Upheld, recommendations

Summary

Mr C complained about the care and treatment that his late wife (Mrs A) had received at University Hospital Crosshouse across a number of admissions. Mr C was concerned that staff were overly focussed on Mrs A's existing conditions and did not pay enough attention to new symptoms that were unconnected to these. Mrs A passed away after she became very unwell with a bleeding duodenal ulcer (an ulcer in part of the bowel, just after the stomach) following a number of admissions to the hospital across four months.

After taking independent advice on this case from a consultant geriatrician, we upheld Mr C's complaint. We found that while many aspects of Mrs A's care had been good, there was a failure to carry out appropriate investigations to determine the cause of her anaemia after this was revealed by blood tests during one of her admissions. We received advice that this meant a potential opportunity to diagnose the ulcer earlier was missed and that this could have led to specific treatment to reduce the risk of this bleeding. We made a number of recommendations to address the issues we identified.

Recommendations

We recommended that the board:

• issue Mr C with a written apology for the failure to take further action to establish the cause of Mrs A's anaemia following a specific admission;
• ensure that this case is included for discussion at the appraisals of the relevant clinicians; and
• discuss this case at an appropriate clinical governance forum.

Summary

Ms C complained about the treatment her father (Mr A) received from the practice over a five month period in 2013. Mr A had been diagnosed with bladder cancer in 2012 and attended the practice on a number of occasions complaining of back pain. Ms C did not feel that his condition was taken seriously or that adequate treatment was provided by the practice.

We sought independent medical advice on this case. Whilst we generally found that the practice provided good treatment in line with national guidance during the period in question, we found that the GPs could have been more proactive in arranging specialist investigations when Mr A's pain failed to reduce. Our investigation also highlighted significant concerns about the management of Mr A's pain some months later on the day he died. We were critical of the practice for failing to react to the urgency of the situation when family members contacted them, and for failing to have important palliative care drugs available to alleviate Mr A's pain.

Recommendations

We recommended that the practice:

• apologise to Ms C's family for the failings identified;
• discuss the adviser's concerns with the relevant staff members at their annual appraisals; and
• take steps to ensure that they have an adequate supply of ‘just in case’ drugs available to their palliative care patients.

Summary

Mr C complained that the board failed to take reasonable steps to diagnose and treat his elbow pain after he raised concern at Ayrshire Central Hospital in August 2013. He was unhappy with the time taken to carry out nerve conduction tests at the end of December 2013, which indicated that he had cubital tunnel syndrome (nerve compression). He was not given the results until six weeks later and was then referred for specialist surgical review. Mr C felt that, had his diagnosis been reached sooner and surgery carried out promptly, additional nerve damage would not have occurred.

We took independent advice from two advisers: a physiotherapist and an orthopaedic consultant (a specialist in conditions involving the musculoskeletal system). We noted that the board apologised to Mr C for a delay in Mr C receiving his results and they took reasonable action to carry out a review and make improvements in this respect. However, we identified that when Mr C first presented with his elbow pain, the physiotherapist did not take into account the possibility of nerve compression. In addition, whilst a different physiotherapist noted motor deficit two weeks later, they did not arrange immediate referral to a specialist in accordance with the board's musculoskeletal guidance. Instead, they raised concern in an email to an orthopaedic doctor but did not mention all the relevant symptoms. We also found records indicating that there had been earlier discussion about referring Mr C for nerve conduction tests at the beginning of September 2013 but this was not organised until four weeks later. Whilst we concluded that staff acted unreasonably in not referring Mr C for specialist review from the outset and arranging the tests sooner, there was insufficient evidence to demonstrate that he sustained additional nerve damage.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified;
• share the findings with the physiotherapy and orthopaedic staff involved in Mr C's care; and
• consider reviewing their musculoskeletal guidance to ensure that appropriate information is provided on cubital tunnel syndrome as a specific condition.

Summary

Miss C complained about the university regarding charges for repairs required to her previous accommodation. She disputed that she was responsible for the damage in question and was unhappy that she had not been provided with evidence to support the charges.

On investigation, we found that the university had failed to photograph the damage, in line with their procedures. We also considered that the level of detail recorded about the damage was insufficient to justify recharging the repairs. As such, we upheld the complaint.

