Upheld, recommendations

Summary

Mr C complained that the Scottish Prison Service (SPS) included inaccurate information in his risk management team (RMT) paperwork, and he was concerned that this might have a detrimental effect on the consideration of his parole. In dealing with Mr C's complaint, we explained that our role was to check where the SPS sourced the information that was included, and if that information was up-to-date. We looked at the SPS' file on Mr C's complaint, the prison records provided to us by the SPS, and the SPS' RMT guidance. The guidance said staff at an RMT meeting should thoroughly research all relevant information and take account of it.

We found that prison staff were aware before the RMT meeting that there was more recent information about Mr C which could be provided by his new probation officer. However, the RMT paperwork made no reference to this and, at least in part, referred to information from Mr C's previous probation officer. In responding to our enquiry, the SPS referred us to other SPS documents, which they said would have informed Mr C's RMT paperwork. However, Mr C was transferred to the SPS from outside Scotland, and they were aware there were problems with the records that arrived with Mr C. The SPS documents about Mr C's time outside Scotland must have been informed by records from that other jurisdiction; however, the SPS did not provide us with the original evidence which first told them of Mr C's history there. This meant the SPS were not able to demonstrate to us that the information included in Mr C's RMT paperwork was accurate and up-to-date. We upheld Mr C's complaint.

Recommendations

We recommended that SPS:

• ensure that they obtain all relevant information about Mr C's history outside Scotland, including the most up-to-date information from his new probation officer;
• ensure that the next RMT takes account of the most up-to-date information about Mr C's history; and
• ensure that any information provided to the relevant parole authority is up-to-date.

Summary

Ms C owned a property, behind which were three garages. Planning consent was granted for one of the garages to be converted into an office. Due to its close proximity to Ms C's property, a condition was included in the consent requiring the developer to replace the garage's window with glass blocks, to maintain Ms C's privacy. However, the developer installed a plain window which, whilst opaque, could be opened.

Ms C was disappointed to find that the council declined to take enforcement action to ensure that the required blocks were installed. She complained that the council failed to respond to her correspondence on the matter and failed to review their decision not to enforce the condition.

We found that the council had concluded that the original condition was worded in such a way that it was unenforceable. We accepted independent planning advice that this was not the case and that the council could have done more to ensure that Ms C's privacy was protected in line with the planning consent. We were also critical of their handling of her complaints and their failure to respond to relevant information she presented to them.

Recommendations

We recommended that the council:

• provide us with details of the action they have taken to improve their mechanisms for logging and responding to correspondence coming into the planning enforcement service;
• conduct a review of their handling of this case with specific regard to the adviser's comments and consider what action may still be open to them to ensure that the purpose of the condition of consent is achieved;
• apologise to Ms C for the poorly worded condition and the impact that this has had on her amenity (enjoyment of her property or surroundings); and
• share our decision with the relevant staff.

Summary

Mrs C complained that the step at the gated footpath access to her house was broken by a contractor who was working for the council. Mrs C said the damage occurred while the contractor was replacing street lighting on the public footway outside the house.

Mrs C lodged a claim for the damaged step with the council. The council referred the claim to the contractor as they said it appeared from the information Mrs C had supplied that responsibility for the damage lay with the contractor. The council explained they had a contract with the contractor which required the contractor to have in place their own insurance. The council also stated that an indemnity clause in the contract meant that the council were not liable for any damage caused by the contractor and were not required to investigate matters that had been passed to third parties to manage in terms of the contract. The contractor subsequently rejected Mrs C's claim.

Mrs C complained to the council. We considered, from the evidence supplied to us, that it was reasonable for the council to have referred Mrs C's claim to the contractor and that the investigation of the claim and its outcome were a matter for the contractor. However, we also considered this did not absolve the council from addressing the concerns Mrs C had raised in her complaint about the alleged failure of the contractor in communicating with her. We found that no proper consideration had been given to whether Mrs C was still pursuing a claim for damages or making a complaint and that a lack of communication and coordination within the council had led to an unreasonable delay in the investigation of Mrs C's complaint. For this reason we upheld the complaint.

