Upheld, recommendations

Summary

Mrs C complained to us that the board had failed to provide reasonable care and treatment to her son (Mr A) when he attended the Royal Alexandra Hospital after taking an overdose of prescribed medication. Mr A was discharged from the hospital later the same day. Mr A had continuing symptoms of nausea and was given medication to prevent nausea and vomiting. He died two days later. This is thought to have been due to the effects of the overdose he took before attending hospital.

We took independent advice from a consultant in emergency medicine. They found that the level of medication taken by Mr A fell into the range that could cause death and required careful medical assessment and close observation. They noted that staff in the hospital ought to have contacted the National Poisons Information Service to discuss the matter, particularly as Mr A had taken a multi-drug overdose. We considered that the information service would have advised that Mr A should not be discharged until he was free of symptoms, as death can occur up to 54 hours after ingestion of the prescribed medication. Mr A was not free of symptoms as he required medication to control his vomiting.

Although we could not say whether Mr A would have survived had appropriate action had been taken, his symptoms could have been managed better had he remained in hospital. We therefore upheld Mrs C's complaint. However, we were satisfied that the board had learned lessons from the failures in Mr A's care and that the action they had taken in response to these failings was reasonable.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the failings in her son's care.

Summary

Mr C had surgery on his prostate at Forth Valley Royal Hospital and he subsequently experienced a common complication of the procedure. He complained that he was not told in advance that this complication would be permanent and he considered that the information he was provided suggested it would only be temporary. He said he would not have gone ahead with the procedure if he had realised that the complication was irreversible.

The board noted that the potential risks were explained to Mr C before the procedure and were listed on the consent form which he signed. They also noted that he was given a patient information leaflet, which stated that three out of four men would experience the complication in question. However, Mr C stated that the leaflet said the complication would only last a few weeks.

We obtained advice from a consultant urologist, who was not critical of the consenting process and considered that Mr C was in a position to provide informed consent. They noted that the leaflet did not state that the complication would only last a few weeks. They considered that it was implicit in the leaflet that the complication could be permanent, however, they said it could benefit from being changed so that this is stated explicitly. We agreed that the leaflet did not state that the complication was temporary. However, we noted that it did refer to some other side effects as being temporary. Given that there is a 75 per cent chance of the complication in question occurring following surgery, and as it is often permanent, we considered that this position should be made clearer in the board's information leaflet. On balance, we upheld the complaint and made some recommendations.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failure to make it clear in the information leaflet the likelihood of the complication of his surgery being permanent; and
• clarify in the information leaflet the likelihood of the complication being permanent.

Summary

Mr and Mrs C complained to us about the treatment they received at an out-of-hours centre where they took their baby on the advice of NHS 24 as he was not feeding well and was blue around his lips. There was a wait to see a GP and the baby went pale and struggled to breathe. The baby was seen urgently by a GP who examined him through his clothing and told Mr and Mrs C to take the baby to the A&E department at Crosshouse Hospital in their car. On arrival at the hospital, the baby stopped breathing and had to be resuscitated. The baby remained in hospital for three days. Mr and Mrs C felt that the GP should have given their baby oxygen and arranged for an ambulance transfer to hospital.

We took independent advice from an adviser in general practice medicine and concluded that the GP had carried out an inadequate examination of the baby as they did not remove the baby's clothing. In addition, we noted that the GP had maintained that they did not administer oxygen to the baby as it would have delayed the referral to hospital. We found that as oxygen was available at the out-of-hours centre, the GP should have administered it to the baby. We also found that it was inappropriate to have asked Mr and Mrs C to have transported their baby to hospital without clinical support. We upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for the failings in care and treatment which have been identified during this investigation;
• ensure that the GP discusses this complaint with their GP appraiser as part of their yearly appraisal; and
• ensure that the GP considers whether there is additional learning in relation to the initial management of patients with unstable blood pressure. The GP may benefit from the clinical support group in this regard.

Summary

Mr C complained on behalf of a transport company (the company) that Business Stream had unreasonably failed to fully refund overpayments going back to 2002. Mr C said that a hybrid meter should have been installed to differentiate between the water flow required for fire fighting and the water required for normal usage. Instead, a single meter had been put in in 2003, which was much larger than the company required. It was, however, smaller than the meter it replaced, which resulted in a reduction in the company's water bills. The company had, therefore, been unaware that the wrong type of meter had been installed until 2013. Mr C was able to provide correspondence sent to the company at the time of installation, in which they were told explicitly a hybrid meter had been installed.

