Upheld, recommendations

Summary

Mr C complained that he was inappropriately released from prison on interim liberation on a Sunday. He also complained that there was an unreasonable delay in assigning his low supervision level and that the handling of his application for early release under the home detention curfew (HDC) scheme was inappropriate.

The Scottish Prison Service (SPS) told us that Mr C was granted interim liberation on the Friday but prison staff only noticed the fax sent by the court on the Sunday. Because of that, there was a delay in releasing Mr C on interim liberation. Therefore, whilst we did not see any evidence to suggest that it was inappropriate to release a prisoner on a Sunday, we did consider that there had been a delay in releasing Mr C on interim liberation so we upheld his complaint.

In addition, the SPS told us Mr C was assigned low supervision level but his computerised record was not updated until a month later. This meant that Mr C was unable to apply for HDC as quickly as he should have been. Therefore, we upheld this complaint.

Finally, Mr C received a letter indicating that his HDC application had been considered in full, but it went on to say that he was not a suitable candidate for early release because further information was required. We asked the SPS why a letter had been issued to Mr C refusing his HDC application but also suggesting that further information was needed. They told us that was normal process. The SPS also said information was missing from Mr C's community assessment report. However, the information they told us was missing was actually available in the report. We agreed that the handling of Mr C's HDC application was inappropriate and upheld the complaint.

Recommendations

We recommended that the SPS:

• apologise to Mr C for the failings our investigation indentified; and
• share our findings with the controllers at the prison and advise us of the steps that will be taken to avoid the same thing from happening again.

Summary

Mr C complained that his child had been bullied at school and that the response from the school and the council had been inadequate and inappropriate. Mr C said they had regularly reported incidents of bullying to the school but these had not been properly recorded. When they complained to the headteacher, Mr C said that their concerns were dismissed, and a subsequent investigation by the council's head of education had contained significant factual errors, which the council had failed to acknowledge or apologise for.

The council maintained there was no evidence that bullying had taken place. They said Mr C had insisted on the exclusion of the pupils he considered responsible for bullying and that he was not prepared to accept any other outcome. They acknowledged there had been errors in the head of education's investigation, but suggested that the conclusions this investigation had reached remained sound.

Our investigation found that the council were unable to supply adequate or accurate records. The investigation findings and complaint response from the council were not supported by the evidence available. The council also could not explain why statements had been made about what Mr C had insisted on as a resolution (exclusion of pupils) when these were not backed up by documentary evidence. It was noted, however, that the flaws in the investigation were due to a failure to follow the council's relevant policies and procedures (bullying and complaints handling) rather than evidence of systemic failings within the council's policies and procedures.

Recommendations

We recommended that the council:

• provide evidence that staff at the school have been reminded of the importance of adhering to the appropriate guidance when investigating allegations of bullying;
• provide evidence that the bullying prevention assessment tool has been completed for the school in question; and
• apologise unreservedly to Mr C and his family for the failures identified in this investigation.

Summary

Mr C complained that the council had unreasonably charged him for work carried out that was not in the statutory notice (where the council arrange for work to be done and then recoup the cost from the property owners) that they had issued to him and his neighbours. The statutory notice referred to the repair of defective stair treads. However, the contractors appointed by the council to carry out the works resurfaced the whole stairwell and landing. The council then billed Mr C and his neighbours for this. Mr C had raised this with the council when the contractors arrived to carry out the work, but the council failed to respond to him at that time.

We found that the council should have informed property owners of the additional flooring work exceeding the work referred to in the statutory notice. We said that the council should only charge Mr C for the work carried out under the statutory notice, particularly as he had raised the matter with the council on the day that the contractors arrived, but had not received a response. We upheld this aspect of Mr C's complaint.

Mr C also complained about the council's handling of his complaints. There had initially been significant delays by the council in responding to Mr C's complaint. The council had then carried out a review, but this only considered Mr C's complaint about the quality of the work by the contractors. The council failed to consider Mr C's complaint about the additional work that was carried out that was not in the statutory notice. In view of this, we also upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the council:

• amend Mr C's outstanding bill so that he is only charged for the cost of repairing twelve defective stair treads, rather than the resurfacing of the landings and the whole stairwell;
• issue a written apology to him for the failure to adequately deal with his complaints; and
• make the staff involved in the handling of his complaint aware of our decision on the matter.

