Upheld, recommendations

Summary

Ms C complained to us that the university had not followed their harassment and bullying policy and procedures for students after she made a complaint that she had been harassed and bullied by her PhD supervisor. Ms C sent the university a recording of a meeting with her supervisor with her complaint. She said that the supervisor had made her feel threatened at the meeting. The university decided that they could investigate Ms C's complaint without listening to the recording and destroyed it before they met the supervisor to discuss the matter.

We found that the university had not carried out an adequate investigation into the matter. The allegations Ms C made were serious and we considered that the university should have recorded more clearly the reasons why they felt they could investigate the complaint without listening to the recording before they destroyed it. We also found that the university had not issued an adequate response to the issues Ms C had raised. The response said that they would implement the three requests she had made but did not advise her of the outcome of their investigation into her allegations. In addition, the response did not advise her of how to escalate the matter if she considered that the outcome was not satisfactory. In view of these failings, we upheld this aspect of her complaint.

Ms C also complained that the university had not followed their complaints policy. The university's complaints policy states that it is important to be clear from the start of the investigation exactly what is being investigated and to ensure that both the person making the complaint and the complaints officer understand the scope of the investigation. However, there was no evidence that the university had contacted Ms C to discuss the scope of the investigation before issuing their response to her. We did not consider that the university's email to her was an adequate response to the issues she had raised. In addition, the university did not advise her in the initial response that she could contact our office. In view of these failings, we also upheld this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to follow their harassment and bullying policy and procedures for students. Further apologise for failing to follow their complaints policy. These apologies 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:

• Supervisors should be competent, and adequately trained, to conduct difficult conversations. In particular, it should be ensured that Ms C's previous supervisor has the required competence and skill.

In relation to complaints handling, we recommended:

• Complaints handling staff should be made aware of the findings of our investigation with regards to their failure to follow the harassment and bullying policy and procedure for students, and failure to follow the university's complaints policy.

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 considered that his water bills were excessive and he contacted Business Stream to raise his concerns. Business Stream confirmed that Mr C's water meter was also supplying the premises next door. Mr C complained that Business Stream had been aware of the meter set-up for some time. Business Stream confirmed that Scottish Water had carried out a site visit some years previously and had established that Mr C was on a shared supply with his neighbours.

Both Scottish Water and Business Stream said that this was a private matter between Mr C and his neighbours. They explained that at the time of the meter installation the two properties were in one building, and that Scottish Water were under no obligation to split the supply. Business Stream told Mr C that water resale rules applied. They continued to bill Mr C, saying that he could recover charges from his neighbours. However the neighbours refused to pay Mr C any money, as they said they were also being billed by Business Stream.

Scottish Water advised Mr C that he could have a new meter installed, but that he would have to bear the cost of this.

Mr C complained to us that Business Stream unreasonably failed to notify him that his water meter was supplying a neighbouring property, unreasonably charged him while also charging his neighbours for the same supply and unreasonably delayed in responding to his complaint. We upheld each of these complaints.

We found that Business Stream ought to have notified Mr C as soon as they became aware from Scottish Water that the water supply was shared. We found that Business Stream had been misapplying water resale rules and were unreasonably charging two parties for the same supply. We found that the delay in responding to Mr C's complaint had been unreasonable.

When we told Business Stream what we intended to recommend, they agreed to arrange instalment of a new meter serving only Mr C's property, at no cost to Mr C.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings identified in this investigation.
• Credit Mr C's account with an ex-gratia payment of £200.
• Assess Mr C's average usage once a new meter has been installed, serving only his property, and amend the previously issued usage to ensure that he is only billed for his own usage since October 2014.

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

• A policy should be put in place which would appropriately address situations similar to this, in such a way that they cannot double-charge for the same supply. Any such policy should include guidance on assisting the customer in resolving the matter, without inappropriate reference to the Water Resale Rules. They should also conduct an audit, identifying other customers they are aware of who are also supplying a neighbouring property. Any such customers should be notified and advised of the steps they can take, with Business Stream working with them to find an acceptable way forward. They should ensure that where they become aware of any customers in the future who are also supplying a neighbouring property, notification is made and advice is given, as above.

In relation to complaints handling, we recommended:

• Staff should be confident in identifying and escalating complaints, and in ensuring that complaint progression is monitored closely.

