Upheld, recommendations

Summary

Miss C complained to us that the council did not respond reasonably to her complaint about the transition arrangements for transferring her child from nursery to primary school and that her child's educational needs were not being appropriately met at the school. Miss C's child has additional educational needs and, at the time she complained to us, was being assessed for autistic spectrum disorder.

We were satisfied that the council took Miss C's complaint seriously. They appointed a council education officer to investigate, who met with Miss C to discuss the complaint and the proposed investigation. The findings and proposed recommendations of that investigation were discussed with Miss C at a second meeting during which the council accepted that there were failings in the service Miss C had received. They said that lessons had been learned and they apologised.

However, we were of the view that the council's final decision letter, issued after the second meeting, was premature. This was because Miss C's comments on the minutes of the meeting had not at that time been received and because the officer had told Miss C that she was postponing sending the final decision letter as her involvement was ongoing and a further meeting had been scheduled for a later date. Also, as the decision letter was the council's final response on Miss C's complaint, we considered that the council should have informed Miss C of her right to independent mediation and adjudication under the Education (Additional Support for Learning) (Scotland) Act 2004, if she was dissatisfied with the outcome of the investigation of her complaint. There was no evidence the council did so at that time and this alternative avenue did not appear to have been raised until two months later when Miss C made a request for independent mediation after she had removed her child from the school. We were critical of the council for their failure to do so.

Recommendations

We recommended that the council:

• issue a written apology to Miss C for the failings identified in the handling of her complaint; and
• take steps to ensure that parents of children with additional support needs are appropriately advised of their rights under the Act to access independent adjudication and mediation.

Summary

Mr C complained to us about the council's handling of an application for local housing allowance (LHA) from the tenants of his flat. As landlord, Mr C became concerned when his tenants were late with their rent payment. He requested the council pay the LHA directly to him, and submitted appropriate evidence. They assured him he would receive the appropriate payment when they had processed his application. Two months later the council processed the tenants' claim for LHA, along with Mr C's claim for direct payments and found that the tenants were already receiving payments for a previous tenancy. Mr C, therefore, only received a payment for two weeks' rent, as that was the amount of LHA outstanding at the time of processing.

The council admitted that there were delays in processing the LHA claim. However, they said that they could not make further payments as the tenants had received appropriate LHA payments and they could not raise further payments for the account.

We confirmed that the council delayed in processing both claims. We found that this led them to provide Mr C with inaccurate information, and to continue payments to the tenants even when Mr C had provided sufficient evidence of rent arrears. We concluded that, as the council were responsible for these failures, they should pay Mr C the equivalent of the LHA payments made after his application for direct payments.

Recommendations

We recommended that the council:

• pay Mr C the equivalent of his tenants' rent for the relevant period;
• apologise to Mr C for the delays in handling his tenants' LHA application, for providing him with misleading information, and for the time and effort involved in this complaint; and
• put arrangements in place to ensure that landlords are appropriately informed of any delays in processing and the possible impact this may have on their tenants' LHA claim.

Summary

Mr C's home was regularly affected by flooding. Mr C complained that this was due to an inadequate road drainage system. He said that the council had accepted this, but although they had committed in 2012 to resolve the problem, no work had been carried out. The council said they had been actively seeking a solution to the problem since 2013 following a formal complaint from Mr C. They required access to privately owned land and negotiating this had proved complicated. They accepted matters had taken longer than they would have wished, but felt they had acted reasonably and that the delays were due to matters outside their control.

We upheld Mr C's complaints. Our investigation found the council had made a written commitment to resolve the problem in 2012. The evidence showed that they had not, however, pursued this solution until Mr C had formally complained and contacted us about their lack of response. We found the delay in starting work on the project was excessive and was due in part to failures by the council. We also found that the council adopted a contradictory position by accepting responsibility in 2012, before suggesting, when Mr C complained in 2013, that he was responsible for managing flood risk. This also contributed to the delay in commencing work to mitigate the flood risk to his home.

Recommendations

We recommended that the council:

• apologise for the failings that our investigation identified;
• update Mr C and us on the progress being made against the timetable for completion of the project; and
• provide Mr C and us with a clear timetable for completion of the project.

