Upheld, recommendations

Summary

Ms C, an advocate, complained to the board on behalf of her client (Mrs A) about the care she received at A&E at Borders General Hospital after she had fallen at home. Mrs A had fractured a bone in her arm and was discharged home the same day. The following day, she returned to the hospital in significant pain and further tests showed that she had fractured her kneecap and had bone cancer. Ms C also complained about a delay in Mrs A being reviewed by an orthopaedic specialist and physiotherapy.

We took independent medical advice from a consultant in emergency medicine who considered that Mrs A did not receive a reasonable standard of treatment when she initially attended A&E. There was insufficient evidence to show that the emergency doctor had carried out a thorough examination of Mrs A's joints below the fracture or her lower limbs despite ambulance staff having documented bruising to the right knee. We also took independent medical advice from an orthopaedic consultant who considered that the one day delay in identifying the fractured kneecap was unlikely to have impacted on Mrs A's overall outcome. However, we also found that Mrs A's significant pain level was not reassessed prior to being sent home and had it remained high, then she may have required intravenous morphine and admission to hospital. There was also no evidence to show that any assessment had been carried out of how she might manage at home and who was able to care for her if required.

In considering Ms C's complaint about the delay in Mrs A being reviewed by an orthopaedic specialist and physiotherapy, our orthopaedic adviser told us the eight week delay in Mrs A being reviewed was unlikely to have had a detrimental effect on the healing of her arm fracture. However, given she was to be reviewed within three weeks we found the delay in this case to be unreasonable.

We upheld all of Ms C's complaints, although we noted that the board had apologised to Mrs A that the pain relief they gave her was inadequate and acknowledged that a mistake had been made in her not being referred to the orthopaedic clinic and physiotherapy for further review. They also arranged for the hospital's discharge procedure to be reviewed with a view to making improvements in order to prevent the matter recurring. However, we made recommendations which related to the treatment of Mrs A when she initially attended the A&E department.

Recommendations

We recommended that the board:

• apologise to Mrs A for the failings identified; and
• ensure that the emergency doctor reflects on the failings and confirm when this has been done.

Summary

Mrs C complained about her discharge from a private hospital, which she had been admitted to for NHS-funded hip replacement surgery. She felt she was not fit to be sent home as she had severe diarrhoea, which she blamed on being given too many laxatives on the day of discharge. She needed to be admitted to hospital a few days later, where she remained for over four weeks. The board said that she had not been given any laxatives on the day of discharge and they considered that she had been fit to go home.

We took independent advice from one of our medical advisers and he said there was no evidence of Mrs C having been given laxatives on the day of her discharge. However, he did not consider that her bowel symptoms had been properly investigated and treated prior to sending her home. He said there seemed to have been undue focus placed on meeting the planned discharge date rather than ensuring Mrs C was fit to go home. As such, Mrs C required prompt readmission to have her bowel symptoms addressed. The adviser also noted that the records from Mrs C's admission lacked the detail that could reasonably have been expected. We accepted this advice and upheld the complaint.

Recommendations

We recommended that the board:

• confirm that the identified failings will be discussed at the consultant's annual appraisal;
• remind staff of the importance of comprehensive record-keeping; and
• apologise to Mrs C for the identified failings in her care.

Summary

Mrs C complained about the treatment her late father (Mr A) received from the board. Mr A had died soon after being diagnosed with cancer and Mrs C felt his treatment had been unreasonably delayed (she was aware that her father was very unwell but felt things could have been handled better, including providing end of life care sooner). Although the board had acknowledged certain delays to Mrs C and said they would recruit additional staff, she remained dissatisfied and brought her complaint to us.

We considered whether Mr A's treatment at University Hospital Ayr was reasonable in the circumstances at the time. We took independent medical advice which confirmed that Mr A's cancer had been a very rare and complex kind. Our adviser, having reviewed the records, also said that Mr A's initial treatment pathway had been reasonable and confirmed that Mr A had not fallen between the cracks of different clinical disciplines (Mrs C had been concerned about this). However, our adviser said the delay for a subsequent investigation that was needed for Mr A's diagnosis and treatment was unreasonable and also that end of life care should have been discussed sooner than it was.

We found the evidence indicated that Mr A's condition was complex and that his initial care was reasonable. However, we considered the delay to his subsequent investigation to have been unreasonable as was the delay in discussing end of life care. We upheld Mrs C's complaint and made three recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings we identified;
• confirm to us that they have taken steps to recruit the staff detailed in their correspondence with Mrs C; and
• ensure that our adviser's comments about Mr A's end of life care are fed back to the relevant staff.

