Upheld, recommendations

Summary

Ms C complained to the practice about treatment that her son (Mr A) had received. She was unhappy with the response that she received and information that was provided about the principal dentist at the practice.

After investigating, we upheld Ms C's complaint. We considered that although the response to her complaint about treatment addressed her concerns adequately, there were a number of other complaints handling failings. We found that the response letter did not refer Ms C to us if she remained dissatisfied with her complaint and that the practice's complaints handling procedure was not in line with the relevant Scottish Government guidance. We also found that there had been a failure to advise Ms C of changes to the staff structure at the practice in a timely fashion.

Recommendations

We recommended that the practice:

• issue a written apology to Ms C, acknowledging the failings our investigation found;
• review staff training needs, to ensure complaints are appropriately coordinated and responded to; and
• review the complaints handling procedure to ensure that it reflects the requirements of the Scottish Government's 'Can I help you?' guidance.

Summary

Mrs C complained about a delay in providing treatment in the ear, nose and throat (ENT) clinic at Wishaw General Hospital. Her GP referred her with a suspected acoustic neuroma (a benign tumour on one of the nerves connecting the inner ear to the brain) and she was frustrated at having to attend multiple appointments before receiving a diagnosis. She was seen first by audiology, then an ENT doctor reviewed her and she attended again for a scan, before being seen by ENT again to discuss the results. These four separate attendances occurred over a five-month period. Her scan result was normal and confirmed that she did not have an acoustic neuroma.

The board treated the audiology and ENT appointments as separate specialist referrals and, therefore, as two separate events for the purposes of treatment time targets. This meant that, in their view, the relevant waiting targets had been met. They noted that referrals to ENT were vetted and, if patients met certain criteria, they were sent to audiology. They advised that audiology can often meet patients' clinical needs and, where this is the case, no onward referral to ENT is necessary.

We took independent advice from both a GP adviser and a consultant ENT surgeon. It was noted that Mrs C's GP had referred her specifically to ENT with a particular concern. We were advised that a direct appointment to audiology was common practice and in line with relevant guidance. However, the board's vetting criteria did not appear to match up with this guidance. The advice we received indicated that it would only be appropriate to treat an audiology appointment as a separate specialist referral if audiology were able to fully investigate and decide on treatment for the concern in question. This was not the case with Mrs C and it appeared that it was always going to be necessary for her to see an ENT doctor in order to be fully assessed. As such, the audiology appointment appeared to be a routine precursor to the ENT assessment and should not have been viewed as a separate event. We concluded that Mrs C's overall wait within the ENT clinic system was unreasonable and we upheld the complaint.

Recommendations

We recommended that the board:

• take steps to ensure that ENT waiting times are accurately categorised and provide us with details of the action taken;
• review their ENT and audiology referral process to ensure it is reasonable and takes account of relevant guidance;
• consider introducing a system of writing to patients when assessment results are normal, to avoid causing unnecessary anxiety for them while waiting for a follow-up appointment to discuss these results; and
• issue a written apology to Mrs C for the failings we found.

Summary

Mrs C's father (Mr A) was diagnosed with cancer, and underwent surgery followed by a course of chemotherapy. About six months later, Mr A began experiencing new symptoms, and a scan was arranged. Mr A was told that the scan showed 'no evidence of recurrence', and he was discharged (with a follow-up planned for four to six weeks). However, Mr A's symptoms continued and he was admitted as an emergency a few days later, and underwent further surgery. While Mr A thought the surgery was to address symptoms resulting from his previous surgery, the surgery found that Mr A's cancer had returned and he was given a purely palliative procedure. Mr A passed away a few months later.

Mrs C was concerned that her father was told he was 'all clear' after the chemotherapy, only to find out his cancer had returned six months after this. Mrs C was also concerned that her father was not given regular scans, and she queried how the scan he was given could show no return of the cancer, when Mr A was found to have cancer just a few days later.

After taking independent medical advice, we upheld Mrs C's complaints. While we found no evidence Mr A was given incorrect information about being 'all clear' from cancer following chemotherapy, there was also no evidence that he was offered information about his prognosis and the high possibility of recurrence at this time. In relation to Mrs C's concerns about scans, we found that the board had undertaken reasonable follow-up of Mr A, consistent with national guidance (which did not require regular scanning). However, we found that, although the scan showed a possibility that the cancer had returned, the consultant surgeon did not share this with Mr A, which was unreasonable.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings our investigation found;
• feed back our findings on the lack of communication and record-keeping about post-treatment prognosis to the surgical and oncology staff involved in Mr A's care; and
• ensure the consultant surgeon involved reflects on the findings of our investigation as part of their next annual appraisal.

