Upheld, recommendations

Summary

Mrs C, who works for an advocacy and support agency, complained on behalf of her client Mr A. Mr A's late wife (Mrs A) had been diagnosed with lung cancer. Mrs A began to suffer severe neck pain which subsequently spread to her shoulder and arm. Mrs A was admitted to Dr Gray's Hospital at the request of her GP. Given that a recent scan of the shoulder had shown no problems, a further x-ray or scan was not requested by clinical staff at the acute medical assessment unit. Mrs A was discharged home the following day. Mrs A's pain continued and a few days later she was admitted to Aberdeen Royal Infirmary. X-rays and a scan were performed which showed that Mrs A's cancer had spread to two cervical vertebrae (neck bones) and to the brain. Mrs C complained that the board had failed to provide Mrs A with adequate care and treatment during her admission to Dr Gray's Hospital.

The board acknowledged that Mrs A should have been referred to the oncology team and that a neck x-ray should have been performed. They apologised for the delay in diagnosis and that they did not recognise or control the cause and nature of Mrs A's pain. The board explained that they have taken action following this complaint, including using the National Cancer Treatment Helpline, as well as considering direct referral to the oncology team. They explained that they are working to maintain the awareness of these mechanisms to prevent a recurrence through information on their intranet and documentation in induction packs. We have asked the board to provide evidence of these actions.

We took independent advice from a consultant in acute medicine. The adviser's view was that the possibility of the cancer spreading to the cervical vertebrae or the spinal cord should have been considered. The adviser said that Mrs A's pain should have been managed as a possible malignant spinal cord compression (an issue that develops when the spinal cord is compressed by bone fragments, a tumour, an abscess or other lesion. This is an issue that is usually treated as a medical emergency). The adviser's view was that there should have been a discussion with oncology and that the use of steroids and an MRI scan should have been considered. The adviser stated that they would expect doctors working in an acute medical assessment unit to recognise this and perform this role. In light of this, we upheld the complaint.

Recommendations

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

• The board should have a malignant spinal cord compression protocol.
• All clinical staff within the Acute Medical Assessment Unit should be made aware of the malignant spinal cord compression protocol.
• Clinical staff within the Acute Medical Assessment Unit should learn from this case.

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 daughter (Miss A). He complained that there had been an unreasonable delay in her receiving treatment for a foot injury at Aberdeen Royal Infirmary.

We took independent advice from a consultant orthopaedic paediatric surgeon. We found that an appropriate initial referral and examination of Miss A's foot had been carried out and that an appropriate treatment plan had been instigated, which included the use of interventional radiology treatment (treatment that is used to precisely target therapy to affected areas). However, we found that due to staff shortages there was an unreasonable delay in Miss A receiving interventional radiology treatment at Aberdeen Royal Infirmary. We found that there were a series of cancellations and that it was then decided that Miss A should be referred onto another board for treatment. We found that there was also a delay in sending that referral. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss A for the delay in initiating treatment.

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

• Patients requiring interventional radiology treatment should receive treatment in a timely manner or be referred to an alternative provider, such as another NHS board.

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

Miss C complained about the care and treatment provided to her at Victoria Hospital. Miss C complained that when she first presented at the hospital with symptoms relating to an infection in her groin area, she was discharged too early and had to be readmitted later that day. Miss C also complained that the abscess which formed in her groin area was inappropriately drained at her bedside, and that there was a delay in a diagnosis of necrotising fasciitis (a rare infection that destroys the soft tissue of the skin) being made.

We took independent advice from a general surgeon and a consultant physician. We found that Miss C was inappropriately discharged from the hospital on her first admission as she had been newly diagnosed with diabetes and had an ongoing temperature. The advice we received was that it may have been helpful for Miss C to have had input from a diabetologist and earlier surgical management of her skin infection. We also made a recommendation regarding the documentation of timings in medical records as we found this to be poor.

We further found that the drainage procedure carried out at Miss C's bedside was not reasonable as pain relief was not documented, and the signs that were present at this point, namely skin blistering and fluid filled tissues, were not reasonably acted upon.