Summary

Ms C complained that the council had unreasonably failed to require her neighbour to submit a planning application to install roof lights (velux windows). She said that they had allowed her neighbour to install the roof lights on the basis that planning and listed building consents for this work had been granted in 1996 and were 'kept alive' because the building had been painted and works to the internal stairwell were carried out within five years of the consent being granted. The council took the view that as the consented works had started, the permissions should not lapse. Ms C was of the view that these permissions should have lapsed after five years and new applications submitted for any further works. She was also concerned that without the requirement to submit a new application, she had lost the right to make representations to the council.

We considered the background to the case and sought independent advice from our planning adviser. We found that there was no evidence to support the council's view that the building had been painted since 1996, and that this work did not form part of the original planning consent. We also found that the internal stairwell, where works appear to have taken place, also did not form part of the original planning permission. The only work which required planning permission, and which was granted in 1996, was the installation of the roof lights. However, as these roof lights were not installed until 2014, the original planning and listed building consents should have lapsed in 2001, five years after the original permission was granted.

We noted that the council had based their decision solely on information provided by the neighbour and failed to take any steps to verify what works had been carried out under the original permissions. We also noted that even when it should have become apparent that the original permissions had lapsed, they did not take steps to consider any form of enforcement action to have the roof lights approved. Furthermore, we noted that the council had failed to provide reasonable, or accurate, responses to Ms C's complaint. As we were satisfied that the original permissions had lapsed, in line with the time limits applied by planning law at the time, and as the council's subsequent justification for their decision making was very poor, we upheld Ms C's complaint.

Recommendations

We recommended that the council:

• carry out a full review of the facts and circumstances surrounding this case and give careful consideration to what action would now be appropriate in order to obtain the necessary consents for this development (both planning and listed building) within the terms of the relevant legislation;
• introduce appropriate procedures to ensure any similar cases, relating to historic applications, are assessed against the correct legal framework and provide training to staff to ensure they are familiar with this process;
• review how their planning department responds to stage 2 complaints in order to ensure that the factual basis of any decision is checked before the decision letter is issued; and
• apologise to Ms C in writing for providing her with inaccurate information in their response to her complaint and for failing to give proper consideration to the question of whether or not the installation of the windows required submission of a new planning application.

Summary

Ms C made a request for consideration under the special circumstances clause of the housing association's allocation policy. This was refused but Ms C felt the reason she received for this decision contradicted the wording of the policy. She then made a formal complaint and the association reviewed their decision, but again refused her request. The reason given in the final complaint, which signposted Ms C to the SPSO, was that they felt the points available through this clause would have been excessive in her circumstances. She then complained to us about this decision, and that they had failed to respond fully to her complaint.

The association told us that the clause was intended to be totally discretionary, and that they felt they had acted correctly in exercising this discretion. However, on reviewing the policy, we found that the wording did not grant them the discretion to deem the points to be excessive. We therefore upheld Ms C's complaint, and also found that the association had not responded fully to her complaint.

Recommendations

We recommended that the association:

• apologise to Ms C for the failings identified in this investigation;
• review the wording of the special circumstances clause in their allocation and transfer policy to clarify its intended function;
• reconsider Ms C's application for special circumstances points and provide a response giving detailed reasons for their decision; and
• respond fully to Ms C's complaint.

Summary

Miss C raised a number of issues about the time taken by the health board to arrange her appointment for day surgery and that, when it eventually took place, it was outwith the timescales for the Treatment Time Guarantee (TTG) of 12 weeks. Miss C also mentioned that she had told staff she was willing to take a cancellation if that meant earlier surgery but that this was not noted in her records. She was also dissatisfied with the time taken to deal with her formal complaint.

We found that the board had in fact noted that Miss C was willing to take a cancellation and that they had arranged for an earlier admission which would have met the TTG but that it had to be cancelled due to the unavailability of a bed. We found that the board were taking action behind the scenes but this was not adequately communicated to Miss C. We also found that there were delays in the complaints handling and that there was a failure to keep Miss C updated on developments. Therefore, we upheld Miss C's complaints.

We were also concerned to note that the board said that, according to their access policy, they would not routinely contact another health service provider should they not be able to meet the TTG. However, there is a requirement for boards to contact alternative health service providers when they are not able to meet the TTG. We also made a recommendation to the board in this regard.

Recommendations

We recommended that the board:

• apologise to Miss C for the failure to communicate with her adequately about the date for surgery;
• review its access policy to take into account the requirements in the Patient Rights (Treatment Time Guarantee) (Scotland) Regulations 2012; and
• apologise to Miss C for the failings in the way her complaint was handled.

Summary

Mr C complained to the health board that a staff member accessed his patient record without authorisation. Mr C complained to us about the time taken for the board to deal with his complaint, and that the board's response did not answer his concerns.

