Upheld, recommendations

Summary

Mrs C complained that the board failed to provide appropriate nursing care to her husband (Mr A).

Mr A suffered from ischaemia (inadequate blood supply), which had previously resulted in the amputation of his right leg below the knee. He was admitted to hospital with ischaemia of his left foot and an ulcer. There was no surgical option available to address this issue and the plan was to delay amputation as long as possible. Mr A was being seen twice a week by district nurses following discharge from hospital.

Some months after discharge, a nurse identified deterioration in Mr A's foot and contacted Mr A's GP practice. The GP prescribed antibiotics; however, the district nurses did not schedule a further visit at that time. A nursing visit did not take place until six days later. The nurse who attended discovered a maggot infestation in Mr A's wound. Mr A was subsequently taken to hospital and received an above-knee amputation of his left leg.

Mrs C complained about the missed visit. She also complained about the board's communication. The board acknowledged failings had occurred and apologised to Mrs C.

After receiving independent advice from a nurse, we upheld Mrs C's complaint. We found that the board had failed to ensure twice weekly visits as required under Mr A's care plan. We also found the board's communication was below a reasonable standard. In addition, we found that while the board generally complied with wound management guidance, formal wound assessments were not conducted regularly. We made a number of recommendations to address these issues.

Recommendations

We recommended that the board:

• confirm they will audit district nursing formal wound assessment charts to ensure that they meet local and national guidelines and provide evidence of this;
• remind staff of the importance of ensuring requested visits are followed up and documented within patients' records;
• provide evidence that there are improved systems in place for communicating a patient's plan of care between team members and other healthcare providers;
• consider a scheme of each patient having a named nurse to contact if they have concerns outwith their scheduled visits;
• consider a scheme for planned visits to be on set days of the week; and
• apologise for the failings identified in this investigation.

Summary

Mrs C complained that the practice failed to provide appropriate medical care to her husband (Mr A).

Mr A suffered from ischaemia (inadequate blood supply), which had previously resulted in the amputation of his right leg below the knee. He was admitted to hospital with ischaemia of his left foot and an ulcer. There was no surgical option available to address this issue and the plan was to delay amputation as long as possible. Mr A was being seen twice a week by district nurses following discharge from hospital.

Some months after discharge, the practice was contacted by the board's district nurse who had identified deterioration in Mr A's foot. A GP at the practice did not consider a visit was necessary at that time, and instead prescribed antibiotics for Mr A. On the fourth day after the visit, Mrs C further contacted the practice when she received no subsequent visit from the board's district nurses. A second GP from the practice attended Mr A at home. The GP did not examine the wound, but prescribed further antibiotics. Two days later, the practice was further contacted as a district nurse had attended and discovered a maggot infestation in Mr A's wound. A GP attended and Mr A was taken to hospital. Mr A subsequently received an above-knee amputation of his left leg.

Mrs C complained about the actions of the two GPs. She also complained about the practice's communication with the board. The practice acknowledged communication failings had occurred, and apologised to Mrs C.

After receiving independent advice from a GP, we upheld Mrs C's complaint. While we found the first GP acted appropriately in prescribing antibiotics, we found the second GP should have examined the wound given Mr A had previously received antibiotics and his symptoms were worsening. We also found that the practice's communication with the board fell below a reasonable standard.

Recommendations

We recommended that the practice:

• ensure the relevant GP is made aware of the findings of the investigation for reflection and learning;
• issue an apology for the identified failings in care.

Summary

Mrs C complained that she had been overcharged by Business Stream. Business Stream accepted that Mrs C had been overcharged but would not pay more than five years of backdated charges. Mrs C said she had repeatedly tried to raise the issue without success and that Business Stream had ignored her correspondence.

Mrs C believed that the issue spanned a period of about 25 years. She explained that a neighbouring property had sub-meters, which deducted from the main meter reading. She used relatively little water, while the neighbouring property used a lot of water. One meter had not been read for an extended period and Mrs C had paid for water used by the neighbouring property, as well as her own water.

Business Stream had refunded Mrs C for a five-year period. A lack of records made it difficult to establish water usage before this. Business Stream stated they had rejected the first overpayment offer from Scottish Water, before achieving an offer which reflected Mrs C's overpayments during a ten-year period. This was a period longer than that for which they were legally required to pay.

We found that Business Stream had taken an excessive length of time to address Mrs C's complaint. She had had to use a firm of solicitors before Business Stream began a full investigation, which we found to be unreasonable as Mrs C had incurred unnecessary costs in order to access the complaints system. We asked Scottish Water if their refund covered a period greater than five years. Scottish Water denied this and their position was supported by their correspondence with Business Stream. We found Business Stream had unreasonably and misleadingly stated to this office and to Mrs C that their Redress and Compensation Policy had been applied, which had resulted in a payment greater than the five-year legal requirement.

