Upheld, recommendations

Summary

Mr C, a lawyer, complained to us on behalf of his client (Miss A). Mr C complained that the council failed to collect recycling bins from Miss A's address as scheduled, and about the council's handling of Miss A's complaint.

The council acknowledged there had been operational failures leading to missed collections from Miss A's address. For example, collection crews failed to record missed uplifts. This resulted in Miss A having to report missed collections and complain to the council on several occasions. The council's response to Miss A's complaint said they would ensure collections were not missed.

However, as Miss A had to report further missed collections to the council and complain to us, it was clear the council's response to her complaint failed to ensure recycling collections would take place. This called into question the quality of the council's investigation into Miss A's complaint and the remedy put in place as a result of her complaint.

We upheld Mr C's complaints and made recommendations. However, the council has taken action to address the failings in complaints handling and therefore we have made no recommendation in relation to this.

Recommendations

We recommended that the council:

• apologise to Miss A for missed recycling collections and explain to Miss A why collections were missed and the steps that have been taken to prevent this from happening;
• ensure that the depot manager engages with Miss A directly to allay any future concerns and give a direct response and assurances in relation to recycling collections; and
• provide us with copies of monitoring sheets for recent collections to show that all recycling collections at Miss A's address have been carried out as scheduled.

Summary

Mrs C is the chair of the board of trustees for a charity and complained on behalf of the charity. The charity had applied for funding from the council's area committee discretionary fund, and their application was considered along with others.

The grant application scoring panel had recommended an award to the charity. However, following a vote to award another organisation a sum of money, a decision was made to award the charity a sum less than had originally been recommended. The other organisation had been recommended for a nil award by the scoring panel, and had not met the minimum points in two key criteria to be eligible for funding, in terms of the scoring framework. The shortfall in the budget had been balanced by reducing the award recommended for the charity. All other applicants were awarded grants in line with the scoring panel's recommendations.

We found that although the council's decision was discretionary, they ought to have provided a clear and robust rationale for deviating from the scoring panel's recommendations. The reason the council gave for their decision was vague, and called into question the entire scoring process. We upheld the complaint.

Recommendations

We recommended that the council:

• apologise to Mrs C for the lack of transparency in their decision-making process;
• remind elected members of the importance of transparency in all decision-making; and
• review Mrs C's case and reflect on the issues raised in it, with a view to identifying learning and improvement to ensure transparency in future decision-making.

Summary

Mr and Mrs C raised concerns about the council's handling of various planning applications for a site, including their home. In particular, they said that certain applications failed to protect their home by ensuring that its floor level and that of its neighbour were built to a similar level. As a consequence of this, they said that the council failed to assess the impact of their neighbour's sun lounge on their amenity and privacy.

We made enquiries to the council who confirmed that they had since established that the levels of the properties concerned were not in accord with the applications granted and the houses were not built as envisaged. The difference in levels had led to Mr and Mrs C's property being overlooked.

We took independent planning advice and we found that one of the properties concerned was too high, whereas, the other was too low. The consequence of this was that overlooking of Mr and Mrs C's house was unavoidable. The council were largely responsible for this. Similarly, because the floor levels were incorrect, the council would not have been able to properly assess the impact of the neighbours' sun lounge on Mr and Mrs C's property. We upheld the complaint.

Recommendations

We recommended that the council:

• make a formal apology to recognise the situation;
• review the staff guidance notes to include the treatment of window alterations during the course of development as consent variations or as permitted development;
• make a formal apology for their inability to assess the impact of the sun lounge;
• be prepared to meet the costs of any agreed solution; and
• review staff guidance notes on planning application handling with regard to successive permissions issued for the same site; the consistency of conditions which require to be carried through from one permission to any future permission; consideration of site levels and especially any proposed changes for residential amenity and overlooking.

Summary

Miss C complained that the housing association failed to respond reasonably to her complaints of anti-social behaviour by other tenants in her tenement block.

We found that the association did not act in accordance with their procedures when responding to Miss C's concerns and we were not satisfied that they made sufficient efforts to respond to her complaints. For this reason, we upheld Miss C's complaint.

