Upheld, recommendations

Summary

Ms C complained to the council about the waste provision for her building, as there were ten communal wheelie bins which were often not collected as scheduled. The council upheld her complaint and agreed to conduct a review. They also agreed to replace the wheelie bins with larger communal bins where possible, as there was some confusion about which team should collect the bins.

When the bins had still not been replaced one month later, Ms C emailed the council for an update but did not receive a response. She emailed two further times and again did not get a response, so she brought her complaint to us.

We contacted the council, who said that there had been delays due to competing priorities but agreed to carry out the review. However, Ms C was keen to ensure that the communication issues she had experienced were also addressed. The council accepted that they had failed to respond to her emails, so we upheld this complaint.

Recommendations

We recommended that the council:

• apologise for the failings identified; and
• contact Ms C to discuss her building's waste provision.

Summary

Mr C complained that the council had failed to assess a planning application for a house next to his property. We took independent advice on Mr C's complaint from one of our planning advisers. We found that the council had not assessed the site levels of the new house adequately, and had not correctly anticipated the size a screen fence would have to be to mitigate Mr C's concerns about the loss of privacy for his own property. Therefore, we upheld this aspect of Mr C's complaint.

Mr C also complained that the council did not impose a reasonable planning condition to mitigate the issue of overlooking. He was unhappy that his neighbour had not put up a screen fence and that the council had not taken action to enforce this. We found that the planning condition the council had relied on was not precise enough, and that there was considerable doubt as to whether the council would be able to successfully enforce the planning condition. In view of this, we also upheld this aspect of Mr C's complaint.

Finally, Mr C complained that the council had failed to respond to his complaint within a reasonable timescale. We upheld this aspect of Mr C's complaint as there had been a considerable delay by the council in responding to the complaint and they had not acted in line with their complaints procedure.

Recommendations

We recommended that the council:

• consider recording the details of site visits in their files;
• consider facilitating the provision of an effective screen fence at their cost between the properties, if this is acceptable to Mr C;
• take steps to ensure that their use of planning conditions is in line with the Scottish Government's guidance on the use of conditions in planning permissions;
• issue a reminder to staff in their planning service that complaints must be dealt with in line with their complaints handling procedure; and
• issue a written apology to Mr C.

Summary

Mr C told us he received an enforcement notice from the council's debt recovery agent, which said he owed money for unpaid non-domestic rates. Mr C had never had a business or paid non-domestic rates in the council's area. He asked the council to confirm that he did not owe the money, and that his credit rating would not be adversely affected. He asked the council to explain how the error had occurred. Mr C sent a further email after two weeks and, when he did not receive any reply, made a complaint. Even taking into account that the council said they did not receive Mr C's first email, we found it had taken them too long to reply to him and to confirm that he was not the person who owed them money. They exceeded their target timescale for replying to correspondence. There was no evidence that they prioritised Mr C's correspondence considering the error he was alleging or the fact he had made a complaint.

The council's explanations about why the enforcement notice was sent were confused and inaccurate. Due to Mr C's efforts in pursuing the matter, the council later accepted that he should have been sent a much softer letter in order to establish whether he was the person they were trying to find.

We found that the council had not provided a reasonable response to Mr C's complaint. His complaint was acknowledged and responded to within the target timescales at each stage and, rightly, the responses contained an acknowledgement of and apology for the delay. However, at each stage they failed to address the substantive point about the letter sent to Mr C in error.

Recommendations

We recommended that the council:

• apologise to Mr C for the failings identified and for the distress he has outlined; and
• inform Mr C what steps are being taken to address these failings.

Summary

Mr C told us that, in error, the council had opened the grave in which his son was buried. When the family discovered the grave had been disturbed, they contacted the council and were initially told the grave had been dug to the depth of two feet and then filled in. We found that the council had not provided a clear and consistent account as the grave had, in fact, been fully prepared for a burial.

The council explained that the mistake was down to administrative error, in that the wrong section row had been identified by a member of administrative staff. Gravediggers also failed to notice or question why the plaque at the grave did not match the details recorded on their work instruction.

We found the council's handling of Mr C's complaint to be relatively poor in view of the clear failings which had caused considerable distress and upset. The complaint was not treated with the degree of priority that it should have been, and Mr C did not receive a proper response to his request for a meeting.

Recommendations

We recommended that the council:

• give a full apology for the distress caused and for the failings identified in this case, and offer an opportunity for the complainants to meet with the chief executive; and
• demonstrate that the lessons learned from this complaint have been communicated to relevant staff members.