Recommendations

We recommended that the council:

• apologise to Mrs C for the delay in dealing with her complaint; and
• review their processes in relation to complaints handling in cases where more than one council department is involved; and where claims have been made against their contractors.

Summary

Mrs C complained about how school staff handled a report of bullying of her daughter. While Mrs C was satisfied with the handling of the matter at the time, she became concerned some months later when the pupils involved in the bullying behaviour were given additional opportunities within the school. She raised this with the school, as she thought that the bullying incident had been recorded on the pupils' education record, but the school told her the bullying was only recorded on the school's bullying log. Mrs C was dissatisfied with this, and she was also concerned that the school referred to the incident as an 'allegation of bullying' in their later correspondence with her, whereas she thought it had been agreed that bullying had occurred.

The council said the school handled the incident appropriately and in line with their bullying policy (which encourages a restorative approach). We asked the council to clarify whether they had found that bullying had occurred as this was not clear from the bullying log, and they confirmed that the incident had been recorded as one of bullying behaviour.

After investigating the matter, we upheld Mrs C's complaint. We found that staff complied with most aspects of the school's and the council's policies, including involving parents, arranging a restorative meeting and supporting Mrs C's daughter. However, the bullying log completed by the school did not match the form set out in the council's policy, so there was no detailed contemporaneous record of the investigation and findings. We also found that staff did not appear to be familiar with the school's bullying policy which required the incident to be recorded on the pupils' records, and they were following the council's bullying policy instead (which did not include this requirement).

Recommendations

We recommended that the council:

• apologise to Mrs C and her daughter for failing to comply with some aspects of their policies in responding to their concerns about bullying; and
• review the school's bullying policy and reporting forms, to ensure that there is clear and consistent guidance on this process (and that this complies with the council's bullying policy and templates).

Summary

Ms C's mother was admitted to a care home and the council provided Ms C's family with a breakdown of the charges for the care home and invoiced the family accordingly. Following an admission to hospital, Ms C's mother returned to the care home, however, Ms C's family received no further invoices for the care home fees until the council wrote to them in the following year explaining that, following a recent review, it had been identified that, due to an administrative error, no invoices had been raised for the care home fees. Due to the amount of fees outstanding, a charging order was placed on Ms C's mother's property. Ms C complained to us that the council had acted unreasonably by failing to ensure that invoices for the care home fees were issued at the correct time.

Our investigation found that the council had made an administrative error in failing to invoice Ms C's family for the care home fees at the correct time – Ms C's mother's file was misfiled which led to her being omitted from the manual list of clients requiring yearly financial reassessment. Therefore, we upheld Ms C's complaint. The council have recently introduced a system-generated automatic financial reassessment process which should prevent a similar situation occurring again in future.

We also had some concerns about the way in which the council had handled Ms C's complaint. The council had referred Ms C's complaint to a charging review panel on more than one occasion. This led to delays in responding to Ms C's complaint. Ms C's correspondence was not fully answered and the council's final response to Ms C's complaint failed to inform her of her right to submit her complaint to our office as the final stage in the complaints procedure. In light of this, we made recommendations to the council.

Recommendations

We recommended that the council:

• review their handling of complaints which are referred to a charging review panel to ensure that they are handled in line with the model complaints handling procedure for local authorities and legislative requirements; and
• provide Ms C with a full response to the four points she sought clarification on in her original complaint letter.

Summary

Mr C's garden bordered a field. The council granted planning permission for a residential development on the field. To achieve the desired ground levels for the new site, it was necessary for the developer to dig down some three metres. This resulted in a steep banking being created, running the length of Mr C's western boundary, partly in the garden of one of the new properties and the remainder within an amenity space (an area designed to enhance enjoyment of the surroundings) at the development. Mr C found that his garden ground was being eroded with earth slipping down the banking into the new development. He complained to the council about the lack of retaining wall but was advised that this was not something that would normally be considered under the remit of a planning application. They maintained that this would normally be included by the applicant as part of their proposal, rather than at the insistence of the council. The council also advised Mr C that it was not a building control matter and that he should seek legal advice if he felt the actions of others had had a negative impact on his property.