Summary

Mrs C complained about an unauthorised development immediately adjacent to her home. She said that in June 2013 work began in the field next to her house and it quickly became apparent that this was to develop a caravan site. A planning application was submitted for part of the site. In September 2013, the council issued a temporary stop notice with regard to the works and also obtained an interim interdict from the sheriff (a temporary court order stopping a particular course of action). Court proceedings began after the interdict was breached and a planning enforcement notice was issued. Thereafter, another planning application was made for the remainder of the site (for which no application had been made).

No appeal was made against the council's enforcement notice which, therefore, took effect in December 2013. The compliance date expired in January 2014 without any action being taken against the developer. Then, in April 2014, both planning applications were withdrawn. Court proceedings against the alleged operator were dismissed in August 2014 and, the following month, two new planning applications were made for the site which were subsequently deemed to be invalid.

Mrs C complained that although the opportunity existed for the council to take action and clear the site, they failed unreasonably to do so. As a consequence of the unauthorised works that have taken place, she said that her house and business have been detrimentally affected and her home is at risk from flooding.

The council said that they took such breaches of planning control very seriously but that the situation next to her home was not straightforward; once the notice had expired which allowed time to appeal or comply, the only action remaining to the council was to remove the caravans and associated buildings by direct action. The council said they were considering this and developing a formal strategy to address the unauthorised development which they hoped would be in place by June 2014.

We took independent advice from one of our planning advisers and we found that there was uncertainty of timing of action regarding ongoing court action and the planning applications. There was also uncertainty over the need to obtain powers over the entire site before taking direct action which required professional judgement on the part of planning officers. Up until spring 2014, all of the measures taken by the council to remedy the breach were reasonable and part of the suite of statutory planning enforcement instruments available under planning legislation. Similarly, it was reasonable for the council to await outcomes of planning applications and court action at the same time as formulating a strategy of action. However, although the council had spoken about a plan of action, they had, in fact, made very little meaningful progress towards it and towards an effective remedy for the breach of planning control. Little was done to expedite action and there was little assessment of the available options. Throughout this time, Mrs C was left with a large and unauthorised development next to her house, so we upheld her complaint.

Recommendations

We recommended that the council:

• make a full apology for the delay in pursuing a plan to deal with the unauthorised development and for the distress and inconvenience suffered; and
• ensure that relevant planning officers review the circumstances of this complaint to see where opportunities were lost to progress matters and to develop an action plan to avoid them in the future. They should inform us of the plan they agree.

Summary

In January 2013, Mr A attended the medical practice as he had ongoing chest pain and a cough. A chest x-ray and blood tests were arranged and the results came back normal. However, as his pain was continuing he was given painkillers. In March 2013, Mr A attended the practice again because his symptoms were continuing and he was referred to hospital for a specialist opinion. Mr A was seen in hospital in May 2013 although, in the meantime, the practice prescribed him increasing painkillers and his tests were repeated but again with no result. After a difficult diagnosis pathway, Mr A was advised over the phone by his GP in September 2013 that he had cancer, and he died in May 2014.

Mr C complained to the practice on behalf of Mr A's widow (Mrs A) that it had taken the practice too long to refer Mr A for appropriate tests and opinion and that there was a lack of urgency to provide him with any meaningful treatment. He further complained that a GP within the practice told Mr A of his diagnosis over the phone, which he said was inappropriate and showed a lack of compassion.

We took independent advice from one of our GP advisers and we found that while Mr A was treated reasonably and appropriately and that efforts were made to treat his pain, he was not referred to hospital in line with national guidelines for suspected cancer. His referral should have been urgent rather than routine. Because of this, there was a delay in him being seen in hospital and a delay in his treatment being started. While it was confirmed that Mr A had been told of his diagnosis over the phone, this was for the best of intentions in order to explain his increasingly strong painkillers. Nevertheless, this should not have happened and arrangements should have been made for a house call or for Mr A to attend the practice. In light of the advice we received, we upheld Mr C's complaint.

Recommendations

We recommended that the practice:

• make a formal apology to Mrs A for this failure;
• ensure that all medical staff familiarise themselves with the national referral guidelines for suspected lung cancer; and
• ensure that the GP reflects on the distress caused and he ensures that the matter is raised at his next formal appraisal. He should advise us that he has done so.

Summary

Mrs C complained on behalf of her client (Mrs A) who was unhappy with the care and treatment she received from her GP practice in relation to a finger injury.