We found this to be unreasonable. We found that Business Stream should have given consideration to refunding the costs incurred by Mrs C and to applying their Redress and Compensation Policy to reflect the inconvenience and loss incurred by Mrs C during the period she was being overcharged as well as the failures within Business Stream's complaints process.

Recommendations

We recommended that Business Stream:

• apply their Redress and Compensation Policy in a manner which is proportionate to the loss and inconvenience caused as they appear to have accepted that a discretionary payment should be paid in this case for the charges back to 2005, but Scottish Water's evidence that itemises the period covered by the refund for overpayment was solely for 2008 to 2013;
• provide evidence they have reviewed their complaint investigation, to establish why they provided misleading and inaccurate information regarding the period of time the allowance granted by Scottish Water was intended to cover; and
• refund the cost of the solicitors fees incurred by Mrs C during the complaint.

Summary

Mr C complained that he had twice reported faulty street lights to the council and that they had failed to repair the lights, as they were required to do. He also complained about the way in which the council dealt with his complaint.

The council had acknowledged failings in their repairs process and subsequent communication and advised Mr C that these lights would be repaired.

We found that the council's records of Mr C's initial reports and their subsequent actions were poor. We were unclear as to what action had been taken by the council as the evidence was limited. We also noted that the council had failed to address Mr C's subsequent complaints to them, to speak to Mr C to discuss his concerns, and to respond to his correspondence in line with their complaints process. We therefore upheld Mr C's complaints.

Recommendations

We recommended that the council:

• review their handling of Mr C's request for repairs to the street lamps in order to establish why they do not appear to have reacted to his multiple reports of street lighting faults within the required timescale and also review their record-keeping to ensure that accurate records are retained of reports of faults and repairs carried out; and
• reflect on their handling of this complaint in order to identify why responses were not provided within the appropriate time frames, why Mr C was not contacted to clarify his complaint and why the points he raised were not addressed in either their stage one or stage two responses.

Summary

Mr C complained that the council had failed to fully reflect his concerns about a neighbouring planning application when they made a report to committee, in particular with regard to noise and loss of sunlight.

The council acknowledged that they had failed to fully reflect Mr C's concerns. They advised Mr C that the measurement of sunlight loss used for the application was appropriate but accepted that they should have communicated more clearly in their report about the loss of daylight. They also acknowledged that they did not properly reflect Mr C's concerns about the potential impact of noise.

We took independent advice from a planning adviser. The adviser found that while the council had failed to fully reflect the representations made by Mr C, these would have been available in full to committee members. They also found that the daylight test was in line with the council's guidance. As the council did not fully reflect Mr C's concerns about possible noise, we upheld Mr C's complaint.

Recommendations

We recommended that the council:

• remind planning officers of the importance of accurately reflecting public representations on material planning matters in the report of handling.

Summary

Mrs C complained to us regarding a planning application at a neighbouring site. In particular, she was concerned that the council had failed to re-notify neighbours following the submission of further information from the applicant. Mrs C also complained that the development management sub-committee had not been provided with a reasonable standard of information about ground levels.

We took independent advice from a planning adviser. They noted that when responding to Mrs C's complaints, the council had accepted that neighbours should have been notified of the additional information submitted and been given the opportunity to make further representations. The council also accepted that members of the development management sub-committee should have been made aware of the proposed site levels. We were advised that while reasonable action had been taken by the council to address these findings, further action should be taken by the council. We therefore made five recommendations.

Recommendations

We recommended that the council:

• consider the need for the planning service to accept direct responsibility for securing an acceptable solution in this case and report to us on any action taken;
• ensure that all options, including a specific proposal, are identified and considered and report back to us on the progress of a resolution;
• consider the need to ensure that where they are both planning authority and developer, it is essential to ensure that the standards of the planning service are met, and report back to us on any action taken;
• provide an update on the options developed for landscaping; and
• provide a copy of the practice note on site levels which has been prepared by the service delivery team.

Summary

Mr and Mrs C's child made a disclosure to their class teacher about an incident they found upsetting within the family home. The class teacher spoke to the head teacher and the child was interviewed by the head teacher. The head teacher then contacted another member of the education department for advice and they suggested that social services be contacted. The head teacher said they were clear that they did not make a social services referral. However, the social work department contacted Mr C and arranged a meeting with him and Mrs C.