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 council failed to appropriately explain the charges relating to two statutory notices served in respect of a property of which he was one of the owners.

A tender process occurred and the contract administrator advised the owners of the property of the estimated costs. Subsequently, an update from the contract administrator advised owners of increased costs to the project. Owners of the property, including Mr C, raised concerns about this. Following the completion of the works the project was subject to a review by an independent external consultant. This review resulted in a number of reductions to the costs of the work.

Mr C complained to the council about the explanations they provided regarding the works. He requested further explanatory material from the council about reconciling costs through the course of the project. The council provided additional information on the expenses for the project, but they also relied on the professional judgement of the independent external consultant who said that the remaining costs were recoverable.

Having reviewed the relevant guidance, and the correspondence between Mr C and the council, we noted that there had been some shortcomings in the explanation given during the course of the works. We did acknowledge, however, that the council had subsequently sought a review of the project, applied a reduction to the costs and provided additional explanations. On balance, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Mr C with a copy of the relevant documents detailing changes in the costs to the project.
• Apologise to Mr C for the failures in communication highlighted in this investigation.

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 about the standard of street cleaning in her area, particularly in the autumn when leaves are blocking drains and causing flooding. She said that despite her reporting problems with blocked drains and leaf litter many times via the council's online reporting system, and despite the council's agreement that they would carry out a deep clean of the street and add the street to their list for priority leaf removal in the autumn, the council failed to take reasonable steps to effectively clear the street.

The council acknowledged to us their failures to effectively clear Ms C's street when requested to do so and the evidence we considered supported this. As a result, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C, if they have not already done so, for failing to clean her street in line with their responsibilities.
• Arrange for a full street clean to be carried out in Ms C's street, if they have not already done so.
• Add Ms C to their list as a priority for leaf removal during the autumn due to the risk of flooding.

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

• Staff should be aware of their duty to record and action requests for street cleaning, in line with their responsibilities.

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 there was an unreasonable delay in the board providing him with treatment on his right eye. Mr C is diabetic and was referred to Gartnavel General Eye Hospital when he began having problems with the vision in his right eye. Mr C was seen by the vitreo-retinal (relating to the back of the eye) unit at the hospital eight weeks after the initial referral was made, and it was determined that he needed surgery on the eye. Surgery was carried out around three weeks later, and afterwards Mr C was told that he would not regain sight in the eye. Mr C complained that in the time he had to wait for an appointment at the hospital he went from being able to see to losing sight in his right eye.

In response to our enquiries, the board explained that when Mr C's referral to the hospital was made, it was not logged in the normal way on the electronic system and therefore was not given a clinical priority. The board apologised for this and said that they had taken measures to prevent the likelihood of this reccurring in the future.

During our investigation, we took independent advice from a medical professional who is an ophthalmologist. We found that, given the symptoms that were recorded in the referral, Mr C should have been given clinical priority and an urgent appointment. We found that the delay between Mr C being referred to the vitreo-retinal unit and being seen by them was unreasonable. We also found that had surgery been carried out at an earlier point, Mr C would have had more of a chance of maintaining a better level of vision. Therefore, we upheld his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in providing treatment for his right eye.

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

• Consultants should be aware that one of the biggest determinants of visual outcome following retinal surgery is the visual acuity when surgery is carried out.
• Referrals to the vitreo-retinal service should be appropriately logged.

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 a number of concerns about the care provided to his mother (Mrs A) at Queen Elizabeth University Hospital. During Mrs A's admission, she was found to have fallen whilst in the bathroom. The nurse who found Mrs A did not identify any immediate signs of injury and noted that Mrs A had not reported loss of consciousness. Nursing staff subsequently carried out observations, and a doctor carried out an examination, noting no injuries. Following the examination, Mr C noticed that the bed sheets by Mrs A's elbow were spotted with blood and he reported this to nursing staff, who arranged for a small wound on Mrs A's arm to be dressed. The following day, Mr C noticed bruising around his mother's hairline and reported this to nursing staff, who had not previously noted this. A scan was then arranged, the results of which indicated that Mrs A had an acute subdural haematoma (bleeding in the space between the brain and the skull). Mrs A was subsequently transferred to a neurosurgical ward, and a procedure to evacuate the subdural haematoma was carried out.

