Upheld, recommendations

Summary

Mr C's company paid for water and trade effluent through Business Stream. He found that the company's trade effluent bills, which are based partly on the metered water usage, were unexpectedly high for one quarter in 2013. He queried the high bill with Business Stream and an investigation was carried out. This found that the company's water meter was faulty. However, a meter accuracy test found that the meter was under-reading rather than over-reading. With this in mind, Business Stream advised that the charges should stand. Mr C disputed this, as the meter was faulty and, therefore, unreliable. He contended that, if the meter was under-reading, the company's bills should have been lower than normal.

We found that the meter had actually stopped altogether and there was no evidence to support the claim that it was under-reading prior to the meter accuracy test. That said, we acknowledged that faulty meters normally under-read and there was evidence of the company increasing production over the period in question. Ultimately we were concerned by the lack of transparency and independence in the meter accuracy test and the fact that the wrong size of meter appeared to have been installed, increasing the likelihood of failures. We considered it fair for Business Stream to share the burden of the increased charges with the company.

We made three recommendations for redress and improvement.

Recommendations

We recommended that Business Stream:

• recalculate the trade effluent charges over a specified period based on the average daily usage for the previous billing period and credit the company's account with 50 percent of the overcharge;
• consider reviewing their procedures with a view to ensuring customers are able to obtain a truly independent meter accuracy test in disputed cases; and
• consider checking whether the new meter servicing the premises is of the appropriate size.

Summary

Mr C sat an exam that was provided by an awarding body regulated by SQA Accreditation (part of the Scottish Qualifications Authority that regulates awarding bodies and accredits their qualifications). There was a problem with the exam and because of this all the marks, including Mr C's, were voided. Mr C complained to SQA Accreditation about how the awarding body dealt with his complaint. As Mr C was not happy with SQA Accreditation's response, he complained to us.

We found that it was appropriate for SQA Accreditation to have considered the awarding body's handling of the matter by referring to the most recent SQA Accreditation Regulatory Principles. However, we found that SQA Accreditation's complaints procedure did not comply with the model complaints handling procedure (CHP) that organisations under our jurisdiction must follow. We also found that SQA Accreditation did not respond to each agreed point of Mr C's complaint separately. It would have been good practice to explain to Mr C what SQA Accreditation could or could not look at, answer each of the specific points of complaint that were agreed with him, and set out the key evidence on which their conclusions were based. In addition, there were insufficient records of phone calls made during SQA Accreditation's handling of Mr C's complaint, and they did not advise Mr C clearly about how to take his complaint further. We upheld Mr C's complaint.

Recommendations

We recommended that SQA:

• provide us with a response to the outstanding points of Mr C's complaint;
• share the findings of our investigation with staff, to learn from the failings identified in the handling of Mr C's complaint; and
• ensure that SQA Accreditation's complaints procedure is compliant with the model CHP.

Summary

An escorting agency that provides custody escorting services on behalf of the Scottish Prison Service (SPS) transferred Mr C to a hearing. Mr C complained that he was not escorted appropriately. In particular, Mr C said the escorting crew parked the vehicle some distance away from the location and because of that, he had to walk handcuffed in view of the public. Mr C also said his complaint about the matter was not responded to appropriately.

In response to Mr C's complaint, the escorting agency said that they were satisfied the crew carried out their duties to an acceptable level when escorting Mr C. They said there was no need for further action. However, we obtained a copy of the relevant procedure which outlined the instructions that the crew should have followed when they arrived at the location of the hearing. In particular, the instructions said the crew should have reported to the on-site manager for further instruction. That did not happen in Mr C's case. In response to our enquiries, the escorting agency said that in some situations it was not always possible to keep prisoners out of sight of the public. However, they said that in Mr C's case, this could have been avoided.

In light of the evidence available, we upheld both of Mr C's complaints.

