld this aspect of his complaint.

Recommendations

We recommended that the board:

• bring the communication shortcomings to the attention of relevant staff.

Summary

Ms C complained to us about the treatment she received for a sore knee, and for delays in diagnosing and treating the problem. Ms C was referred to the orthopaedic (conditions involving the musculoskeletal system) department at Crosshouse Hospital for consideration, and was seen by a consultant shortly after. She was referred for an injection in her hip, as an initial approach to treatment, which took place three weeks later. She had a follow-up appointment six weeks later, and was seen by a junior doctor who referred her for an MRI scan (a magnetic resonance image – a special kind of scan). She had to wait a further six weeks for the scan. She had a follow-up appointment with the consultant ten weeks later, and was then referred to an orthopaedic surgeon. She waited 14 weeks to see the surgeon, who then put her on his list for a knee operation. The surgeon told her she could expect to wait around nine weeks for the operation. However, Ms C had an operation on her knee in England while she was waiting for her operation.

We sought independent orthopaedic advice on this case. Our adviser noted that the injection Ms C was given was an appropriate first line treatment for her knee pain. He said that it may have relieved her pain, and if it had, it would have helped to diagnose the source of the pain, so we did not uphold Ms C's complaint that this treatment had been unnecessary. In terms of the timescales for Ms C's diagnosis and treatment, our adviser noted two significant delays: the wait for a clinic appointment following her scan and the wait for an appointment with the surgeon; and concluded that these were both unreasonable delays.

We considered the evidence of the delays in the clinic appointments, and concluded that there had been unreasonable delays and that the board could have managed the appointments differently.

Recommendations

We recommended that the board:

• apologise to Ms C for the delay in diagnosing and treating the source of her pain; and
• review their procedures for making appointments within orthopaedics to minimise any delays during or following requests for scans.

Summary

Mr C complained that the Scottish Prison Service (SPS)'s arrangements in relation to Mr A's terminally ill mother were not handled properly. Mr C was concerned that Mr A was only allowed to spend 30 minutes with his mother at a hospice; that the security measures were excessive when Mr A visited his mother at the hospice and when he attended her funeral; that there was a lack of privacy when Mr C broke the news of her death to Mr A at the prison; that there was no reason to strip (body) search Mr A; and that the prison failed to respond properly to the complaints.

Whilst the evidence showed that there had been a delay of an hour in Mr A being escorted to the hospice, we found that the prison took reasonable steps to provide the resources they had available to allow Mr A to visit his mother at short notice after he had returned from court that same day. We also found that the prison followed their procedures in relation to the security measures in place when escorting Mr A to the hospice and to the funeral, so we did not uphold these complaints. However, we were critical that the prison did not have a record of their decision to refuse Mr A a further visit to the hospice so we made a recommendation to address this.

In relation to the strip (body) search, the SPS acted in accordance with the prison rules, in that they are entitled to search a prisoner at any time and we did not uphold this complaint. However, we recommended that the SPS consider recording strip (body) searches and develop guidance for staff. Subsequent to this, the SPS apologised for misinforming us that they had no staff guidance on the searching of prisoners. They provided written evidence of a protocol already in place.

We upheld Mr C's complaint about the way his complaint was handled. Although the prison have since taken proactive steps to review their mail process and raise awareness with relevant staff, we still recommended that they apologise to Mr C because his complaints were not handled in line with their procedures.

Recommendations

We recommended that the SPS:

• remind staff at the prison to ensure their responses to all Escorted Exceptional Day Absence requests are recorded;
• consider recording when a prisoner is strip (body) searched and consider developing guidance for prison staff on prisoner searches; and
• apologise to Mr C for the inadequate handling of his complaint.