Business Stream stated they believed the Prescription and Limitation Act (1973) (the Act) applied, and they were, therefore, justified in restricting any refund to the company to a five-year period.

We found that it would not be appropriate for us to comment on the interpretation of the Act by Business Stream as ultimately this would be a matter for the courts. We considered, however, that Business Stream had failed to demonstrate that their redress and compensation policy had been appropriately or proportionately applied to this case. Business Stream told us that they did not believe further payment was merited, but they did not provide any explanation for this decision. Nor did they explain why this consideration was only made after Mr C's complaint had been submitted to us, rather than as part of their complaint investigation. We considered that this was unreasonable and upheld Mr C's complaint.

Recommendations

We recommended that Business Stream:

• refund the cost of the original meter installation in 2003;
• provide evidence that they have reviewed the case, applying their redress and compensation policy to reflect the circumstances of the case, including both the original failings and subsequent overcharging in a manner which is proportionate to the loss suffered by the company; and
• provide evidence that they have reviewed their complaints process to ensure that due regard is given to the redress and compensation policy and that decisions relating to it are documented contemporaneously as part of the investigation.

Summary

In March 2013, Mr C requested that Business Stream, his licensed water provider, provide him with a resized meter to improve his water supply. Business Stream then contacted Scottish Water, who own and operate the water infrastructure, and they advised that Mr C would first require to provide a water impact assessment. This was completed in November 2013 and Scottish Water were contacted to progress the meter upgrade. To date the necessary work has not been undertaken. Mr C complained to us about the delay.

We found that there was much contact between Business Stream and Scottish Water but that there was evidence of long periods of delay when Scottish Water were inactive. However, quotes have now been provided to Mr C and both Business Stream and Scottish Water have acknowledged their poor service and each have agreed to make an ex gratia payment in recognition of this. We also found that after Mr C made formal complaints to Business Stream in February 2014 and October 2015, both complaints were closed despite the meter upsize not having taken place. We upheld Mr C's complaint.

Recommendations

We recommended that Business Stream:

• make a formal apology for closing the complaints made to them prematurely.

Summary

Ms C, a solicitor, complained on behalf of Miss A about the time it took for the Scottish Social Services Council (SSSC) to carry out a fitness to practise investigation after allegations were raised about Miss A's conduct. The investigation took 15 months. Ms C also complained that the SSSC did not keep Miss A informed of the progress of their investigation.

In responding to the complaint, the SSSC indicated to both Miss A and Ms C that there had been problems with obtaining statements from witnesses. The SSSC also acknowledged that Miss A had not always been kept informed of the progress of her case.

The SSSC told us that significant matters had affected their investigation of the case. These matters included the performance of individuals who had dealt with Miss A's case and the capacity of the department at the time.

While we identified that Miss A had delayed initially in responding to the SSSC's request for comments on the allegations, over a period of seven months little investigation work was carried out. We considered that a more structured approach to exploring the evidence, along with arranging interviews and statements, should have taken place sooner.

We found that the level of activity on the case appeared disproportionate to the 15 months it took to reach a decision. We were also critical of a lack of communication with Miss C about the progress of the investigation. We therefore upheld the complaint.

Recommendations

We recommended that SSSC:

• issue Miss A with a written apology for the failings identified;
• demonstrate to us that clear mechanisms are in place to ensure any protracted period of inactivity on a particular case is identified and addressed; and
• demonstrate to us that effective mechanisms are in place to ensure case workers routinely inform registrants about the progress of their case.

Summary

Miss C complained to us about the length of time it took for the Scottish Social Services Council (SSSC) to carry out an investigation following her informing them of an offence with which she had been charged. She also complained about the lack of information provided to her by the SSSC on the progress of their investigation.

After Miss C contacted the SSSC to query the delay, they apologised to her and said that their investigation could have been concluded around a month earlier had they pursued information needed from her employer and from the court service sooner. In the course of our investigation, the SSSC told us that matters such as increased case numbers and challenges with staffing had contributed to their handling of the case.

We considered that there was a substantial delay of four months during which there was very little action on the case. Although the SSSC have procedures in place for monitoring and supervising investigation work on a monthly basis, we did not see any evidence of a timely discussion of the case. We also found that over a period of five months, Miss C only received information about her case when she contacted the SSSC. The SSSC were unable to provide an explanation for this. SSSC procedures state that staff need to keep registrants informed of progress and also to plan communication when periods of inactivity are likely. We concluded that there was a failure to keep Miss C reasonably informed during the investigation process. We therefore upheld Miss C's complaints and made three recommendations.