Recommendations

We recommended that the SPS:

• apologise to Mr C and accept responsibility for the failings identified by our investigation; and
• make arrangements for relevant complaints handling staff to undertake appropriate complaints handling training.

Summary

Mr C complained that the Scottish Prison Service (SPS) unreasonably refused his request to transfer cash from his prison account to his bank account. He said the SPS also refused to allow him to hand cash over to a visitor.

In their response to his complaint, the prison told Mr C that prisoners were not allowed to transfer cash from their prison accounts to their bank accounts. They also told him that handing money out at visits was prevented for security reasons. We reviewed the SPS finance manual which stated that cash could be handed out at a visit, or sent out. It said that when cash was being handed out at a visit, a receipt needed to be obtained from the recipient. We asked the SPS why they told Mr C this process was not allowed. They recognised that the response provided to Mr C was unclear. The response had not explained that a prisoner could only hand cash out at a visit when they had made a formal request. The SPS said that although Mr C said he had made a request to hand money out at a visit, there was no evidence of him having done that.

We accepted that the SPS had discretion when it came to deciding whether to allow prisoners to transfer funds to their bank accounts. However, in relation to handing money out at visits, we found that the prison had a local policy in place which supported the requirements of the national finance manual. We considered this to be reasonable. However, in Mr C's case, we considered that the prison unreasonably failed to explain to him that he had not followed the process properly. Additionally, they gave a misleading response which created the impression that requests to hand money out at visits were not allowed for security reasons. In light of this, we agreed that the SPS unreasonably refused Mr C's request.

Mr C also complained that the prison failed to handle his complaint appropriately. We agreed because the information he received was inconsistent. In light of our findings, we upheld Mr C's complaints.

Recommendations

We recommended that the SPS:

• apologise to Mr C for the failings identified by our investigation; and
• ensure staff and prisoners are aware of the local arrangements to be followed when a prisoner wants to send money out of the prison, as outlined in the SPS finance manual.

Summary

Mr C complained that the council had not handled his correspondence and complaints reasonably. He was unhappy that correspondence he had sent had not been answered, that he had not been able to speak with the complaints handler when he called and that there were inaccuracies in the final response to his complaint.

Following careful consideration of the documentation, the council appeared to have only received one letter. There was no acknowledgement or response sent to Mr C. Mr C then contacted the council on a number of occasions to express his dissatisfaction at not receiving a response. The council did not identify these contacts as a complaint. It was only when Mr C approached us that the council logged a complaint - and used a phone note dated two months earlier as the complaint from Mr C, which led to inaccuracies when referring to timescales in the council's final response. We therefore upheld Mr C's complaint that his complaint had not been handled reasonably by the council. We recommended that they apologise to Mr C for the failings identified by our investigation and remind housing staff of the definition of a complaint and the importance of identifying, logging and responding to complaints and keeping complainants updated as set out in the council's complaints procedure.

Recommendations

We recommended that the council:

• remind housing department staff (including call handlers) of the definition of a complaint and the importance of identifying, logging and responding to complaints and keeping complainants updated as set out within their complaints procedure.

Summary

Mrs C complained about the council's handling of her social work complaint. We found that the council did not follow their own procedures correctly. The council did not tell Mrs C that she could refer her complaint to an independent panel called a complaints review committee (CRC). Mrs C asked for a CRC anyway and the council convened a CRC with an independent chair and two elected councillors, according to the rules.

Mrs C told us there were two specific documents related to the complaint that she wanted CRC members to see. She had asked for them to be included on the agenda but they were not. We found there was evidence of an internal discussion about sharing these two documents, which contained third party information. It was unclear what the outcome of that discussion was. We found no evidence that the council had asked permission from the third parties involved, or that they had told Mrs C the two documents could not be shared, as should have happened. Although we found the council's communication was poor regarding the two documents, we were satisfied that the CRC was able to reach a decision on each of Mrs C's complaints without seeing the documents.