Finally, we found that there was an unreasonable delay in the diagnosis of necrotising fasciitis as, when there were clear features of this occurring, the appropriate action was not taken in a timely manner. Additionally, the advice we received noted that there was clear indication for surgical incision and drainage at a far earlier point than was carried out and that, had surgical treatment been carried out at an earlier point, necrotising fasciitis may not have occurred. We upheld all of Miss C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for inappropriately discharging her from hospital, inappropriately carrying out a clinical procedure at her bedside and unreasonably delaying in reaching a diagnosis of necrotising fasciitis. 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:

• All entries in clinical records should be correctly dated and timed.
• The board should ensure it has clear guidelines that comply with recognised standards for how to manage skin and soft tissue infections, which include when surgical treatment should be commenced. Staff should be competent to apply them to an acceptable standard.
• In otherwise unwell patients with newly diagnosed diabetes, consideration should be given to seeking input from a diabetologist.
• Surgical staff should be familiar with signs of necrotising skin and soft tissue infections.

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 applied for, and accepted, a place on a course at the college. The price of the course was advertised on the college's website and in the course brochure as being £650. During the first unit of the course, Ms C received an invoice for £1,950 in course fees. Ms C queried this with the college but did not receive a response. When she received a further invoice, which she received after starting the second unit, she contacted the college again. The college explained that the fee was actually £650 per unit and that the course consisted of three units. They offered to reduce the fee by ten percent in light of the poor customer service, but would not reduce the fee to £650. Ms C highlighted to the college that the fee of £650 was as advertised on their website and in the course brochure. The college offered to further reduce the invoice, and stated that Ms C had five working days to accept the offer or she would be immediately withdrawn from the course. Ms C complained to us that the college acted unreasonably by charging her more than the cost of the course as advertised on their website and in the brochure. She further complained that the college acted in an unreasonable manner when they emailed her asking her to pay the amount they considered she was due the college.

We examined information from the college's brochure, which indicated that the fee for Ms C's one year course was £650. We also examined the college's website, which noted the start date, the length of the course and the cost as £650. There was no indication that the cost was £650 per unit. In their responses to Ms C, the college had accepted that the information on their website was misleading. We concluded that it was reasonable for Ms C to have interpreted the information on the college's website and brochure as meaning that the course fee was for the whole course, rather than for each individual unit. We upheld Ms C's first complaint because we considered that the college had not provided her with clear and accurate information about the course fees before the course began.

Having considered the contents of the college's email to Ms C when they asked for the outstanding amount, our view was that the college did not appropriately recognise the particular circumstances of her complaint and that the wording could be perceived to have been threatening. Therefore, we upheld Ms C's second complaint. We made a number of recommendations to the college as a result of Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Reimburse Ms C for the amount she paid over the advertised £650 fee, taking into account that she was entitled to some Student Awards Agency for Scotland funding towards this. The payment should be made by the date we have indicated. 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.
• Apologise to Ms C for the content of their email to her. 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:

• The college should have clear and accurate information about course fees on their website and in their course brochure.

In relation to complaints handling, we recommended:

• The particular circumstances of a complaint should be recognised when staff are responding to the complaint. Staff should be mindful of how the wording of their complaints responses could be perceived.

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

Miss C, a utilities consultant, complained about Business Stream on behalf of her clients, a trust. Miss C told us that she had recently requested that the trust's water accounts be transferred to another supplier. She said that Business Stream had initially blocked this request, as the trust had entered a contract with them until 2018.

Miss C then contacted Business Stream to ask about the contract and any exit fees and was told that there was no record of a contract, so no fees would apply. She then reapplied for the transfer and the accounts were moved to another supplier.

Business Stream contacted the trust shortly afterwards, once again confirming that a contract had been in place and requesting payment for exit fees incurred as a result of breaking the contract. Miss C then submitted a complaint about the miscommunication, requesting that the fees were written off. Business Stream accepted that they had failed in their communication and apologised. However, they refused to write off the fees as they had supplied the trust with copies of the contract before the accounts were transferred.

On investigation, we found that Business Stream had incorrectly told Miss C that there was no contract in place on more than one occasion. The reason given to Miss C for this was that staff in the customer service team were not able to access a copy of the contract, as this was stored on a part of the system reserved for account managers.

We found that all staff should still have been able to confirm the existence of the contract by referencing discounts showing on any of the trust's invoices. Despite this, we also considered that Business Stream should have done more to ensure that their systems made clear to staff when a contract was in place. For these reasons, we upheld the complaint.

