Upheld, recommendations

Summary

Ms C complained to the board about the care and treatment provided to her mother (Mrs A) during an admission at University Hospital Ayr. Mrs A was admitted to hospital after her GP noted that she had low sodium levels. During the admission, Mrs A received treatment for heart failure and low sodium. Her condition did not improve and she died a number of days later. Ms C complained to the board about communication with the family, the nursing care provided to Mrs A, the medical treatment provided to Mrs A and the board's failure to respond to a claim for lost property.

In response to Ms C's complaint, the board arranged two meetings with the family to discuss their concerns. The board acknowledged that communication was poor and that nursing care could have been more compassionate, and apologies were offered for these shortcomings. Ms C remained dissatisfied and brought her complaint to us.

In the course of our investigation, we took independent advice from a medical adviser and a nursing adviser. The medical adviser found that Mrs A was very unwell and said that staff should have informed the family of this from the time of Mrs A's admission, not just at the time of her deterioration. The nursing adviser did not find evidence that nursing staff had advised the family of the seriousness of Mrs A's condition, although they could not confirm if nursing staff had recognised this themselves. We noted that the board had identified a number of points of learning and improvement in relation to communication, and we asked the board to provide evidence that appropriate action had been taken. We upheld this complaint and made further recommendations based on the advisers' comments.

We also investigated Ms C's concerns about nursing care. The nursing adviser noted a number of gaps in the fluid balance and clinical risk assessment recording, but otherwise found that the records were generally of an acceptable standard. However, the nursing adviser was critical that nursing staff did not escalate Mrs A's condition to medical staff earlier in the admission, given the family were raising concerns about her condition. The nursing adviser concluded that, on balance, the nursing care fell below a reasonable standard. We upheld the complaint and made a number of recommendations.

Ms C also raised concern about the medical care provided to Mrs A. The adviser noted that Mrs A was very unwell at the time of admission and her condition was complex to treat. The adviser was critical that there was not a proactive plan to manage Mrs A after the day of admission, and noted that the assessments by medical staff were more superficial than they would have expected to see. The medical adviser said that the most important aspect of Mrs A's care was to assess her response to treatment and make sure her sodium level was rising in a safe manner. The adviser noted that this did not happen, and concluded that the care was unreasonable in this case. We upheld this complaint and made a number of recommendations.

Finally, Ms C said that a number of items of Mrs A's jewellery had gone missing on the ward, and complained that the board had failed to respond timeously to a claim for lost property. The board acknowledged that the belongings procedure had not been followed in this case and apologised to Ms C for the delay in responding to the claim. We upheld the complaint and asked the board to supply us with evidence that their review of the lost property claim results in learning and improvement to ensure that the correct procedure is followed in the future.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and her family for the specific failings in medical assessment and treatment and the failings in nursing care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Systems should be in place for senior nursing staff to monitor nursing communication sheets on an ongoing basis. Systems should also be in place to monitor feedback received from a range of sources about communication with relatives and significant others.
• Nursing staff should recognise when a patient's condition is deteriorating and take appropriate steps to respond.
• Medical staff should make a detailed plan of treatment for patients with heart failure and low sodium levels. Medical staff should also be proactive in providing treatment and monitoring the response to the treatment.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C complained that the way the Scottish Prison Service (SPS) handled his sentence management was unreasonable. Mr C was particularly concerned that the final outcome of a disciplinary hearing was being reflected incorrectly in some of his paperwork. He was concerned that this was recorded as a guilty finding when it was overturned to not guilty after Mr C appealed. Mr C complained that this was impacting on his progression and that the SPS were wrongly saying in some of their communication that he had been downgraded when he had not been. Mr C was worried that inaccurate paperwork might eventually go to the parole board. We had no authority to decide how Mr C's sentence was managed. Nor could we decide whether or how he should progress. However, we found that some of the SPS's communication with Mr C about how he was progressing, and whether or not he had been downgraded, had been confusing and inconsistent. We also found that some of SPS's record-keeping was incomplete or inconsistent. As such, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the communication failings and for the confusion and stress that this caused. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance
• Ensure that all significant records note that Mr C was not downgraded, particularly those documents which will be included in submissions to the parole board.
• Share the findings of our investigation with the staff involved.

