Upheld, recommendations

Summary

C is a council tenant and lives with their family. C complained that the property they were living in suffered from significant problems with damp and mould. C believed that the conditions in the property were adversely affecting the family’s health and damaging their possessions. It was acknowledged by the council that C had been raising concerns for some time.

Although the council had carried out works and surveys on C’s property, damp problems remained. We found that the primary cause of damp had not been identified and the council accepted further works were required, and that the time taken to address the problem had been excessive. We found that the council could not evidence that they had considered the impact on C of their living conditions and it was not clear that the property was treated as a priority in line with the council’s revised damp and mould policy. We upheld C’s complaint that the issues with their property had not been dealt with reasonably.

Recommendations

What we asked the organisation to do in this case:

• Develop an action plan, to be shared with C, setting out clearly the steps that they intend to take to address mould and damp in C’s property, and dates for updating C on implementation.

In relation to complaints handling, we recommended:

• Responses to complainants and the SPSO should be thorough and complete, ideally in one response.

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 to the council that their teenage child (A)'s school had not taken reasonable action following the report of an assault on A and a report of bullying. A reported continued bullying behaviour early in the next term and measures were put in place, such as allowing A to leave classes early. Just over a week later A was involved in a pre-arranged fight with another pupil close to school grounds in school time.

The council’s investigation did not uphold C’s complaints about the action taken following the report of the assault and bullying. C was dissatisfied and raised their complaints with SPSO.

We found that the school did not follow their Anti-Bullying Policy following the assault on A. They did not advise C of their decision that the school could take no further action regarding the reports of bullying as there was no concrete evidence of this, and they were imprecise in how they described contact with other parents/carers to C. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A that the school did not follow their Anti-Bullying Policy following the reporting of the assault and that they unreasonably failed to manage the report of the assault. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C that in the their complaint response they incorrectly stated that, as C knew, the lack of evidence had made it difficult to pursue the matter further. The apology should meet the standards set out in the SPSO guidelines on apology availale at www.spso.org.uk/information-leaflets.

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

• The school should follow their anti-bullying policy and advise parents/carers of any decisions reached or actions taken following reports of bullying.
• The school should follow their Anti-Bullying Policy in relation to reports of bullying.

In relation to complaints handling, we recommended:

• The council’s complaint investigations take full account of all the circumstances and their conclusions are supported by evidence. The council’s investigations and complaint responses only deal with specific matters once. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.
• The council’s responses to SPSO are properly considered and that it is clearly stated when, on reflection or further consideration, a different view or conclusion has been arrived at.

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 the association did not respond reasonably to their reports of anti-social behaviour from a neighbour. We found that the association unreasonably concluded that a number C’s reports did not amount to anti social behaviour (ASB). We also found that the reports that the association did consider to include ASB were not dealt with in line with the guidance and policy documents that the association provided. This included failures to acknowledge reports, reasonably complete forms, undertake checks of previous incidents, undertake (or make proper records of) interviews and log reports within a reasonable time.

We found that the association provided inaccurate information to C about their use of CCTV footage in the investigation of reports of ASB and did not reasonably respond to C’s complaints about the handling of the ASB reports. We upheld this part of C’s complaint.

C complained that the association did not take reasonable action to address issues regarding an allocated parking bay for their property. When C accepted their tenancy they understood it included a dedicated disabled parking bay but this was being regularly used by others.

The association told C that numbered parking bays are not included or detailed as part of individual tenancies but continued to explore options to indicate the bay was for C’s use.

We found that the association took an unreasonable length of time to substantively respond to the parking bay issues C raised. We upheld this part of C’s complaint.

C complained that the association did not take reasonable action to address issues with their heating and hot water systems.

We found that the length of time C waited for repairs to the heating and hot water system was unacceptable. We also found that the association had unreasonably concluded C’s complaints had been resolved before the effectiveness of an intended repair had been confirmed. We upheld this part 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 association respond to reports of ASB in line with their guidance and policy documents.
• The association carry out repairs within a reasonable period of becoming aware that they are needed.
• The association respond or take action following tenant’s raising of issues within a reasonable timescale.

In relation to complaints handling, we recommended:

• The association respond reasonably to complaints. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.
• The association retain records in line with the relevant circumstances and the MCHP.

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 of their late parent (A) following an admission to hospital with a hip fracture, and about the communication surrounding this. C raised concerns about A’s fitness for discharge, including a lack of rehabilitation in hospital and length of wait for community rehabilitation, as well as a lack of support with food and fluid intake, and a lack of adequate skin care. C also raised concerns about a lack of engagement with them as A’s next of kin and power of attorney.

We took independent advice from a consultant orthopaedic surgeon and a registered nurse. We found that A’s discharge was medically reasonable, and that the level of input from therapists was reasonable. The board acknowledged shortcomings in communication with C around their discharge, and a failure to document the nursing handover with the care home. The board also apologised that the target timescale for community rehabilitation was not met.