The CRC recommended that the council apologise to Mrs C. This did not happen for many months, until we contacted the council. The council told us that the person responsible no longer worked there and that the outstanding recommendation was not picked up by anybody else. They also issued an apology to Mrs C.

Recommendations

We recommended that the council:

• offer an apology for the communication failures we identified in relation to the handling of Mrs C's complaint; and
• review internal procedures to ensure, in relation to CRCs, that proper records are kept, that communication with complainants is robust, and that there is a system in place for monitoring any outstanding recommendations.

Summary

Mr C complained about the care his mother (Mrs A) received from the Scottish Ambulance Service (the ambulance service). Mrs A had a history of vertigo and migraine but she had been recently advised that she had symptoms of having suffered a transient ischaemic attack (TIA, often referred to as a mini-stroke, where blood supply to the brain is interrupted). Mrs A's GP had advised her to stop taking her migraine medication.

When Mrs A collapsed, her husband (Mr A) called for an ambulance. The crew arrived, assessed Mrs A's condition and decided against hospital admission. The crew believed Mrs A had suffered a migraine and advised her to take her medication, despite being informed her GP had told her to stop taking it. Six days after this Mrs A suffered a stroke. She died two days later.

Mr C complained about the ambulance service's decision not to transport Mrs A to hospital. We took independent advice from a medical adviser who is a GP. They said that there was enough evidence to give suspicion that Mrs A had suffered a further TIA and conclude that she required hospital assessment. The adviser also commented on the crew's advice to Mrs A to take her migraine medication. The adviser said this was unreasonable and outside the scope of their expertise. The adviser said that non-prescribers should not advise patients to take medication without medical advice, particularly medication recently stopped by the patient's own GP. We upheld the complaint and made recommendations.

We also identified problems with the way Mr C's complaint was handled. We were not given evidence that the recommendations made by the ambulance service during their own investigation had been carried out. We also noted that when Mr C raised new questions with the contact listed on the ambulance service's final response letter, that person declined to correspond on the complaint further. We did not believe this to be reasonable.

Recommendations

We recommended that the ambulance service:

• apologise to Mr C and his family for the failings identified in this letter;
• provide us with the outcome of their own recommendations;
• review the role of named contacts at the end of complaints letters; and
• remind non-prescribers of their role in advising patients on medication.

Summary

Mr C complained about the care and treatment of his wife (Mrs C). Mr C was particularly concerned that the clinical notes showed Mrs C had symptoms of a stroke late on the evening of her admission to the Balfour Hospital (and doctors were told about this), but her stroke was not diagnosed until the doctor reviewed her early the next morning. Mr C was concerned that the delay meant that Mrs C was not able to receive thrombolysis treatment (a kind of treatment that can only be used within 4.5 hours after the onset of a stroke), and this may have impacted on her subsequent condition.

The board explained that thrombolysis treatment was not suitable for Mrs C, because it was not clear at the time that Mrs C's condition was due to an acute stroke and in any case the 4.5 hour window for treatment had already passed by the time of admission. The board also explained that doctors are cautious in offering thrombolysis to patients with diabetes (which Mrs C had) because there is a higher risk of complications, and because low blood sugars can sometimes 'mimic' the effect of a stroke.

After taking independent medical advice, we upheld Mr C's complaints. We agreed that thrombolysis would not have been suitable for Mrs C, because there was no clear time of onset for her stroke and by the time her symptoms were clear it was over 4.5 hours from when she was last known to be well. However, we found that staff should have considered the possibility of a stroke when Mrs C was admitted, and this should have been diagnosed that evening when the symptoms became clearer. This would have enabled staff to explain the decision about thrombolysis to Mr and Mrs C at the time, and put in place appropriate monitoring and assessment of her deterioration overnight, as well as better managing her diabetes the next day.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the delay in diagnosing Mrs C's stroke; and
• ensure that staff involved reflect on Mrs C's care and discuss our findings, with reference to the specific points raised by the adviser.