Recommendations

We recommended that the association:

• apologise to Miss C for the failings identified in our investigation;
• ensure that any of Miss C's outstanding concerns about anti-social behaviour are fully investigated and responded to; and
• reflect on the failings identified in this investigation and advise us of the actions they will take to address these.

Summary

Mr C made a complaint against his housing association as he had ongoing problems with damp and water penetration in his property. He first raised a repair request on this matter over two years prior to bringing the case to us. He was of the view that the property needed re-roughcast and re-rendered to resolve the issues. He was not satisfied with the action taken by the association and the length of time it had taken to resolve this issue.

The association apologised for the delay, although they stated that they had completed repairs as requested, in good faith. Part of their investigation uncovered that a redundant chimney stack was the main cause of water ingress in the property. After some further repairs and inspections the association arranged for the chimney stack to be removed. They also apologised to Mr C for the delay and offered compensation, which was declined.

We investigated the case and obtained information from the association. We assessed their response to Mr C's repair requests against their repairs policy and noted that on several occasions repairs were not completed within the set timescales. We also noted that there did not seem to be any measure in place to ensure that repair targets had been met. Mr C was looking for his property to be re-roughcast and the association had said that his house was identified as a property that was due for this type of work but that it was assessed as not being high priority. Given the missed timescales for individual repairs and the overall length of time taken to resolve the problem, we upheld Mr C's complaint.

Recommendations

We recommended that the association:

• ensure that they adhere to the deadlines for repairs as laid out in their repairs and maintenance policy;
• ensure staff check that repairs have been completed within an appropriate timescale; and
• conduct a further survey of Mr C's property to assess the current condition of the roughcast and rendering and to determine what priority rating is currently appropriate.

Summary

Mr C complained about the care his late wife (Mrs A), who suffered from diabetes, received from the board. In particular he complained that when a home visit was made by a district nurse, his wife's podiatry appointment was not brought forward by the board.

During our investigation we took independent advice from a consultant podiatrist. The adviser considered that when Mrs A's diabetic foot ulcer was noted during the home visit, an urgent referral should have been made to the board's multi-disciplinary diabetic foot care service which would have given her access to vascular assessment and a vascular consultant.

The adviser, when commenting on the care given during the home visit, also referred to the podiatry care Mr C's wife received when she was admitted to Western Isles Hospital. In particular, the adviser commented that there was no record of a vascular assessment having being carried out and that this represented a failure in assessment by podiatry.

Recommendations

We recommended that the board:

• ensure podiatrists and district nursing teams have the competencies required to provide assessment for patients with diabetes and acute foot conditions;
• ensure all health care professionals are aware of the available guidance for diabetic foot conditions;
• ensure the pathways and signposting for urgent referrals are in place and implemented;
• consider the adviser's comments on referral to an acute multi-disciplinary diabetic foot care team and report back on action taken;
• ensure clinical data is available across the organisations; and
• issue Mr C with an apology for the failings identified in this investigation.

Summary

Mr C complained that, following a collapse in the street where he vomited blood, his son (Mr A) was taken to Ninewells Hospital where he was discharged after treatment for a head injury. Later that day Mr A was again found collapsed in the street and he was again taken to Ninewells Hospital where he died that evening. Mr C noted from the post-mortem report that the cause of death was recorded as a massive gastrointestinal haemorrhage (bleed) and said that had this been identified during the first visit to hospital then the outcome may have been different.

We obtained independent advice from a consultant in emergency medicine about the treatment provided during the first attendance at hospital. We found that the assessment of the cause of Mr A's collapse was reasonable. We also found that the assessment of his head injury was reasonable. However, we found that an insufficient risk assessment had been made when considering Mr A's reporting of vomiting blood and as such he should have been admitted to hospital on the first attendance or kept in for a longer period of observation. However, even if this had been case we could not say with certainty that the outcome would have been different, but we acknowledged that Mr A would have had an earlier review by clinical staff. We upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified in this investigation; and
• share our report with the relevant staff so that they can reflect on their actions.

Summary

Mr C underwent an operation at Ninewells Hospital to remove a skin tag on his penis. He was concerned about the outcome of the operation and the appearance of the resulting scar, and he said that he was left with some disfigurement. Mr C complained that the consultant urological surgeon told him before the operation that the appearance of his penis would improve with surgery and that he was not warned that there was any risk of disfigurement. Mr C also had concerns about the standard of the operation itself, and follow-up care.