Recommendations

We recommended that the university:

• apologise to Miss C for the failings identified;
• refund the charges for the repairs in question to Miss C and her flatmates; and
• review their inspection procedures and paperwork to ensure that adequate evidence is gathered to support rechargeable repairs.

Summary

Mrs C complained to us about Business Stream's handling of a leak at her property on the private supply pipe. She complained that while a leak was identified by Scottish Water contractors in August 2014 there was then an unreasonable delay by Scottish Water in taking action, leading to a large water bill from Business Stream.

We found that Business Stream had acted in line with their metering policy in carrying out two meter readings, one in April 2014 and one in October 2014. When the October reading suggested a significant increase in consumption, Business Stream alerted Mrs C. We therefore found that there was no evidence that there was any fault on the part of Business Stream in this regard. We also recognised that Mrs C had been charged only for normal consumption during the period of the complaint, and a leak allowance granted for the period of time from the April 2014 reading until the point at which the leak was identified in August. However, Business Stream explained that Scottish Water accepted there was a lack of communication and inaction on their part during the period of the complaint following the August site visit. As ultimately Business Stream are responsible for the service provided to Mrs C, in light of the communication failings and the delay in taking action after the leak was identified, we upheld Mrs C's complaint.

Recommendations

We recommended that Business Stream:

• offer a formal written apology for the failings identified.

Summary

In September 2014, after reading his water meter, Business Stream told Mr C that he had used a high level of consumption and that he may have a leak. He was issued with a bill in excess of £4,000. Mr C phoned Business Stream about this and it was suggested that he test whether there was a leak in his supply pipe. A leak was subsequently confirmed and Mr C was advised to contact a plumber as soon as possible because water was continuing to leak.

Mr C then raised concerns that there may be others attached to the supply pipe but in November 2014, it was confirmed that his was the only connection. He also complained that the leak had not been fixed as his costs were increasing and Business Stream liaised with Scottish Water to confirm ownership of the supply pipe. Scottish Water confirmed Mr C's ownership and thus the fact that any repair was his responsibility.

In February 2015, Business Stream explained that in terms of the Water (Scotland) Act 1980, the owner of the supply pipe was responsible for its maintenance (that is, Mr C). He was urged to complete repairs as soon as possible as his bill continued to mount. Mr C complained that Business Stream had not made this situation clear to him when he first complained in September 2014.

We investigated the complaint and made enquiries of Business Stream. We found that although he was billed in September 2014 and told that repairs to the pipe were for him to carry out, it was not until February 2015 that Mr C was sent a detailed explanation for the reasons why he was responsible for the leak. We upheld his complaint.

Recommendations

We recommended that Business Stream:

• provide Mr C with an appropriate apology; and
• ensure that explanations about the public's liability for payment are clearly explained to them.

Summary

Mr C complained that the adjudicator unreasonably failed to follow the correct process at his disciplinary hearing. In particular, he said that the adjudicator did not give him the chance to cross-examine the witness.

In their response to his complaint, the Scottish Prison Service told Mr C that the adjudicator had concerns about intimidation and that was why he was not allowed to cross-examine the witness. The prison rules say that prisoners must be given the opportunity to call witnesses and to cross-examine them. In addition, the relevant guidance says that a prisoner must be allowed to ask questions of witnesses but if they abuse that right, the adjudicator should require the questions to be put through them. That did not happen in Mr C's case.

We upheld Mr C's complaint because we concluded that he should have been given the opportunity to question the witness by putting his questions through the adjudicator.

Recommendations

We recommended that Scottish Prison Service:

• apologise to Mr C for the failings identified by our investigation; and
• feed back the findings of our investigation to the adjudicator.

Summary

Mr C complained that the risk management team failed to appropriately demonstrate that they had taken a defensible decision in relation to his progression to less secure conditions. We found that the prison did not initially provide enough written detail to show how they had reached their decision on Mr C's progression. While the issue of Mr C's progression was entirely a matter for the prison to determine, we upheld Mr C's complaint about the level of written detail they provided to explain their decision.

Recommendations

We recommended that Scottish Prison Service:

• take steps to ensure that written decisions taken by the risk management team contain a sufficient level of detail so as to demonstrate that a defensible decision has been reached when considering a prisoner's progression to less secure conditions.

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.