Summary

Mrs C, an advocacy worker, submitted a complaint on behalf of Ms A regarding the care and treatment received by her late brother (Mr A). Mr A had a history of mental and physical health problems and was an in-patient in the Royal Edinburgh Hospital for more than 15 years. He was discharged into supported accommodation. Daily support was provided by a voluntary sector organisation and his psychiatric care was overseen by the board's community rehabilitation team (CRT). Mr A's physical health deteriorated following discharge and he was diagnosed with renal cancer around five months later. Mr A died the following month. Ms A complained about the time taken to diagnose her brother's cancer and about a failure to involve her in his care and listen to her concerns about his deteriorating condition.

We obtained independent advice from a mental health professional. They noted that the primary responsibility for monitoring Mr A's health following his discharge lay with his GP practice. However, they noted that the CRT had a role in liaising with the GP practice and monitoring Mr A's engagement with them. The adviser considered that the discharge plan lacked clarity surrounding these roles and responsibilities and lacked focus on Mr A's physical health, despite his history of physical health problems and known difficulties engaging with healthcare providers. The plan did not set out a schedule for visits from Mr A's key worker and the adviser observed that there were long gaps between visits, despite Mr A's carers contacting the CRT to raise concerns about his wellbeing.

The adviser also considered that the discharge plan should have set out strategies for involving Ms A in her brother's care and observed that the key worker did not contact Ms A directly until five months after discharge. In light of the advice received, we concluded that the CRT could have been more proactive in overseeing Mr A's care following discharge and in engaging with his family. Arrangements for doing so should have been set out in the discharge plan and we considered that closer monitoring of Mr A's physical health and evident deterioration might have resulted in medical assessments being requested earlier. We therefore upheld the complaints. We could not say that closer monitoring would have led to an earlier diagnosis or altered the outcome for Mr A but we noted that it could have allayed some of the family's distress. We obtained additional independent advice from a GP who noted that, when Mr A was referred for investigation of his deteriorating condition, he was thoroughly assessed and managed appropriately.

Recommendations

We recommended that the board:

• ask relevant staff to reflect on the failings highlighted in this investigation and advise us of identified actions to improve future discharge planning, with a specific focus on monitoring physical health and engaging with family/carers; and
• apologise to Ms A and her family for the identified failure to monitor Mr A more closely following his discharge from hospital.

Summary

Mr C and his father (Mr A) complained about the care and treatment provided to Mr A in relation to an operation to fit a pacemaker. They were unhappy about treatment Mr A received at the Royal Infirmary of Edinburgh when the pacemaker was fitted and said that there was inadequate information about possible complications of the surgery and incorrect treatment during the surgery. They also complained about the response and aftercare following surgery when Mr A reported his levels of pain and concerns. They said that as a result of the failures, Mr A's quality of life had been adversely affected and that he had to undergo another operation to repair the incorrectly positioned pacemaker.

We took independent advice from a medical adviser. We found that there was no evidence that sufficient information was given to Mr A about the procedure and possible complications or that staff took account of his additional needs (given his anxiety and loss of hearing). We also found that while there were problems with the pacemaker that had to be rectified, this does not mean that it was incorrectly implanted in the first place. Having said that, we were critical that staff failed to address Mr A's anxiety or ensure he was adequately sedated which may have contributed to an increased likelihood of lung puncture during the procedure. Moreover, while we found that clinical staff dealt with Mr A's concerns technically following the operation, staff failed to address his anxiety which may have exacerbated his symptoms. We therefore upheld the complaint and made a number of recommendations.

Recommendations

We recommended that the board:

• review their procedures around consent and ensure that the process accommodates patients with additional needs;
• bring the failures related to consent and additional needs to the attention of relevant staff;
• bring the failures related to managing anxiety during the surgical procedure to the attention of relevant staff;
• ensure relevant staff consider referral to rehabilitation in similar circumstances; and
• apologise to Mr A for the failures this investigation identified.