Summary

Mr C was receiving an individual budget from the council under a self-directed support pilot scheme. Mr C was responsible for arranging his own social care support in line with a plan and outcomes he agreed with the council. At the end of the pilot scheme Mr C was asked by the council to repay £1050 which he had withdrawn from the individual budget in cash. The council said Mr C had failed to prove the money had been used to meet agreed outcomes. Mr C said he had given the council clear evidence of legitimate expenditure.

Mr C complained about the way the council had treated his complaint. In particular he said he was not given an opportunity to contribute his evidence to the process before a decision was made.

We found that when Mr C wrote to the council they failed to tell him the matter was being treated as a financial appeal rather than as a complaint. They incorrectly said their resource allocation panel amounted to a statutory appeal process. The council assessed the complaint under their corporate complaints handling procedure when the complaints should rightly have been considered and assessed for eligibility under the statutory social work complaint process. We asked the council to review their handling of Mr C's complaint.

We found that Mr C was not given a proper opportunity to contribute his evidence to the financial appeal process before it was considered by the resource allocation panel.

Recommendations

We recommended that the council:

• review the handling of this complaint taking into account the council's statutory obligations in respect of social work complaints and advise Mr C and us of the outcome; and
• offer Mr C the opportunity to provide further details and / or evidence of the disputed expenditure and provide a further response which fully and clearly deals with all points not already addressed.

Summary

Ms C complained about the housing association after they refused to grant her priority under their exceptional housing need category. She felt that they had failed to properly consider her request. We found that their procedure for assessing requests under this category was unclear. It was difficult to tell how, and by whom, requests were supposed to be progressed and decided. We also found, in her case, that they had failed to show how, why, or by whom the decision had been made. They accepted that they had not followed the procedure in Ms C's case, even though the procedure clearly stated that it was to be used for all requests of this kind. As such, we upheld Ms C's complaint.

Recommendations

We recommended that the association:

• apologise to Ms C for the failings identified by our investigation;
• review their exceptional housing need procedure to clarify when a request will or will not be considered, how decisions will be made at each stage of the process, and who will make those decisions; and
• reconsider Ms C's request under the revised procedure.

Summary

Miss C complained that her mother-in-law (Mrs A) had not been properly assessed by a GP following episodes of dizziness and elevated heart rate and blood pressure. Mrs A had suffered a fatal heart attack three days after visiting the GP.

The GP said that Mrs A had suffered from a number of health problems. At the consultation in question she had been extremely anxious and had been prescribed medicine to counteract this. Her pulse and blood pressure had also been taken.

We took independent advice on the care and treatment provided. Our adviser said the medical records did not show that a comprehensive examination of Mrs A had been carried out. Our adviser noted that Mrs A suffered from diabetes and that the appropriate Scottish guidance for management of patients with this condition had not been followed, which was unreasonable. We found that the GP had not carried out an adequate examination of Mrs A. However, our adviser also said that Mrs A's death had been impossible to predict and that even had a more thorough examination been carried out, it would not have been possible to prevent her fatal heart attack.

Recommendations

We recommended that the practice:

• apologise to the family for the failings identified;
• provide evidence that the GP has familiarised themselves with the Diabetes SIGN (Scottish Intercollegiate Guidelines Network) guidance by including this as a learning need in their yearly appraisal;
• provide evidence that this case and our adviser's comments have been discussed between the GP and their appraiser; and
• carry out a Significant Event Review and discuss this with the GP and the local clinical director to ensure learning from the case is appropriately identified.

When it was originally published on 16 December 2015, this case referred to a Medical Practice in the Tayside NHS Board area. This was incorrect, and should have read a Medical Practice in the Fife NHS Board area. This was due to an administrative error which we have now corrected, and we apologise for any inconvenience that this has caused.

Summary

Mr C complained about the treatment his late wife (Mrs C) received from the practice. Mrs C suffered from chronic obstructive pulmonary disease (a collection of lung diseases) and died three days after she had attended the practice. It was also the day after Mr C had phoned the practice as he had concerns that the medication which Mrs C had been given was ineffective. He said that he had wanted to speak to a GP but was offered a phone consultation which was scheduled for later in the day that his wife died.

We took independent advice from one of our GP advisers, who said that she had concerns about the consultation Mrs C had attended. Our adviser was critical that the GP who saw Mrs C did not check Mrs C's oxygen saturation levels (pulse oximetry); did not ensure that Mrs C was able to use her inhaler appropriately; and failed to prescribe steroid medication. We found that the treatment which was provided to Mrs C was not of a reasonable standard.