However, we confirmed that Business Stream had provided the trust with copies of the contract before the contract began, and after Miss C first requested that the accounts be transferred. The contract clearly explained its term and the fees that would apply if the customer exited before this period had expired. We therefore considered that it was reasonable for Business Stream to expect the trust to pay the fees.

Recommendations

We recommended that Business Stream:

• alter their systems or procedures to ensure that the existence of any contract is clearly indicated in a way that is immediately obvious to all staff.

Summary

Mr C complained about Business Stream regarding a request he made for a burst allowance (an allowance made against sewerage charges when water is lost because of a burst pipe) following an increase in his water bill due to a leak. Mr C explained that the leak was outside his property boundary, on a pipe that both he and his neighbour believed had been disconnected many years ago when the property was separated.

Business Stream refused Mr C's request, stating that, to be eligible for a burst allowance from Scottish Water, a customer must have a waste water connection, which Mr C's property did not.

On investigation, we confirmed with Scottish Water that this was not correct. Scottish Water confirmed that burst allowances could be granted to reduce supply charges, regardless of whether a customer had a waste water connection. We found that Business Stream had failed to recognise this error despite many opportunities to do so in response to both Mr C and our enquiries.

We also found that, as they did not consider the request would be successful, Business Stream chose not to submit it to Scottish Water for their consideration. We considered this to be unreasonable in the circumstances, as this was a decision for Scottish Water to make. For these reasons, we upheld Mr C's complaint.

Recommendations

We recommended that Business Stream:

• apologise to Mr C for the failings identified;
• submit Mr C's request for a burst allowance to Scottish Water for their consideration;
• review their burst allowance policy to ensure it is clear to staff when requests should be submitted to Scottish Water; and
• audit a sample of recent allowance requests to ensure that they have been appropriately processed and evidence the outcome.

Summary

Mr C complained that Business Steam failed to act reasonably in respect of backdating his water charges. Mr C's complaint concerned two adjacent properties (property A and property B) that he rented over a period of some years. Mr C initially rented property A for approximately three and a half years. During this time, there was cyclical re-evaluation of the properties; however, as a cyclical re-evaluation, this was not reflected in billing, consistent with Business Stream's policies. Approximately 18 months later, Mr C also rented property B. He continued to rent both property A and property B for approximately three years. Mr C then ceased to occupy property A. At this point, the Scottish Assessor's Association updated the records to merge the properties retrospectively for the period Mr C occupied them both, increasing the value of the properties to account for the re-evaluation. Business Stream sought to backdate Mr C's water charges for this period. Mr C disputed Business Stream's basis for the charges.

After considering the relevant Rateable Value Policy, and obtaining independent advice from a water policy consultant, we upheld Mr C's complaint. We found that Business Stream had backdated Mr C's water charges based on a later version of their Rateable Value Policy; however, the version of the policy in force at the relevant time specified that water charges would not be backdated in this manner.

We recommended that Business Stream re-assess Mr C's charges, and apologise to him.

Recommendations

We recommended that Business Stream:

• evidence that they have re-assessed the backdating of charges for the relevant period, to take into account the findings of this investigation;
• evidence that they have re-assessed charges from a specific date to ensure that they take into account the appropriate rateable value; and
• apologise for the failings this investigation has identified.

Summary

Mr C complained that the council unreasonably rejected his planning application on the basis of reasons which were outwith their jurisdiction. He said that as a result he had to appeal to the local review body, who granted consent, and that this process resulted in additional costs for him.

We found that the council rejected the application on grounds which did not appear to fall within the remit of the planning authority. The rejection focused on an element of the application which related to the marine environment and which was subject to licensing through Marine Scotland, rather than the planning authority. We noted that, where there was doubt about jurisdiction, this should be reflected in the planning officer's report and that this did not happen in this case. We also noted that no reference to the relevant Scottish Government planning circular was made in the officer's report and that the officer failed to fully explain their assessment of the proposals against the planning policy which was used to refuse the application. For these reasons, we upheld the complaint.

Recommendations

We recommended that the council:

• write to Mr C to apologise for their decision to refuse planning permission on grounds which fell outwith their jurisdiction; and
• reflect on their handling of Mr C's planning application and consider how best to ensure that officers are clear as to the implications of Circular 1/2015 and their responsibilities to justify decisions detailed in their reports in terms of all relevant planning policies.