Recommendations

We recommended that SSSC:

• demonstrate to us that clear mechanisms are in place to ensure that any protracted period of inactivity on a particular case (such as non-responses to information requests) is identified and addressed;
• demonstrate to us that effective mechanisms are in place to ensure that case workers routinely inform registrants about the progress of their case in accordance with the fitness to practise casework procedures; and
• issue a written apology to Miss C for the failings identified.

Summary

Mr C complained that the Scottish Prison Service (SPS) had unreasonably, and without proper explanation, removed an '08' number from the list of numbers he could call. The 08 number in question redirected to his home number and allowed him to make daily contact with his child at a discounted rate. He had had this number on his list for over a year, however this number was removed from his list without consultation or prior warning.

We found that the Scottish Prison Rules (Telephones) Direction 2011 stated that prisoners are prohibited from using a prisoner telephone to make a phone call, without the prior approval of the governor, to a phone number beginning with 08. The prison explained that numbers like this, which divert to numbers unknown, could present a threat to security and organised crime as well as potentially causing operational difficulties by allowing unlimited time on the prisoner phone. We were satisfied that this explanation was reasonable and that the prison was acting in accordance with the rules in removing the 08 number from Mr C's list of numbers. The prison acknowledged that the 08 number was added to Mr C's list of numbers in error and without the prior approval of the governor, as required by the rules, and that Mr C should have been properly informed when the 08 number was removed. We upheld Mr C's complaint. The prison have now taken action to try to prevent a similar situation occurring in the future by reminding staff of the correct process.

We also had concerns about the way in which Mr C's complaint was handled. Our view was that, had the complaint been properly investigated and a detailed response given to Mr C, this may have prevented escalation of the complaint. Also, an Internal Complaints Committee (ICC) response to Mr C had indicated that prison staff should meet with him to discuss alternative options for family contact; however, this had not taken place.

Recommendations

We recommended that SPS:

• apologise to Mr C for the failings identified by this investigation;
• comply with the ICC response and ensure that prison staff meet with Mr C to discuss alternative options for family contact; and
• undertake a root cause analysis of the way Mr C's complaint was handled to identify why errors were made and to learn from this.

Summary

Mr C and his then partner (Ms D) attended a multi-agency meeting at a school in the council's area regarding their foster son. Mr C was unhappy about the way he was spoken to at the meeting by one of the school's staff. Mr C complained to us that the council failed to reasonably investigate his complaint about the way in which he was spoken to at the meeting in line with their complaints procedure.

Mr C's concerns included that the council's investigating officer should have interviewed all four of the meeting attendees to ascertain the truth and that the council's complaints procedure available to him online was out of date. He also said that the council failed to signpost him to us and had to be pressed to confirm that their complaints procedure had been completed.

We considered that it was for the council's investigating officer to determine what evidence she needed in order to make a decision on Mr C's complaint. There was no requirement in the council's complaints procedure for her to have interviewed all persons present at the meeting. However, it would have been helpful if the council had explained to Mr C why they considered that the social worker at the meeting could be a corroborating witness for the member of the school's staff, but that Ms D could not be considered a corroborating witness for his version of events.

The council acknowledged that the complaints procedure available online at that time was out of date. The evidence showed that the investigating officer failed to inform Mr C that her response was the final stage of the council's complaints procedure and the response did not refer him to us. This resulted in several months of unnecessary communications between Mr C and the council on his complaint. We were also concerned that the council failed to make and retain notes of key events in the handling of Mr C's complaint. We upheld Mr C's complaint.

Recommendations

We recommended that the council:

• feed back our decision on Mr C's complaint to the staff involved;
• take steps to ensure that, in future, records of key events during the investigation of complaints are made and retained; and
• provide Mr C with a written apology for the failings identified.

Summary

Miss C complained about the council's communication with her over a series of suspensions to her housing benefit.

We found that the council had communicated clearly with Miss C about the reasons for the suspensions and that she had been told what further information was required.

Although during our investigation we found that Miss C expected the council to reply to her emails unreasonably quickly, we did find administrative failings on the council's part, including sending an important email to the wrong address, not finding an attachment to one of Miss C's emails, and advising Miss C that a notice had been sent when it had not. They also failed to reply to two separate emails sent by Miss C. We therefore upheld the complaint and made a recommendation to address this.

Recommendations

We recommended that the council:

• review the handling of this case to establish the cause of administrative errors, and identify what steps might be taken to avoid recurrence. The council should then share learning from the review with relevant staff members.