We found that there were unreasonable failings in the nursing documentation, person centred care, and pressure care that A received. A’s person centred care plan was not completed, and a documented instruction that A required full assistance with nutrition and hydration was not adhered to.

We identified frequent gaps in skin inspections and repositioning, and inconsistent completion of a pressure ulcer risk assessment. The relevant foot care did not take place in light of A’s diabetes, and there was no referral to podiatry when pressure damage to A’s heel was discovered. We were concerned to note that A’s nutritional needs were not met, and that there was a failure to protect A from pressure damage. We upheld this complaint.

We also identified inconsistencies in the board’s complaint responses and noted that important failings were overlooked. We made recommendations to the board to address these.

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/meaningful-apologies.

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

• Food, fluid and nutrition standards should be met. Instructions set out in care plans to be adhered to, and patients to receive the appropriate level of assistance.
• Patients’ person centred needs should be fully considered. Documentation should meet the professional standards required by the NMC – The Code.
• Pressure ulcer prevention standards should be met, and patients protected from healthcare acquired pressure damage.

In relation to complaints handling, we recommended:

• Stage 2 complaint responses should meet the aims of the NHS Scotland Model Complaints Handling Procedure. They should aim to establish all the facts relevant to the points made in the complaint and to give the person making the complaint a full, objective and proportionate response that represents the organisation’s final position. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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 from the board. C said that following gynaecological surgery, they were left with side effects including recurrent pain and the need for further treatment.

C complained that the board failed to provide them with adequate care and treatment in relation to the operation. The board did not identify any failings in C’s care, but did apologise for communication failings relating to the operation. They said that C had experienced a rare complication, but that this had been recognised and treated appropriately.

We took independent advice from a consultant gynaecologist. We found that C’s care and treatment during and after their operation was reasonable and noted that the complication that occurred was swiftly identified and managed. However, we also found that prior to their operation, C was not provided with adequate information about other possible treatment options, including a lack of discussion about the surgery. We also found that the surgical consent process was inadequate.

The board accepted that discussions relating to informed consent and counselling to support patient decisions should be fully documented, and that this had not occurred in C’s case. The board also acknowledged the importance of discussing and documenting all potential post-operative complications with the patient, so that the patient has informed choice when agreeing to a management plan.

We found that there were aspects of C’s care and treatment prior to their operation that fell below a reasonable standard. Therefore, we upheld 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/meaningful-apologies.

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 their sibling (A) received whilst in hospital following a fall. C also raised complaints about communication issues with the board. The board accepted that there had been poor communication with A’s family but did not indicate any concern regarding the care and treatment of A. C and their family were dissatisfied with the board’s responses and brought their complaints to the SPSO.

We took independent advice from a nursing adviser. We found that A did not receive timely medical intervention due to documentation and assessment gaps, particularly in relation to A’s positioning, their need for increased oxygen support, falls prevention and support for hydration. We upheld this part of C's complaint.

In relation to communication and complaints handling, we found that the board did not respond within reasonable timescales. We also found that it was unreasonable that the board did not apologise for the time taken to provide their response, that they did not take action to prevent any recurrence, that they included an inaccurate statement and that they did not respond to all of the complaints that they had clarified with C. We upheld these parts of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family 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.
• Apologise to C that they did not respond reasonably to their 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:

• The board review the handling of C’s complaint to understand why there had been a delay in the drafting and approval of the response and devise an action plan to prevent any recurrence.

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 the practice failed to handle their telephone call reasonably. C called the practice while being discharged from hospital to speak to a GP about an urgent review of their GP prescribed medication. In particular, regarding the safe discontinuation of pregabalin (an anti-epileptic drug that can also be used to treat nerve pain and anxiety) following surgery.

We found that the call did not address C’s concern that C needed advice about how to safely discontinue GP prescribed medication. C was also not told that further fit notes could be accessed by requesting one through the practice website or that they needed to wait until they had received a discharge letter so that the pharmacy team and the GP had the correct information.

C was not informed that they could call for a same day triage appointment on their discharge from hospital. Although C was offered a routine appointment which is consistent with the practice’s policy on GP access, C was not given the chance to say whether they wanted to accept this before the call was terminated by the practice.

We found that no offer was made to send a message to a GP informing them of the problem, to be actioned by the GP as and when appropriate. No explanation was provided to C about why their request to speak to the Practice Manager was refused and no consideration was given to requesting someone else (such as the Team Leader) to call C back. Therefore, we upheld this part of C’s complaint.