Summary

Miss C complained that the council had failed to provide a clear and understandable explanation for the council tax changes on her account over a five-month period. She also complained that the council failed to adequately communicate with her following her contact with them over a ten-month period.

We found that while the council had, following our enquiries, been able to provide us with as clear and understandable an explanation as possible, they had not done so for Miss C. We therefore upheld Miss C's complaint.

We noted that the council had not provided either Miss C or us with an explanation for reassessing her council tax on one specific occasion. We also felt that, when it became apparent to the council that the information they were providing was not clear to Miss C, it would have been helpful for them to consider alternative means of communicating this information, for example through a face-to-face discussion. We made recommendations to address these issues.

In relation to Miss C's contact with the council, the council had already recognised that they had provided a poor level of service to Miss C and had apologised to her. We upheld Miss C's complaint. We identified three specific areas where the council's service had been poor and made recommendations accordingly.

Recommendations

We recommended that the council:

• provide Miss C with a clear explanation for reassessing her council tax;
• remind the relevant complaints handling staff to consider all means of resolving a complaint, including face-to-face discussion with the complainant;
• apologise to Miss C for failing to provide a clear and understandable explanation for changes to her council tax; and
• review the circumstances giving rise to the three service issues identified by the council and provide us with evidence that they have taken action to prevent a similar situation occurring in future.

Summary

Mrs C complained about the council's handling of the decision to change her son (child A)'s school class for the following academic year. Child A had been informed of his class before the school summer holidays. However, very shortly before the beginning of the school term, Mrs C was told that he would not be going into the class of which he had been previously informed.

Mrs C was unhappy with the way the council handled this decision. Specifically, she felt that they had failed to take into account the provisions of the Scottish Government's 'Getting it Right for Every Child' (GIRFEC) approach by not consulting with her, her husband or child A about the decision and that they had failed to provide her with details of the information on which the council's decision had been based.

Mrs C also felt that the council had failed to give a reasonable explanation for their decision, delayed unreasonably in informing her and child A about the decision, and failed to consider the effect the decision would have on child A.

As part of our investigation, we received further information from the council about the complaint. Although we could not provide Mrs C with the confidential information received which had led to the council's decision, we were satisfied that the council's explanation for reaching their decision was reasonable and was in line with their policy on the selection of pupils for classes.

We also considered the provisions of GIRFEC in relation to children, young people and their families understanding what is happening and having their wishes heard and understood. In this case, child A and his family were not adequately informed about what was happening and why, or given the opportunity to have their wishes heard and understood before the decision was reached. We thought that, had the council contacted child A and his family, this would have also prepared them for the possibility that child A may have to change classes, rather than this decision coming without warning so close to the beginning of term.

We also had concerns that, contrary to the joint working approach set out by GIRFEC, it did not appear that the school was involved in the discussions about the decision, which took place over the summer holiday period. We also concluded that there was an unreasonable delay between the decision being made and this being communicated to child A.

Given that the council did not keep Mrs C's family properly informed and involved and that there was an unreasonable delay in informing them of the decision, we considered that the council did not take appropriate action to limit the upset caused to child A.

Although it did not form part of Mrs C's complaint to us, we identified concerns with record-keeping at the school and the council. The council acknowledged that there was very little physical evidence in relation to this complaint. Our view was that it would be good practice for the school and council to keep a record of discussions where important matters which could have an impact on a child's well-being are discussed. In this case, it was difficult to establish exactly what had happened as there was no record of the relevant discussions within the school and the council.

In light of the above, we upheld Mrs C's complaint and made recommendations.

Recommendations

We recommended that the council:

• share the findings of this investigation with staff within the education department and remind them of the provisions of GIRFEC in relation to: children, young people and their families being kept informed about what is happening and why, and being listened to and having their wishes heard and understood; and the importance of joint working when making decisions which will impact on a child’s well-being;
• apologise to child A and his family for failing to keep them informed about what was happening and why and not giving them the opportunity to have their wishes heard and understood before the decision was reached, and for the delay in informing them of the decision;
• remind staff involved in this complaint (including the school) of the importance of recording discussions (including with parents, carers, children, young people and other staff) where important matters which could have an impact on a child’s well-being are discussed; and
• reflect more broadly on the failings identified in this investigation and take any necessary improvement action to prevent a similar situation occurring again, and inform us of any improvements.