A number of weeks following the fall, the board decided to undertake a significant clinical incident investigation. This took a number of months to be finalised, and it concluded that the assessment of Mrs A's risk of falling was not carried out appropriately and made a number of recommendations. To assess whether the board had taken appropriate steps in response to the failings identified, we took independent advice from a nursing adviser and a medical adviser.

Based on the nursing advice we received we could not conclude that Mrs A would not have fallen had the falls risk assessment been carried out appropriately, and had the appropriate interventions been in place. However, we considered that it was unreasonable that the board did not take the steps that they could reasonably have been expected to take to reduce the risk of Mrs A falling. We upheld this complaint, and we made a recommendation in relation to falls risk assessment.

Mr C was unhappy that nursing and medical staff failed to identify and treat his mother's injuries. In response to Mr C's complaint, the board acknowledged that nursing staff should have observed the bruising to Mrs A's head when delivering personal care and apologised that medical staff also missed this injury. The medical adviser was critical that a top-to-toe examination was not carried out by medical staff following the fall, and was also critical of how the medical examination was documented. We were satisfied that a dressing was appropriately applied to the cut to Mrs A's arm, and that a scan was arranged within a reasonable time after the bruising on her head was noticed. However, we found that the examination following the fall was not reasonable, and we upheld this aspect of the complaint. We made a number of recommendations for improvement.

We were also critical of the way the board handled Mr C's complaint. We found that staff had potentially missed an opportunity to recognise Mr C's complaint at an earlier stage, and we considered that this may have delayed the start of the complaint investigation. We noted a number of other shortcomings in the way the board handled and responded to Mr C's complaint. We upheld this aspect of the complaint and made a recommendation.

Recommendations

What we asked the organisation to do in this case:

• Send Mr C a written apology for failing to carry out a reasonable assessment of Mrs A following her fall.

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

• Junior medical staff should be trained on how to carry out appropriate assessments for patients who have fallen.
• The member of medical staff who assessed Mrs A should reflect and learn from the adviser's comments on record-keeping.

In relation to complaints handling, we recommended:

• Complaints should be handled in accordance with the proper 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 on behalf of his wife (Mrs A) about the care provided by mental health services at Dr Gray's Hospital. Specifically, Mr C complained about the way in which a psychiatrist and a community psychiatric nurse (CPN) handled a request for a letter for Mrs A to be excused from attending court as a witness and that they had discharged her from the service without notifying her or offering alternative support.

We took independent advice from a consultant psychiatrist and a mental health adviser. We were critical that the psychiatrist had not made a record of a phone conversation that took place with Mr C at the time to evidence the advice and support offered. This was contrary to national guidance in relation to record-keeping which we were critical of and we made recommendations in relation to this. We also found that the board had acknowledged and apologised that their psychiatrist and CPN had not properly communicated with Mrs A regarding her discharge from the service. The board said that they had taken action to remind staff to share all important communication with patients. We considered that the psychiatrist had not documented adequate reasons supporting why Mrs A was discharged, nor had they offered her the option of another consultation or seeing a different clinician. We also found that it would have been more appropriate for the CPN to have written to Mrs A and explained the options available to her in terms of continuing or not continuing the service. We upheld Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and Mrs A for failing to keep appropriate records.
• Apologise to Mrs A for failing to offer her the option of a further consultation or follow-up appointment with a different clinician prior to being discharged.

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

• The findings of this report should be shown to the doctor involved to ensure that in the future timely and adequate records are maintained.

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 to the council about the actions of their social work department. She was dissatisfied with their response and a Complaints Review Committee (CRC) was held. Ms C complained to us about the processes involved leading up to and including the CRC. In particular, she said that the terms of her complaint were not agreed with her in advance, further issues that were raised in advance of the CRC were not considered and her complaints about her dissatisfaction were not properly considered.

We made further enquiries of the council and found that contrary to their procedure, Ms C's complaints had not been agreed with her in advance. While the further information she provided was considered, it had not been acknowledged and she had not been told that it would be heard by the CRC. This led to Ms C feeling that her case had not been properly heard. We, therefore, upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• The council should apologise to Ms C for failing to agree the terms of her complaint in advance.
• The council should apologise to Ms C for failing to acknowledge the issues she raised prior to the CRC.