Summary

Mrs C complained about the care and treatment given to her late mother (Mrs A) during an admission to the Royal Alexandra Hospital. She said that staff at the hospital delayed in attending to Mrs A and in providing her with treatment, and that she was given too much fluid intravenously. Mrs C believed this all contributed to Mrs A's death. Mrs C also complained that there were delays in transferring Mrs A to a treatment ward which she said was also to her detriment.

We took independent advice from a consultant in emergency medicine and we found that while Mrs A had been assessed in the emergency department as an urgent case to be seen within an hour, she was not seen until after two hours of arrival on the ward. It also took 11 hours to transfer her to a ward for treatment which was far too long for someone who was sick, elderly and frail. Furthermore, Mrs A had been given a litre of saline solution which was too aggressive given that she was known to have pre-existing heart disease. For these reasons, we upheld the complaint. However, there was no evidence to suggest that the failures identified had contributed to Mrs A's death.

Recommendations

We recommended that the board:

• make a formal apology to Mrs C recognising the shortcomings identified;
• satisfy themselves that such delays in the emergency department could not happen again and advise us of the processes since put in place to avoid this; and
• ensure that our findings are brought to the attention of the doctors and staff in the emergency department for them to consider further.

Summary

Mr C failed a piece of course work on his postgraduate certificate course. His appeal against the result was not upheld. He submitted a request for information under the Freedom of Information Act and received evidence that suggested the university had not followed the assessment regulations when they held assessment boards that confirmed his fail. Specifically he received an email that the external examiner had sent stating that Mr C's resubmitted work should not be a fail. Mr C complained to the university that they had not followed assessment regulations and had not followed the advice of the external examiner. He also complained that the assessment board meetings were not quorate (having the necessary number of people present for decisions to be allowed to be made) nor properly attended by relevant board members. The university investigated and did not uphold his complaints.

Our investigation found that the university had not followed its regulations, although following Mr C's complaint, advice had been sought retrospectively from the examinations office, which suggested that the external examiner's views could be presented in writing. This had not been done at Mr C's assessment boards either.

We found that the inability to provide evidence that the external examiner's views were presented to the assessment board constituted an act of maladministration and that Mr C was entitled to an assessment board attended by the external examiner. We also found that the only available evidence of the external examiner's view showed they disagreed with the decision to fail Mr C. We did not find evidence that the assessment boards were not quorate or that the appropriate staff members did not attend.

It is not our role to consider questions of academic judgement and accordingly, it was not possible for our investigation to consider whether the correct mark was awarded, or whether the course as a whole should have been passed or not. Nor was it possible for us to order that a certain mark or qualification be awarded. It is our role to look at whether procedure was followed and in this case, mistakes were made. Where we find mistakes, our aim is to address them in such a manner as to place the complainant (if possible) in the situation they would have been in, had the error not occurred. We therefore recommended that the assessment board be re-held, while making it clear that this did not prejudge the outcome of the board, or require them to reach a specific decision on the work.

Recommendations

We recommended that the university:

• provide evidence in the form of a formal minute to show the assessment board for Mr C has been re-held with the external examiner in attendance;
• provide evidence that the university regulations regarding the attendance of external examiners are being reviewed at the earliest opportunity; and
• apologise to Mr C for the failings we identified.

Summary

An escorting agency that provides custody escorting services on behalf of the Scottish Prison Service (SPS), transferred Mr C from hospital to their escort vehicle in order to transport him back to prison. Mr C complained about the way in which the escorting agency carried out that transfer and about their handling of his complaint.

When the escorting officers arrived to transfer him to the vehicle, they attempted to use a restraint method but would not explain why to Mr C. He resisted and, therefore, they carried him through the hospital to the vehicle. Mr C complained to us about being carried in full view of other people in the hospital and about the way in which they had carried him - for example, bending his back inappropriately and laying him face down on the floor when they needed a break from carrying him.

Our investigation found that, although an escorting officer had received authority from the agency's control centre for the restraint method, that was inappropriate. We also found Mr C should not have been moved in that way, and that such techniques were not taught, recognised or approved. We upheld this part of the complaint.

Mr C also had a number of complaints about the way the agency handled his complaint, such as that their reply did not address all of his concerns. Our investigation showed that their investigation of the complaint was thorough and appropriate, but we agreed with Mr C's complaints about their reply, which gave very little information. Our investigation showed that the investigation by the agency had revealed shortcomings and indicated that action, such as staff training, needed to be taken. However, their reply to Mr C gave no indication that any shortcomings had been identified or that any action would be taken as a result of his complaint. We upheld this part of the complaint.