We took independent advice from an adviser who specialises in urological surgery. We found failings in the consent process. We found that there was no evidence that Mr C had been warned of the risk of scarring and that the outcome of the surgery may not meet his expectations until the day of the operation. This meant that he had not been given enough time and appropriate information to make an informed decision, particularly in light of his additional needs. We found no evidence to suggest that the standard of the operation was not reasonable and while there were failings in relation to a follow-up appointment, this was addressed by the board.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified in this investigation;
• bring the failings identified in this investigation to the attention of relevant staff; and
• review the consent process and related documentation to ensure that clinicians properly obtain, and document, consent for procedures.

Summary

Mr C complained that his wife (Mrs A) was inappropriately diagnosed as having suffered a miscarriage and that she was not provided with appropriate and timely treatment.

Mrs A was in the early stages of pregnancy when she experienced bleeding. During the night, Mr C and Mrs A attended the gynaecology out-of-hours service at the Royal Infirmary of Edinburgh. After waiting, they were seen by a doctor, who examined Mrs A. A procedure was offered and it was noted that this would not harm the baby should the pregnancy still be viable. Miscarriage was recorded as being very likely and the couple were sent away to return the following morning for a scan.

The scan confirmed that the pregnancy was ongoing and that the bleeding had been caused by a haematoma (a collection of blood outside the blood vessels).

Mr C felt that the lack of scanning facilities at night time meant they had an unnecessary wait to find this out. Mr C also said that the doctor they had seen told them that Mrs A had miscarried and that he was concerned about the procedure that was offered.

After taking independent advice from a consultant gynaecologist, we upheld Mr C's complaints. The board previously acknowledged that there had been an inappropriate diagnosis of miscarriage and had apologised for this. The advice we received was that the doctor had mistaken blood clots that were present during the examination for tissue and that it was inappropriate to make a firm statement about miscarriage without a scan taking place. We noted, however, that the availability of scanning facilities at the hospital was in line with the relevant guidance. We found that there were issues with record-keeping and that the procedure offered by the doctor was not clinically necessary.

Recommendations

We recommended that the board:

• apologise for the offer of a procedure that was not clinically indicated;
• take steps to ensure that all emergency gynaecology referral notes are appropriately completed with timings and an identifiable name and grade of the doctor;
• ensure that the adviser's comments are fed back to the doctor for learning and discussion at their appraisal;
• consider whether further training for doctors working in this area is necessary to improve communication with patients suffering from problems in early pregnancy; and
• consider how electronic records of consultations can be maintained in circumstances such as these in future.

Summary

Mrs C complained on behalf of her brother (Mr A), that staff at the Royal Infirmary of Edinburgh failed to ensure he was safely transferred to a trolley. In addition, Mrs C raised concern that the incident was not properly investigated, that Mr A was not reviewed following the incident, and that the complaints handling by the board was poor.

We took independent medical advice. We found that Mr A was not transferred to the trolley in accordance with the moving and handling plan that had been put in place following his mobility assessment. Furthermore, when the incident was reported to a nurse later that evening, we were critical that the nurse did not take appropriate steps to formally record the incident on the hospital's system for reporting adverse events. We considered this would likely have resulted in the incident being investigated in a timely manner, and that Mr A would have been reviewed by a doctor sooner. We were also critical of the board's handling of the complaint. Specifically, that they had inaccurately said that a nurse had been present at the time of the trolley transfer for which they apologised. We also found that the board had not acknowledged that the porter's recollection of the transfer was contrary to the manual handling plan documented in Mr A's clinical records. We therefore upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr A for the delay in reviewing him after the incident was reported to the nurse;
• share these additional findings with the nurse involved;
• take steps to ensure that porter staff are made fully aware of patients' mobility limitations and needs prior to carrying out inter-departmental transfers; and ensure that nursing staff are available to provide the necessary support indicated in mobility assessments;
• apologise to Mrs C for the additional failings in the complaints handling identified in this investigation; and
• provide evidence of the steps taken to address the issue related to the complaints handling.