In relation to complaints handling, we recommended:

• Staff who act as investigating officers should agree the terms of complaints in advance.

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

Mrs C complained about the care and treatment provided to her husband (Mr A) during hospital admissions to the Royal Infirmary of Edinburgh (RIE), Liberton Hospital, the Western General Hospital and Ellen's Glen House in the months prior to Mr A's death. Mrs C also complained about communication and the board's complaints handling.

The board arranged a meeting for Mrs C with staff from the hospitals involved, and provided several written responses to her complaints, including an independent clinical review of some of the complaints. The board acknowledged a number of failings, including that significant decisions to complete a 'do not attempt cardiopulmonary resuscitation' (DNACPR) form and a 'verification of expected death' form were not discussed with her or Mr A, that the nursing documentation from Ellen's Glen House was completed to a poor standard, and that all of the medical records from Mr A's admission to RIE had been lost. However, Mrs C was not satisfied with the board's response.

After taking independent medical and nursing advice, we upheld Mrs C's complaints. We found some additional failings in medical and nursing care, including that Mr A was discharged from RIE when he was not fit to be discharged, and that nursing staff did not contact the family or carry out a neurological assessment when Mr A suffered a minor head injury. In relation to Mr A's missing medical records, we were advised that the board's actions in relation to the management of files were relevant but not sufficient.

We also found failings in the board's complaints handling. On several occasions the board agreed to take action, but did not follow through on this, and the independent clinical review provided to Mrs C included inaccurate findings, which were contradicted by the board's later responses. However, in making our decision we acknowledged that the board devoted considerable time and effort to addressing the numerous points Mrs C raised, including meeting with her and writing detailed responses to her concerns.

Recommendations

We recommended that the board:

• feed back our findings to the RIE doctor who discharged Mr A, for reflection and learning;
• confirm that the consultant who put in place the DNACPR without informing Mrs C has discussed this complaint at an annual appraisal;
• demonstrate that there are robust auditing processes in place at Liberton Hospital and Ellen's Glen House, to ensure decisions about DNACPR and nurse verification of death decisions are discussed with patients and/or families;
• discuss the nursing adviser's comments in relation to the treatment of Mr A's head wound with relevant nursing staff, for reflection and learning;
• demonstrate they have taken the action identified in their improvement plan to improve record-keeping (introduction of transfer letters and discussion of the process of filing notes at a quality meeting);
• review training needs of relevant staff in relation to information governance;
• update the management of misfiled and missing records procedure to include reporting responsibilities of staff;
• apologise to Mrs C for the additional failings our investigation found;
• review their systems for tracking actions agreed with a complainant, to ensure they follow up on these; and
• confirm that the failings in the independent clinical review have been fed back to the relevant doctor for reflection and learning as part of their next annual appraisal.

Summary

Mr C complained that staff at Hairmyres Hospital failed to provide him with appropriate care and treatment.

Mr C became unwell with sepsis (an infection of the blood) following an operation to treat an abscess on his abdominal wall. He was discharged with arrangements to have his wound cared for by district nurses. Mr C was later readmitted with symptoms of pain, swelling and wound discharge and was discharged the same day. Mr C then went on to develop a hernia some months later.

Mr C raised specific concerns that the operation to treat his abscess was carried out too late in the evening. He said the surgeon did not take into account information relayed concerning a scan that he had undergone. Mr C also said a surgeon opened his wound with a scalpel to further drain it while he was on the ward. Mr C attributed his subsequent health problems to the way the board handled his condition. The board said Mr C's condition was identified accurately, and that he received appropriate surgery. They considered Mr C's subsequent problems were not due to any deficit in care.

We took independent advice from a surgeon. We found that overall, the board had provided appropriate treatment. In particular, we found that the surgeon carried out the correct operation, including taking into account Mr C's scan, and that this was not carried out at an inappropriate time. However, we did find that there was an unreasonable delay in Mr C receiving surgery, as this occurred several days into his admission. We found that the board should have made a decision and operated on Mr C at an earlier stage. We therefore upheld Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the delay in surgery identified in this investigation; and
• consider steps they can take to reduce the impact of avoidable delays on treatment in the future.