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

• The SPS should reflect on how and why the original disciplinary hearing guilty finding was arrived at, so that any learning and improvement can be identified in a supportive way.
• Staff should be aware of the importance of good record-keeping.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Ms C complained on behalf of Mrs A, who is the director of a company. Ms C complained about the way the Scottish Government had handled a complaint about wages from a former employee of the company. Whilst working for the company, the former employee had contacted the Government in relation to the underpayment of agricultural wages. As part of their statutory investigation function in relation to agricultural wages, the Government inspected the employee's payslips and calculated that there had been underpayments of wages relative to the legislation that fixed the minimum rates of pay. The company disputed this finding and corresponded with the Government over the following months. In concluding their consideration of the case, the Government maintained that the former employee had been underpaid, but decided it was not in the public interest to take enforcement action in this case.

Ms C identified arithmetical errors in some of the calculations, and noted that the method the Government had used to calculate the underpayment of overtime pay in this case was not consistent with the method they had used in a previous case. Ms C complained that the Government had not explained the inconsistency in the handling of the two cases, or why the method they now adopted was correct. In response to Ms C's complaint, the Government apologised for the inconsistency and also identified a number of service improvements to ensure that calculations were correct in the future. In response to our enquiries, the Government provided us with further comments on the inconsistency and an explanation in relation to the legislation that they had taken into account when reaching their decision. We were satisfied with the explanation provided to us. However, we were critical that the Government did not provide this explanation to the company in the course of their handling of the former employee's case. We upheld this aspect of the complaint.

Ms C also complained that the Government had not provided an explanation in relation to the method they had used to calculate the holiday pay in the former employee's case. We did not find evidence that the Government had provided a reasonable explanation to the company. We considered that they should have explained what legislation they had taken into account in reaching their method of calculation. We upheld this aspect of the complaint.

In the course of our investigation, we found a number of instances where the Government did not follow their complaints procedure. In view of this, we made a recommendation for learning and improvement.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Mrs A for failing to provide reasonable explanations in relation to their calculations. This apology should comply with the SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.
• Provide Ms C with an explanation of the legislation that was taken into account when the decision was made that, for the purposes of calculating overtime, hours taken as holiday count towards total hours worked.

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

• Officers should provide full and informative explanations of their decisions, including, as appropriate, details of the legislation under which they have calculated underpayments.

In relation to complaints handling, we recommended:

• Complaints should be recognised effectively. They should be logged, acknowledged and responded to appropriately, and in accordance with the Government's complaints handling procedure.

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

Mr C complained that he was not fully informed about the process for his court case to be heard in his absence. Mr C called the court to advise that his wife would be unable to attend the hearing due to ill health. He said that he was told that as paperwork had been submitted, the case could be heard on the basis of those papers in his absence. The paperwork had not actually been submitted via the correct legal process and therefore, the case was dismissed as there were no attendees and no paperwork to determine the case. Mr C complained to the court service about this, but was informed that they do not record phone calls and therefore did not have evidence of what was discussed when he phoned to advise his wife would not be in attendance. The court service were satisfied that Mr C had not followed the correct process and said it was appropriate that the case was dismissed.

Mr C asked us to investigate the case and we gathered additional information from the court. We noted that they provided content from a 'remarks' field on their case management system which summarised Mr C's call following the hearing and when he wanted to make a complaint. We established that these fields are not used frequently but that information could have been recorded when Mr C called prior to the hearing. We also established that while the court website explained about the process involved in this type of case, Mr C had had his paperwork returned from the court with no indication that he needed to have this served and re-submit. On balance, we concluded this was unreasonable as without any information about the process, it was unclear to Mr C that his paperwork had not been accepted by the court. The content of his call could not be clarified as it was not documented or recorded despite the court having the facility to do so. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to fully inform him of the process to have his case heard. This apology should comply with SPSO guidance on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Applicants should be notified that paperwork needs to be served before being re-submitted prior to the hearing, and that they may wish to seek legal advice in this regard.
• The 'remarks' field should be routinely used to document a brief summary of phone calls when calls relate to matters such as attendance at hearings or the submission of paperwork.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Ms C complained that the council had failed to respond reasonably to the concerns she raised about the quality of service she had received from the council and their contractor in relation to the installation of a new heating system at her home. Ms C had complained to the council about the safety and reliability of the new heating system, as well as damage done to her carpet during the installation work. She was unsatisfied with the council's response to her complaints and brought them to us.