Summary

In 2002, Mr C purchased an outhouse behind his home. The outhouse had previously been used for commercial purposes and was rated by the Scottish Assessor's Asssociation (SAA) as a non-domestic property. In April 2013, Business Stream issued Mr C with an invoice for water used at the outhouse. The outhouse had been identified as a gap site (a property that is listed as non-domestic and, therefore, liable for water charges, but that has not been charged to date). The invoice was backdated to 2008 and covered a period of six years. Mr C complained, stating that the outhouse had no water supply of its own. Whilst he had installed a toilet in 2012, the water for this had been diverted from his domestic supply, which he paid for through his council tax.

Business Stream considered the charges to be legitimate, as the outhouse was listed as a non-domestic property and Mr C had access to water via his home. They advised that the only way the charges could be cancelled was for Mr C to appeal the outhouse's non-domestic categorisation with the SAA.

We found that Business Stream had failed to check what water services, if any, were in place at the outhouse before 2012. We referred to a previous ombudsman ruling that it is not reasonable to charge for water services that are not being provided, and concluded that no water charges could be applied to the outhouse prior to 2012. We also found that there had been a significant delay to Mr C's outhouse being identified as a gap site. Although Mr C had appealed the non-domestic listing with the SAA, the outhouse remained a non-domestic property and we were satisfied that it was reasonable to apply charges after 2012 in line with normal water industry practice.

Recommendations

We recommended that Business Stream:

• cancel all charges on Mr C's account prior to 1 January 2012;
• apply a ten percent discount to all charges on Mr C's account between 1 January 2012 and 31 March 2014; and
• apologise to Mr C for the incorrect calculation of charges for the outhouse.

Summary

Mr C complained that the prison unreasonably failed to make appropriate arrangements for him to attend court. In their response to his complaint, the prison told Mr C that he had not requested to go to court and, in any event, prisoners would not be ordered to attend civil hearings. In support of his complaint, Mr C provided a copy of the court order which confirmed that the sheriff had asked him to appear. He also provided a note that had been typed by an officer which said he was to attend court and confirmed that a manager had given Mr C permission to take paperwork with him.

Based on what the Scottish Prison Service (SPS) told us, there is no clearly understood process in place that outlines what arrangements can, or should, be made to enable a prisoner to attend a civil hearing at court and whether a prisoner would pay for the transport. The decision on whether to allow a prisoner to attend that type of hearing appears to be a discretionary one for the governor and that is not unusual. Governors have a wide range of discretion. However, it is important that the process for seeking and obtaining approval in a situation like Mr C's is clear and understood.

Having examined the information available in Mr C's case, and having asked the SPS for more information, it was not clear exactly what happened in Mr C's case or what should have happened. The SPS told us that Mr C did not ask to attend court or inform prison staff that he had been ordered to appear. However, the note typed by an officer indicated that Mr C was to attend court and had been given permission to take paperwork with him. In our view, the note suggested that Mr C did inform staff that he was to attend court but it was not clear whether he specified that it was for a civil hearing. Nevertheless, we considered the typed note indicated that an officer and a manager discussed Mr C's attendance at court with him and because of that, we believe proper steps should have been taken to explore whether Mr C had been ordered to attend court and whether transport should be arranged. Those steps did not happen in Mr C's case and, therefore, we concluded that the prison unreasonably failed to make appropriate arrangements to allow him to attend court and we upheld the complaint.

Recommendations

We recommended that SPS:

• reflect on Mr C's case and consider what steps can be taken to avoid the same thing from happening again;
• feed back any learning to both us and Mr C; and
• provide a letter for Mr C to give to the sheriff outlining why he did not attend court on the date ordered.

Summary

Mr C complained that the prison's handling of his complaint about an officer was poor. In particular, he said the prison agreed to arrange a meeting between him and the officer in an effort to resolve his concerns but that did not happen.

Our investigation confirmed that the initial meeting did not take place and Mr C was not given any explanation for that. When he escalated his complaint, it was agreed that the meeting would be rescheduled. However, that meeting also did not go ahead because the officer was not available but the prison informed Mr C that it had been rearranged for a later date.

In line with good complaints handling, we felt it would have been appropriate for the manager to follow up with Mr C to find out whether he was satisfied following the outcome of the meeting. If that had happened, the manager would have identified at an earlier stage that the meeting had not taken place and steps could have been taken to reschedule it without Mr C having to escalate his complaint. Therefore, we upheld the complaint.

Recommendations

We recommended that Scottish Prison Service:

• apologise to Mr C for the failures we found with the handling of his complaint; and
• offer Mr C the opportunity to meet with the officer to discuss his concerns as outlined in his initial complaint.

Summary

Mr C complained to us about the council’s handling of his tenant’s application for Local Housing Allowance (LHA). There were significant delays in the processing of the application, and Mr C completed a form to ensure that the first payment was made directly to him. However, a computer system fault meant that the first payment went directly to the tenant’s bank account, instead of to Mr C. When Mr C asked the council about what was happening, the system fault was identified. It also appeared that the council had inappropriately made a second payment to the tenant.