After taking independent advice from a planning adviser, we upheld Mr C's complaint. We found that the council had consistently maintained that no specific consideration was given to stability as this was considered to fall outwith the remit of the planning service. The adviser did not agree with this approach and considered that, given the significant change in ground level from Mr C's property to the new development, this should have been a material consideration in the council's planning report. We also found that there had been issues with a condition that was attached to the new development's planning permission and that this had caused confusion for local residents such as Mr C.

Recommendations

We recommended that the council:

• issue Mr C with an apology for the errors surrounding the condition in question within the planning application;
• provide evidence of the new processes that are in place to prevent a recurrence of such an issue with planning conditions in future;
• issue Mr C with an apology for the failure to take all material considerations into account when determining the planning application; and
• consider how they can assist Mr C to stabilise his entire western boundary at no cost to himself, or otherwise facilitate this outcome. If following consideration, this is not possible, appropriate financial redress should be offered to Mr C.

Summary

Mrs C complained to us that the medical practice had failed to provide appropriate care and treatment to her late husband (Mr C) who died following an overdose. Mrs C said that her family had reported their concerns about Mr C's behaviour and that he should have been referred to the mental health services but the practice did not listen to their concerns.

The practice maintained that, on examination, there was no indication that Mr C suffered from mental health issues or that there was the possibility of a suicide risk.

We took independent advice from a GP. We concluded that as Mr C was showing signs of paranoid ideation (having beliefs that you are being harassed or persecuted, or beliefs involving general suspiciousness about others' motives or intent), verbal aggression, and transient confusion this would warrant a mental health assessment in the first instance with the possibility of referral for a specialist opinion. We also found that the practice should have taken action in view of the concerns voiced by the family. Although there was no evidence that the inactions of the practice directly led to Mr C taking an overdose, we upheld the complaint in light of the failings identified.

Recommendations

We recommended that the practice:

• apologise to Mrs C for the failings identified in this report;
• make contact with the Health Board Clinical Support Group for guidance on training regarding patients with mental health problems; and
• ensure that the GP discusses this case as part of their annual appraisal.

Summary

Mr A was admitted to Forth Valley Royal Hospital after taking an overdose of drugs. His sister (Ms C) said that it was considered that he had suffered an organically induced psychotic state and a few days later, after his blood pressure and temperature returned to normal, he was discharged. Ms C, however, remained concerned about Mr A's state of mind and wrote to his psychiatrist but her contact was rebuffed. Mr A took his life five months after the overdose. Ms C complained that the board had failed to contribute positively to Mr A's care and perhaps change his outcome. She also complained about the psychiatrist's attitude to the family and that he had focussed incorrectly on Mr A's physical, rather than his mental health.

We took independent advice from a consultant psychiatrist and we found that, initially, it had been reasonable to conclude that Mr A's behaviour was due to a transient illness caused by an organically induced psychotic state, and to treat him for this. However, Mr A's psychiatrist later declined important information from Ms C which should have been included in decision-making and clinical management (although it could not be concluded that this would have changed the outcome for Mr A). Subsequently, when Ms C complained, it took too long to provide her with an explanation. We upheld the complaint.

Recommendations

We recommended that the board:

• provide confirmation that the psychiatrist has completed a specialist training programme in communication style and technique;
• bring the General Medical Council document on confidentiality to the psychiatrist's attention and consider whether training on information governance is required; and
• remind all staff involved of their obligations in terms of their own complaints handling procedures. Furthermore, ensure that any changes anticipated to the complaints procedure are first discussed with the complainant and receive their prior permission.