Our investigation found significant shortcomings, however, our only recommendation was that the agency send a written apology to Mr C. This was because we had recently investigated similar complaints by Mr C about the agency, and they had indicated that they would be taking significant actions to help prevent shortcomings in the future. We considered it would be reasonable to give them the chance to carry out those actions.

Recommendations

We recommended that the SPS:

• apologise to Mr C, on behalf of the escorting agency, for the shortcomings we identified regarding Mr C's transfer from hospital to the escort vehicle; and
• apologise to Mr C, on behalf of the escorting agency, for the shortcomings we identified regarding the handling of Mr C's complaint.

Summary

Mr C complained about the Scottish Prison Service (SPS) following their refusal of his application to be released under a Home Detention Curfew (HDC). At the first stage of the application process, the decision letter from the SPS stated that his application was refused because the address he had proposed was assessed as being unsuitable. The letter requested an alternative address. Mr C appealed this decision, stating the reasons he felt that the address was suitable. He also provided an alternative address in the event that the decision remained the same.

His appeal was also unsuccessful. The decision letter stated that not only was the address he provided unsuitable, he was also an unsuitable candidate. He attempted to get further information about this decision and to submit a further appeal. However, this was refused, and he was told he had exhausted the appeals process.

In answer to our enquiries, the SPS stated that Mr C had been assessed at the first stage as being an unsuitable candidate for release but that they had failed to communicate this to him. This was because a standard letter had been used that was meant to be used solely when applications were refused due to an unsuitable address. We felt that this meant Mr C had unreasonably been restricted from making a proper appeal of the decision and upheld his complaint.

Recommendations

We recommended that the SPS:

• apologise to Mr C for the failings identified by our investigation;
• re-assess Mr C's application for release under HDC from the first stage, ensuring that the guidance is followed, and giving clear reasons for the decisions made; and
• provide training to relevant staff on the guidance, with particular focus on communication and recording of decisions.

Summary

Mrs C complained on behalf of her daughter (Miss A) following the council's decision to terminate her cello lessons. Miss A received cello lessons from the council but these were terminated as her instructor had learnt that she was also receiving private lessons, which the instructor felt was a breach of the council's Instrumental Music Services (IMS) policy. However, Mrs C said that she had consulted the policy, and felt that it allowed short-term supplementary lessons, which was what her daughter was receiving. In the council's response to us, it was clear that a member of the IMS management staff agreed with this interpretation and, on review of the policy, so did we. We therefore agreed that Miss A's cello lessons were unreasonably terminated, and upheld the complaint.

Mrs C also complained about the way in which the decision was communicated. Miss A's instructor told Miss A verbally, and Mrs C felt that she and her husband should have been notified. The council confirmed in their response to us that they would expect a discussion to take place with parents before a decision was made, and that the parents should be notified directly of a decision to terminate lessons. As this did not happen, we upheld this complaint.

Recommendations

We recommended that the council:

• apologise to Mrs C for the failings identified by our investigation;
• explain clearly to Mrs C their stance on whether it is appropriate for pupils to receive short-term supplementary lessons alongside authority lessons; and
• provide us with evidence of their stated commitment to provide guidelines to IMS staff regarding termination of lessons.

Summary

Mr C owns a property in Edinburgh. The council issued a statutory notice requiring repairs to chimneys shared with a neighbouring property. A separate notice had been served for work required at the neighbouring property. The property owners asked the council to take over management of the required works, and a project manager and contractor were appointed. An estimate was provided detailing the likely cost and timescale for the works. Scaffolding was erected and a full survey carried out. Mr C complained that, once the scaffolding was erected, the project suffered from unreasonable delays and unexplained increases in the associated costs. Despite his requests for clarification, he was not provided with an adequate explanation as to why the costs had increased.

We found the communication from the council and their contractors to be poor. The costs associated with Mr C's property actually decreased, however, no clear explanation was given to him as to what he was being charged for. An independent investigation was carried out to assess the validity of the charges and we were satisfied that the council took Mr C's concerns seriously, waiving costs that had been added to the project unreasonably. However, we were critical of the quality of their communication throughout the project.

Recommendations

We recommended that the council:

• apologise to Mr C for failing to clearly explain the costs associated with the statutory notice work at his property; and
• waive 50 percent of Mr C's administration fee.

Summary

Miss C complained to the council about damp in her house. Following an inspection, the council advised that they would engage a damp-proofing specialist to remedy the potential failure of a damp-proof course and potential rising damp. The council did not do this within a timescale Miss C considered reasonable and she raised her complaints with us. We found that there had been a delay in engaging a specialist and that this was caused by an administrative oversight. Given this, we upheld the complaint.

Recommendations

We recommended that the council:

• apologise to Miss C directly for the unreasonable delay in the engagement of a damp-proofing specialist.