We found that, although the council acted in line with the requirements of the housing repairs policy, there were failings in their handling and response to Ms C's complaint. The council failed to log Ms C's initial complaint properly and they did not issue a reply to the concerns she had raised. They also failed to acknowledge a subsequent complaint Ms C submitted, and failed to respond within their timescales. We found that the council also failed to be clear with Ms C about their processes for applying for and granting compensation for damaged property. We upheld Ms C's complaint. We noted that the council had since acknowledged some of their failings, and we asked them to provide evidence of the action and staff training they had carried out as a result of Ms C's complaint.

Recommendations

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

• The council should develop a compensation policy.

In relation to complaints handling, we recommended:

• Staff responding to complaints should be aware of their responsibilities, as per the complaints handling procedure.

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

Mr C complained about a neighbouring dog owner who persistently allowed his dog to foul in the street. Mr C repeatedly contacted the council about this problem and made a formal complaint when this issue continued to occur. He was unhappy with the perceived lack of action from the council with no staff visiting his property to discuss this issue. He received a verbal response to his complaint over the phone and noted no improvement following this, so escalated his complaint. The council investigated the matter and partially upheld the part of Mr C's complaint which related to poor communication and the length of time to respond to his complaint. However, they did not agree that staff had misinformed him about the actions they could take.

During our investigation we gathered information from the council, including their policies and procedures on dog fouling. We found that Mr C had made numerous reports of fouling to the council but they had not met with him or contacted him to discuss the situation. It was only once he made a formal complaint that he received a response and this was a delayed response to his complaint which was completed over the phone. The accompanying case note did not sufficiently outline what was discussed and this formed part of Mr C's escalated complaint. The council highlighted that their policy was not to issue a fixed penalty notice unless council officers had witnessed an offence, but the legislation does allow for exceptions to be made where strong, objective evidence is provided. However, this does not appear to have been explained to Mr C until almost four months after his initial report of an issue, and only then as part of the council's final response to his complaint. We upheld Mr C's complaints as there was a lack of contact and communication from council staff during the initial months when Mr C reported numerous incidents. There was also a delayed response to his complaint and the evidence to summarise the council's response was lacking in detail.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to take reasonable action to stop dog fouling in his street. Apologise further for failing to respond to appropriately to him. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• In cases where they make a decision to respond verbally to a complaint at stage one, instead of in writing, the case note to accompany the phone call should include an appropriate level of detail to reflect what was discussed.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mr A). Ms C complained that the council unreasonably failed to respond to Mr A's complaints of anti-social behaviour by a neighbour. Ms C also complained about the council's complaints handling.

Our investigation found that the council did not respond to Mr A's concerns in line with the requirements of their anti-social behaviour procedure. The council told us that they had addressed issues appropriately where they had corroboration, while other issues were more appropriately addressed by the police. Our investigation found that the council had not kept Mr A sufficiently updated regarding the progress or outcome of his complaint, and that their records of Mr A's reports of anti-social behaviour concerns were not sufficiently detailed. In terms of the council's own complaints handling, we found that Mr A had complained three separate times before he received an appropriate response. As such, the council had failed to respond to Mr A reasonably and in line with their timescales. We upheld both of Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to meet their timescales for responding to complaints. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff responding to anti-social behaviour concerns and complaints should be aware of the requirements and relevant procedures.