Mr C was unhappy about this and complained that the head teacher had not followed the correct Getting It Right For Every Child (GIRFEC) procedures. Mr C believed the head teacher should have spoken to him prior to contacting the social work department and they should have created a written assessment of the risk to the child. Mr C also complained the council's investigation into the matter had been rushed and unfair since they had refused to meet with him, despite meeting with the council staff involved.

We found there was no evidence that the head teacher had followed the appropriate GIRFEC procedures as set out in the council's guidance to staff. We found that the head teacher was unaware social services had recorded their contact with them as a referral. We considered it inappropriate that teachers did not know how the social work department recorded requests for advice. We found the council's investigation had not identified the failure to follow council guidance, nor had it explained to Mr and Mrs C why they had been contacted directly by the social work department. We considered the council's investigation into the complaint had not been conducted to an appropriate standard.

Recommendations

We recommended that the council:

• remind the staff at the school of the importance of recording information when following the council's GIRFEC guidance;
• review information sharing between the social work department and education staff, to ensure staff are aware when contact is recorded as a referral;
• review their investigation of the complaint to establish why issues around their failure to follow GIRFEC were not addressed in either response;
• review the investigation to establish why no explanation was provided for the recorded social work referral;
• provide evidence that the learning points identified in the response to us regarding meeting with complainants have been actioned; and
• apologise for the failings we identified.

Summary

Mr C complained on behalf of his daughter (Miss A) about the transfer of school work when she moved between two schools.

We found that while the first school had updated Miss A's exam results promptly after she withdrew from the school, they did not properly deal with requests from Miss A and staff from the second school for evidence of those marks in the form of coursework.

We also found that the council had not identified this poor communication in their complaint investigation. We noted that they appeared to have contacted only the first school during their investigation and not the second school. We found this to be unreasonable. We therefore upheld Mr C's complaints and made two recommendations.

Recommendations

We recommended that the council:

• share the outcome of this complaint with relevant staff; and
• apologise to Mr C for the failure to conduct an effective investigation into his concerns and to his daughter for the distress caused to her by the inadequate communication between the schools.

Summary

Mr C complained to the council about a local bus company's use of the street outside his house for driver changeovers. Various options that would help resolve this problem had been considered but none had been put in place. Separately to this, there were plans to upgrade a nearby junction. This project included measures to accommodate driver changeovers and the council anticipated these would resolve Mr C's problems with driver changeovers.

Following a local consultation, the council began formal proceedings to carry out the upgrade, including a statutory consultation. Mr C complained that the length of time taken by these proceedings was unreasonable. He also complained that the council was not enforcing regulations on buses stopping in a restricted area near his home.

We acknowledged that the statutory process and the way the upgrade project was funded affected the timescale and that this was outside the council's control. However, we found that the council had introduced some avoidable delays that extended the timescale. We also found that the council was aware of drivers being asked by the bus company to stop in the restricted area. We therefore upheld Mr C's complaints.

Recommendations

We recommended that the council:

• apologise to Mr C for the avoidable delay in the process;
• provide Mr C with an update and schedule for the works at the junction near his home; and
• consider whether enforcement of relevant traffic-related legislation is required.

Summary

Mrs C complained about the treatment provided by her dentist. Mrs C said the treatment she received was unsatisfactory and as a result she had been left with problems with her teeth for which she held the practice responsible.

Mrs C had attended for a review appointment, where she complained of tenderness above an incisor tooth when she pressed on the gum. No treatment was provided by the dentist and Mrs C was advised to book a further review appointment at a later date.

We took independent advice from a dental adviser who said Mrs C's symptoms were suggestive of an infection. The adviser said the dentist should have carried out some form of investigation, as a minimum an x-ray, in order to determine the cause and confirm a diagnosis. There was no evidence that they did so.

The adviser said that remedial treatment may then have been appropriate or arranging a further review appointment if it was considered that the problem would resolve without further treatment. The adviser considered that the dentist had not provided Mrs C with appropriate treatment. We accepted that advice and upheld Mrs C's complaint.

The adviser also commented that because Mrs C saw the first dentist with an available appointment whenever she contacted the practice, she was seen and treated by six different dentists in the practice over several months. The adviser said this may have resulted in a failure in communication in that Mrs C was not provided with consistent messages and advice about her treatment, so we made a recommendation about this.

Recommendations

We recommended that the dentist:

• issue Mrs C with an apology for failing to undertake treatment when they saw her;
• reflect on the comments of the adviser in relation to ensuring that they can confirm any clinical findings with an accurate diagnosis before providing advice to a patient; and
• work with other dentists in the practice to give consideration to ensuring that, where a patient is seen and treated by more than one dentist, appropriate processes are in place so that the patient is given consistent messages and advice about their dental treatment.