We also considered whether Mr C's phone call to the practice was actioned appropriately. Mr C believed that he was contacting the practice to explain that Mrs C's medication was not working and that her condition was deteriorating. The receptionist at the practice had recorded the phone call as 'medication and issues' and had not contacted a GP for advice and had made arrangements for Mr C to have a phone consultation with a GP. We found that Mr C should have been given the opportunity to speak to a GP on the day of his phone call and that had they done so then the GP would have had the opportunity to make a clinical judgement as to whether a further consultation was required. The practice have accepted that the system which was in use for phone calls required updating. The system has now been updated and our adviser believes that the service has now been improved.

Recommendations

We recommended that the practice:

• apologise to Mr C for the failings identified;
• review chronic obstructive pulmonary disease management;
• ensure the GP in question discusses the case at their yearly appraisal;
• consider a peer reviewed Significant Event Analysis (provided by NHS Education Scotland) about the way the situation was managed; and
• apologise to Mr C for the failure to offer him the opportunity to speak to a GP when he phoned the practice.

Summary

Mrs C complained about the communication with her family during her late father (Mr A)'s admission to Cornhill Macmillan Centre for end of life care. She raised concerns that the family were excluded from most medical consultations and were not updated on changes to Mr A's condition or treatment. In particular, she complained that the family were not prepared for the fact that Mr A would not receive fluids once he was unable to take them orally. She said there was no continuity of care and there was no single member of staff who seemed to know Mr A well. She also complained that the visiting hours were overly strict, and that staff were defensive and did not support the family to make the most of Mr A's final weeks.

We obtained independent advice from a nursing adviser, who noted that aspects of Mr A's care appeared to be of a very good standard. The adviser said that a reasonable level of discussion with the family was documented, although she acknowledged that their needs did not appear to have been met in this regard. She considered that the family's concerns should have been picked up on early in Mr A's admission and support offered to them through a named individual. She noted that the board's assessment and decision-making in relation to fluid provision was well documented and appropriate to the circumstances. However, she considered that an early explanation to the family of the planned approach could have reduced their distress. The adviser also considered that the visiting policy was overly strict and outdated, when it should be flexible and adaptable to the individual needs of patients.

We were critical of the board that, after failing to resolve the concerns at the time, they did not use Mrs C's formal complaint to appreciate where things went wrong and identify specific learning opportunities. They developed an action plan in response to the complaint but we did not consider it to be robust enough. We felt that their response to the complaint was defensive and often missed the point of the issues being raised. We upheld the complaint.

Recommendations

We recommended that the board:

• further develop their action plan to take account of our findings and inform us of any learning and improvements that have taken place as a result of this complaint;
• consider providing training in early resolution skills, including difficult conversations, to staff involved in this episode of care;
• remind complaints handling staff of the importance of accurately assessing all issues raised, to ensure they are fully understood, and offering compassionate and understanding responses that clearly and specifically set out any learning that has taken place;
• review the visiting policy at Cornhill Macmillan Centre with a view to ensuring that it is person-centred and adaptable to the individual needs of patients and relatives; and
• apologise to Mrs C for the failings we identified.

Summary

Mrs C complained that the Scottish Ambulance Service (the service) did not have the appropriate equipment or vehicle to take her late husband (Mr C) to hospital for a scan. Mr C was terminally ill with cancer and had widespread pain which severely restricted his mobility. Mrs C was also dissatisfied that the service did not apologise or explain why they delayed in replying to her complaint about the matter.

We took independent advice on this case from one of our nursing advisers. We noted that the service had reviewed the way the situation was managed and took appropriate action to prevent a similar situation recurring. We found that there was confusion about what equipment was required to take Mr C downstairs to the vehicle. Whilst the ambulance staff did their best with the equipment and vehicle that was available, there was a lack of communication as to the type of vehicle needed to transport him. As Mr C could not sit for long periods due to his condition, we considered it unreasonable to transport him to hospital in a chair which would have caused him additional pain and distress.

We also found that it took the service over three months to respond to Mrs C's complaint, which was well beyond the 20 working day timescale. Additionally, the service did not provide Mrs C with regular updates about the progress of their investigation or the reasons for the delay.

Recommendations

We recommended that the service:

• apologise to Mrs C for the failure to appropriately transfer her husband and for the distress that this caused; and
• apologise to Mrs C for the failings in the handling of her complaint.