In replying to our enquiry, the board acknowledged failings in how they had handled Mr C's complaint. Board staff failed to recognise that the internal disciplinary process about the staff member involved was a separate issue from providing a response to Mr C's complaint; this failure led to the delay in responding to Mr C. In addition, the board should have provided Mr C with a clear explanation of how these matters were being dealt with, and that they could not tell him the outcome of the disciplinary process, much sooner than they did. We upheld Mr C's complaint.

Recommendations

We recommended that the board:

• provide us with confirmation that the staff who dealt with Mr C's complaint acknowledge where things went wrong, so they will not repeat these errors in future.

Summary

Mr C raised numerous concerns about the way that the practice dealt with an incident when he attended the practice. There was a difference of opinion between Mr C and the staff about what had occurred. Mr C subsequently had a meeting with the practice to discuss his concerns and he was accompanied by an independent witness. Mr C complained to this office that the practice had failed to provide a note of the meeting or provide specific information relevant to the practice's investigation into his complaint. In particular, he wanted to know whether the practice staff had been spoken to prior to the practice contacting the Medical and Dental Defence Union of Scotland (MDDUS) for advice.

We found that although the practice were trying to be helpful in arranging the meeting, they did not provide all the information which was requested. This appeared to be the result of a misunderstanding by the practice staff. The information would have assisted Mr C in determining whether he was going to consider further action in an effort to resolve his concerns. We also found that the practice had failed to include our contact details in their final letter of response which is a requirement under the NHS complaints procedure. We upheld Mr C's complaints.

Recommendations

We recommended that the practice:

• apologise to Mr C for the failings which have been identified in this investigation;
• respond to the issue as to whether staff were spoken to prior to contact with MDDUS; and
• remind staff who are responsible for responding to formal complaints to remember to include our contact details in their final response letters.

Summary

Miss C's father (Mr A) was admitted to Glasgow Royal Infirmary from another hospital where he had been admitted earlier following a fall at home. Mr A was admitted to A&E and then moved to a ward. Mr A died several days after his admission.

Miss C was concerned that many mistakes and problems had occurred during Mr A's admission to Glasgow Royal Infirmary. Miss C met with the board who accepted there had been a number of failures in Mr A's care and treatment, and offered apologies for these. They also shared information with Miss C about actions taken to discuss failings identified with staff, and the procedures put in place to help avoid any repeat for other patients in the future. Miss C, however, remained concerned.

We took independent advice from a medical adviser and a nursing adviser.

Our medical adviser said that on admission, Mr A was noted to have had a fall, underlying liver disease, vomiting and diarrhoea, and a new acute kidney injury. Our medical adviser said that Mr A's medical records were comprehensive and that, overall, his care was of a good standard. However, our medical adviser also said there was a failure to prescribe continuous fluids, and to record and monitor Mr A's fluid balance which, in a patient with vomiting and diarrhoea and a diagnosis of acute kidney injury, were serious failings.

Our nursing adviser said that, overall, Mr A's nursing records and charts were of a good standard and there was a reasonable level of communication with Mr A's family. However, she also considered there was a serious failure in the recording and monitoring of Mr A's fluids by nursing staff. Therefore, Mr A's nursing care had fallen short of the expected standard in relation to the recording and monitoring of his fluid balance.

Recommendations

We recommended that the board:

• provide evidence of policies for fluid balance documentation and of compliance with such policies for the A&E department and the ward involved in this case at Glasgow Royal Infirmary.

Summary

Mr C complained about the care provided to his late father (Mr A) at Aberdeen Royal Infirmary. Mr A was blind, elderly and frail. He had cancer. Early in 2014 he had had many emergency admissions to hospital and in May 2014 he was admitted again. During his stay he experienced two heart attacks and was noticed to have become increasingly more agitated. Mr A required the lavatory and was assisted there by two members of staff and, at his insistence, he was given privacy. However, he fell and broke his hip. After that his condition declined. Due to this, it was not possible for him to undergo surgery and he died. Mr C believed that Mr A should not have been left unattended and he considered that this contributed to his death.

We investigated the complaint and took independent advice from our nursing adviser. We found that while there was a difficult balance to strike between safety and allowing someone dignity and privacy, in this case, because of Mr A's blindness and medical conditions, he should not have been left alone. We upheld the complaint.

Recommendations

We recommended that the board:

• provide an update of the actions/action plan they instigated since the complaint in order to ensure that their staff have the skills and resources to manage older people with delirium.