While the council were responding to Mr C’s complaint, they provided varying explanations about the second payment, but eventually provided payment of this smaller sum to Mr C. However, they said that they were unable to pay Mr C the first payment, as this payment had already been made to the tenant, and it was Mr C's responsibility to seek payment from his tenant.

We found that the council delayed in processing the application, and there were then faults with the payment system. We found that it would have been reasonable for the council to make the first payment directly to Mr C, but they should have confirmed with the tenant that he had not already paid any rent for this period.

We were also critical of the council's handling of Mr C’s complaint. They did not identify the complaint appropriately, or respond within their stated timescales. They also did not tell Mr C why the investigation was taking longer or when he could expect a response. We also identified failures with the way the council responded to the complaint, giving Mr C inconsistent information.

Recommendations

We recommended that the council:

• pay the cost of the first payment which was sent in error to the tenant;
• apologise to Mr C for the errors in handling the tenant’s LHA application, and for the time and effort involved in this complaint; and
• review the need for the staff involved in processing LHA applications to receive training in complaints handling.

Summary

Mr C complained to us that the council had failed to take action on his request for remedial gardening works. He said that he told the council that an area close to his home was in need of works. He said that the council agreed, and advised him that works would take place. He said that he noticed this had not happened and approached the council for an explanation. Mr C said the council responded to say that weeding would only be done once a year and referred him to the complaints section of their website. Mr C added that when he tried to query this with the council they terminated his phone call saying they had no further comment.

We found that the council had advised Mr C that a few areas of improvement would be carried out over the coming weeks but that when Mr C queried this they then said this work is only done once a year. The council were unable to provide us with any evidence that the works had been carried out. We also found their refusal to comment on Mr C's questions to be unreasonable, so we upheld Mr C's complaints.

Recommendations

We recommended that the council:

• issue a letter of apology to Mr C for failing to carry out the promised remedial work;
• issue a letter of apology to Mr C for failing to deal appropriately with his enquiry/complaint about remedial work;
• share the outcome of this letter with the relevant complaints handling staff; and
• take steps to ensure that maintenance work that is agreed to is recorded appropriately and that once the work is complete, this too is recorded and dated on worksheets as appropriate.

Summary

Ms C damaged central heating pipework under her floor. She did not dispute the fact that the cost of the repair should be recharged to her. Her concern was about the amount she was being charged and that it had not been properly explained to her. We found that Ms C had been charged for three hours of work. One hour was for the Friday night out-of-hours call when a contractor attended to make the leak and boiler safe. A further two hours were charged for the replacement of a small section of pipework the following day and for making sure the boiler was working as it should be after the repair was finished.

We upheld Ms C's complaints. The association had not asked the contractor about his arrival or departure times from Ms C's property and so were not in a position to say whether the amount charged was reasonable or not. The repair works order which should have contained this information was incomplete. We asked the association to reduce the rechargeable amount by one hour. We also asked them to apologise to Ms C and asked them to carry out a review to ensure invoices and repair orders are appropriately filled in.

Recommendations

We recommended that the association:

• reduce the amount to be recharged by the agreed amount;
• review the process to ensure that invoices and repair orders, particularly those which will be recharged to tenants, are appropriately filled in; and
• offer Ms C an apology for the shortcomings identified.

Summary

Mrs C complained about her treatment at A&E at Ninewells Hospital. She told us that when she attended with a broken foot she was fitted with a moon boot (a removable cast) and told, since it was the weekend, she was to return home and wait for a phone call on Monday. Mrs C said that she was in extreme pain at home and she said she noted trauma blisters on her foot. She said she phoned the hospital for some advice. She said that the staff member that answered the phone did not give any guidance and said that it was Mrs C's choice as to whether she went back to the hospital or not. Mrs C received a call from an orthopaedic consultant the following day who told Mrs C that she should not have been sent home and asked her go to hospital immediately. Mrs C believed that the delay in treatment had contributed to having to spend more time in hospital and having to have two operations.

As part of our investigation we took independent advice from one of our medical advisers, who said that the doctor reviewing the initial x-ray failed to correctly act on the information that identified that Mrs C’s foot was indeed broken. In relation to Mrs C’s complaint about the phone advice she was given following her discharge from A&E, our adviser also said was also of the opinion that all requests for clinical advice should be recorded and that when Mrs C reported on-going symptoms, clear advice about returning for further review should have been given. The board apologised and described the action they would take to avoid a re-occurrence of this situation, although our adviser expressed disappointment that it had taken a formal complaint to identify a training need.

Recommendations

We recommended that the board:

• remind staff about the procedure to be followed when a patient phones for medical advice.