In relation to complaints handling, we recommended:

• Staff responding to complaints should be aware of their responsibilities concerning timescales.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Ms C complained that the council wrongly advised her about the financial contribution they would make towards her mother (Mrs A)’s care home fees. This money represented Mrs A's entitlement to free personal and nursing care. Free personal care is available for everyone aged 65 and over in Scotland who have been assessed by the local authority as needing it. Free nursing care is available for people of any age who have been assessed as requiring nursing care services. The council over-calculated her entitlement but, while council staff realised this within a few months, they did not notify Ms C or the care home of the reduced payment level for more than two years after Mrs A was first entitled to the payments. Ms C was unhappy that she was only then made aware that a large debt had accumulated and had not had the ability to budget or plan for this. The council accepted their initial miscalculation and offered to cover the additional costs until the point they had picked up the error. Ms C didn't consider this was fair or reasonable as the debt had continued to increase for a further 18 months before the council made anyone aware of the error.

The council told us that they were putting new processes in place to ensure that changes to the contribution amount would be notified to relevant parties, and that the error in this case was a result of a manual input error which could no longer occur as the process had been automated. Our investigation found that the council's initial calculation was incorrect and that Mrs A was only ever entitled to the lower contribution amount. However, we considered that it was poor customer service and unacceptable not to advise Ms C of the correction as soon as reasonably possible. We, therefore, upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Make an additional contribution payment for Mrs A to the care home. The payment should represent the difference between the incorrect and the correct contribution figure for the period from the date they identified the error to the date Miss C was notified. The payment should be made by the date indicated by us. If payment is not made by that date, interest should be paid at the standard interest rate applied by the courts from that date to the date of payment.

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

• Relevant parties should be given prompt notification of unscheduled changes.

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

Mr C raised concerns about the care and treatment the board provided to his late sister (Mrs A) at Wishaw General Hospital. These concerns extended to medical care, nursing care, and communication with Mrs A's family.

Mrs A had previously been involved in a road traffic accident, but had been discharged and was recovering. She attended Wishaw General Hospital after feeling unwell, and was admitted. She deteriorated the next day, but recovered. She experienced a further deterioration approximately ten days later. Her condition did not improve over the following days, and Mrs A died approximately four weeks later.

Mr C raised a number of specific concerns regarding the board's identification of sepsis (a blood infection), their actions regarding providing Mrs A with a cannula (a thin tube inserted into a vein or body cavity to administer medication or drain off fluid), and staff not transferring her to the intensive care unit when her condition deteriorated. He also raised concerns about nursing care, including management of Mrs A's wounds by nursing staff.

We took independent advice from a consultant in acute medicine and from a nursing adviser. Regarding medical care, we found that Mrs A should have been treated more aggressively for sepsis, and that there was some delay in relation to a cannula. We also found that Mrs A had been given a penicillin based antibiotic, though she was recorded as having an allergy. However, there was no evidence in the record that this impacted on her outcome. Regarding nursing care, we had concerns about wound care, and the general condition of the nursing records. Regarding communication with Mrs A's family, we found there was insufficient evidence of this in the records, given the seriousness of Mrs A's condition.

We upheld Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in medical and nursing care provided to Mrs A, and for the poor level of communication with her family. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance

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

• Staff should be aware of the recognition and management of sepsis.
• Staff should be confident in managing situations where vascular access becomes difficult.
• The microbiology or infection team could be involved in the management of complex cases.
• Staff should communicate adequately with a patient's family and should make sure that communication with the family is appropriately documented.

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

Mr C complained about a delay in receiving a respiratory out-patient appointment. He waited 33 weeks in total for an appointment, when the board are targeted to provide first out-patient appointments for the majority of patients within 12 weeks of referral. The board confirmed that they were presently unable to see all patients in a timely manner, but said they were taking steps to try to reduce waiting times. They noted that the appointment Mr C eventually received was for an additional Sunday clinic that was set up to deal with long waits. We considered that Mr C's wait was excessive so we upheld his complaint. We noted that the board had apologised to him for his wait but that he subsequently waited a further two months for an appointment. We also considered that a further apology reflecting the full extent of his wait was appropriate. We also asked the board to provide us with further details of the steps they were taking to reduce waiting times and try to meet the 12-week target.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the length of time he had to wait. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Take steps to reduce waiting times and work towards meeting the 12-week target for respiratory out-patient appointments.

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.