C also complained that the practice failed to handle their complaint reasonably. We found that the complaint response did not address all the issues that C raised. The response also made statements about what C was told that were not supported by the recording of the telephone call to the reception team. We upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not addressing C's concern that they needed advice about how to safely discontinue GP prescribed medication, not informing C that further fit notes could be accessed by requesting one through the practice website, not informing C that they needed to wait until they had received a discharge letter so that the pharmacy team and the GP had the correct information, not informing C that they could call for a same day triage appointment on their discharge from hospital, not giving C the chance to say whether they wanted to accept the offer of a routine appointment before the call was terminated, not offering to send a message to a GP informing the GP of the problem, to be actioned by the GP as and when appropriate, not explaining why their request to speak to the Practice Manager was refused and not giving consideration to requesting someone else (such as the Team Leader) to call C back, not addressing all the issues they raised in the complaint response, and making statements in the complaint response that were not supported by the recording of the telephone call to the reception team. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Patients should be provided with appropriate explanations and advice when they contact the reception team.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised, ensure responses are supported by the relevant records, identify and action appropriate learning and apologise where issues have been identified. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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 was Power of Attorney (POA) for the patient (A). C complained about the care and treatment that A received in hospital. A suffered two falls, resulting in five fractured ribs. A also acquired pressure sores, contracted pneumonia and died shortly after discharge. C that they were not timeously informed of the falls or A’s deteriorating health. C also complained about the board's handling of their complaint.

The board advised that A was assessed by a doctor after both falls and pain medication was increased. Due to ongoing pain, x-rays and a CT scan were taken weeks later which showed the injury. The board advised that treatment would have been the same if they had known of the injury earlier. The board also noted that they had increased care rounding following the falls and provided a pressure relieving mattress.

They acknowledged that on some occasions care rounding had been delayed due to clinical pressures. The board apologised that A had developed pressure sores and that they had not communicated effectively with C. They advised that staff had been reminded of falls guidance, pressure ulcer guidance and to contact POAs and next of kin.

We took independent advice from a nurse. We found that the board had not regularly evaluated the risk of falls before A fell and did not appropriately review A after their falls. We found that they had not sufficiently managed the risk of pressure ulcers and did not appropriately manage the pressure ulcers once they had developed. We also considered that POA documentation was not correctly filled in on admission and that C had not been appropriately updated regarding important health matters or A’s falls.

We found that the complaint response had taken too long, that C had not been regularly updated and that the complaint investigation could have been more thorough. We upheld all aspects of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise that C was not appropriately recorded as POA and was not kept informed of A’s pneumonia and pressure sores. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• 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:

• Documentation should meet the required NMC “The Code” standards, in regards to assessment, planning, implementation and evaluation of nursing care (APIE process), including for falls. Care and comfort rounding should be carried out timeously. Wound assessment should be carried out and recorded, to guide treatment. Datix incidents should be escalated to Adverse Events for review when there has been avoidable harm.

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 given to their partner (A) while in hospital, which they believe led to A's death. In response to the complaint, the board acknowledged and apologised that communication with C had not been effective. However, A had been aware of the severity of their diagnosis and prognosis and was able to make their own decisions and all communication had been with them.

We took independent advice from a consultant in acute and general medicine. We found that, while significant parts of A’s care and treatment had been reasonable, there was a delay in the diagnosis and initiation of cancer treatment. In terms of the Scottish referral guidelines for suspected cancer, patients referred via the urgent suspected cancer pathway should receive their first treatment within 62 days of receipt of the referral, which did not happen in this case.

We also found that there were unacceptable delays in relation to acting upon the results of the PET scan and a delay in A’s subsequent diagnosis. In addition, we found that at the time of A’s death a morbidity and mortality meeting (M&M) had not taken place. However, the board confirmed that a new M&M process had been implemented so that all deaths were reviewed through this process. We upheld the complaint.

During our investigation, we identified issues with the board’s handling of the complaint. We made a recommendation to the board to support improvement of their complaint handling.

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:

• Patients should be treated in line with relevant cancer referral guidelines. Scans should be carried out and reported within a reasonable time frame.

In relation to complaints handling, we recommended:

• There should be a formal review and consideration of a robust investigation process when complaints are received so that any potential learning is identified and actions can be considered to reduce the risk of failures in care in the future.

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 Everflow failed to bill them accurately for their water consumption and failed to communicate reasonably with them about their account. C believed that Everflow had breached their contract with C. Everflow did not accept this, noting that the bill increase was primarily due to increases in wholesale costs.They also said that C’s water usage fluctuated across the year resulting in uneven charges.

We found that there was evidence meter readings were being recorded on C’s account in line with Everflow’s obligations as a Licensed Provider. However, the rateable value for C’s property appeared to be inaccurate. This should have been resolved or explained during the complaints process. Therefore, we upheld this part of C's complaint.

In relation to Everflow's communication with C, we found that C was sent letters about Everflow’s debt collection process. These letters were unclear and inaccurately reflected the legal process in Scotland. They also did not reflect the fact that C was making payments on their account and emailing Everflow about it. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to accurately reflect their property’s rateable value and the failure to communicate with them 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:

• Correspondence about the actions being taken to pursue outstanding payments should be clear, easily understood and accurately reflect the powers of Everflow.
• Everflow must ensure the correct rateable value is used when calculating C's bill.
• Customers should be provided with a copy of their contract.
• Customers should be provided with a specific explanation of the advance billing process.

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.