Summary

Mr C complained that the board failed to provide him with the necessary preparation in advance of a procedure to examine his bowel (colonoscopy). The board acknowledged that Mr C was not given the necessary preparation, which he should have received three days in advance of the procedure, and they apologised to him. We took independent medical advice from a GP. They noted that the hospital had sent clear instructions to the prison health centre regarding the preparation for the procedure and the adviser therefore considered it unreasonable that this was not carried out.

The hospital subsequently recorded that Mr C had refused to attend his appointment and he complained about this as he did not consider that the fault for this lay with him. The board apologised to Mr C for inaccurately recording that he had refused to attend. The GP adviser considered that this incorrect recording was unreasonable as it could have resulted in Mr C not receiving a follow-up appointment when the investigation was important to rule out a potential underlying cancer diagnosis.

As it happened, the prison doctor re-referred Mr C for a colonoscopy but this was vetted by the hospital and the procedure was changed to an examination of only the lower part of his bowel (flexible sigmoidoscopy). Mr C complained that this change of procedure was not explained to him. We were advised that it would have been reasonable for the sigmoidoscopy procedure to be explained to Mr C on the day of the procedure and the records indicated that this happened. However, we could not see any evidence of the reasons for the change in procedure being explained to him.

Mr C also complained about the time the board took to respond to his complaint and for their failure to answer his questions. The board acknowledged that there were inconsistencies in their responses and that they had not answered all of Mr C's specific questions. They also acknowledged that they had taken too long to respond to Mr C's final letter. It had taken them six months to respond to this and we concluded that this was an unreasonable timescale.

We upheld all the complaints.

Recommendations

We recommended that the board:

• reflect on the process failings that have occurred in this case and inform us of the steps they have taken to ensure that similar future failings do not occur;
• remind staff to ensure that relevant information is shared with a patient when a procedure is changed and that this is documented;
• remind complaints handling staff of the importance of responding to complaints in a full, accurate and timely manner; and
• apologise to Mr C for the failings this investigation identified in their handling of his complaint.

Summary

Mrs C complained about the care her relative (Mrs A) received at Forth Valley Royal Hospital. Mrs A was admitted with severe abdominal pain but on her first night in hospital, she suffered a fall. An x-ray was taken but clinicians caring for Mrs A did not identify any fracture after reviewing the image. The x-ray was subsequently reviewed by a radiologist (a doctor specialising in medical imaging) who reported that there was a suspicion of fracture to the pelvis. This report was not acted on for over a week, during which time staff continued to try to mobilise Mrs A. A subsequent scan showed that Mrs A had sustained multiple fractures.

When Mrs C complained to the board, the first response she received included a number of factual inaccuracies including that Mrs A had been admitted to hospital following a fall at home. A later response apologised for these errors. Mrs C remained dissatisfied and asked that we consider her complaints that there was an unreasonable delay in identifying Mrs A's fracture and that she had been unreasonably mobilised.

After taking independent advice from a consultant geriatrician, we upheld Mrs C's complaints about the medical care Mrs A received. The adviser considered it unreasonable that the x-ray report indicating that there was a suspicion of fracture had not been acted on and said it appeared staff caring for Mrs A had wrongly assumed the initial opinion that there was no fracture was correct. We found no evidence that Mrs A had been inappropriately mobilised after her fractures were identified but, in light of the fact that attempts were made to do so prior to this, we upheld Mrs C's complaint on this issue. We also upheld Mrs C's concerns about complaints handling as it is vital that complaint responses are factually accurate. While the board have already apologised for this matter, we found that they had not referred to the delay in acting on the

x-ray report in their response, which we did not consider to be reasonable.

Recommendations

We recommended that the board:

• ensure that our findings are brought to the attention of the staff involved in Mrs A's care and treatment. This should include the adviser's comments on communication and the falls risk assessment;
• provide evidence that they have considered how to prevent the problem in relation to the result of the x-ray not being taken into account from recurring in the future; and
• provide a further apology to Mrs C for the complaints handling issue identified in this investigation.