After injuring her finger, Mrs A attended the hospital minor injuries and illnesses unit, but she was discharged. A week later, she attended the practice as she was still unable to bend her finger. The GP examined her finger and prescribed antibiotics. Mrs A returned a week later and a different GP prescribed different antibiotics. Mrs A returned again another week later, and at this appointment she mentioned that soon after the first injury, she had had a second injury which stretched her finger. The third GP then considered that Mrs A might have an injury to her flexor tendon (the tendon that connects the muscles in the forearm to the bones in the finger), and referred her to the orthopaedic clinic as a routine referral. After further investigations, Mrs A was diagnosed with an incomplete tear of the flexor tendon.

After taking independent medical advice from a GP adviser, we upheld the complaint. We found that, although the first two GPs did not know about the second injury, in view of Mrs A's symptoms they should still have considered the possibility of a flexor tendon injury and referred her for specialist assessment. Although the third GP acted appropriately in referring Mrs A to orthopaedics, this should have been an urgent referral, rather than routine. We were concerned that the GPs' failures to refer Mrs A appropriately led to a delay of over three weeks in her treatment, which our adviser said was significant as flexor tendon injuries are normally treated within a few days.

Recommendations

We recommended that the practice:

• issue a written apology to Mrs A for the failings our investigation found; and
• draw our findings to the attention of the GPs involved, for reflection as part of their annual appraisal.

Summary

Mrs C complained on behalf of her client (Mrs A) about the board's care and treatment of Mrs A's finger injury.

Mrs A attended the minor injuries and illnesses unit with an injury to her finger, but she was discharged as the nurse considered it a superficial wound. However, after some weeks, Mrs A's GP referred her to the orthopaedic unit, as she still could not bend her finger. After further investigation she was diagnosed with an incomplete tear of the flexor tendon (the tendon that connects the arm muscles to the bones in the finger). Mrs A was referred for physiotherapy, but this did not help, and the orthopaedic surgeon offered Mrs A surgery to try and improve the movement in her finger. Mrs A agreed, but the surgery was delayed four months while waiting on an echocardiogram (a scan of the heart), which Mrs A had been referred to by the general medical clinic (for an unrelated issue). Mrs C complained about the care and treatment and the delay in Mrs A's surgery, as well as about the board's response to her complaint to them.

After taking advice from an orthopaedic surgeon and a general medical consultant, we upheld Mrs C's complaints. We found that the first assessment of the wound at the minor injuries and illnesses unit was inadequate, and may have missed an opportunity to diagnose Mrs A's injury earlier, although the later care and treatment by orthopaedics was reasonable. We also found that the delay in surgery was unreasonable, as the adviser said this scan should have been completed within weeks, rather than months (in this case it was delayed because the referral was missed). We also found that the board's response to Mrs C's complaint was inadequate, as they did not acknowledge failings which they were aware of at the time, and they did not explain the delay in Mrs A's surgery.

Recommendations

We recommended that the board:

• remind staff in the minor injuries and illnesses unit of the 'Tayside Hand Unit – Trauma Referral Guidelines' (in particular the guidance on assessment of wounds on page 7);
• consider options for improving the tracking of similar referrals in the general medical clinic;
• bring our findings to the attention of relevant staff for reflection and learning;
• issue a sincere written apology to Mrs A, acknowledging the failings our investigation found; and
• remind relevant staff of the need to ensure complaints are fully investigated in line with the complaints procedure and the responses provide full explanations of the matters raised.

Summary

Mr C complained on behalf of Mrs A, the widow of Mr A. Following a referral by his GP, Mr A was seen in Ninewells Hospital for advice and investigation in May 2013. He was given a computerised tomography (CT) scan (which uses

x-rays and a computer to create detailed images of the inside of the body) which showed an abnormality on one of his ribs which was suspected to be sinister. In July 2013, a biopsy was attempted but this failed because it was too uncomfortable for Mr A. The following month, a further CT scan was taken as was a biopsy under general anaesthetic. The results confirmed that Mr A had cancer. Mr A had further investigations the following month and a treatment plan for him was discussed by a multi-disciplinary team. Mr A was advised of his diagnosis and plan in October 2013. Regrettably, Mr A's condition continued to deteriorate and he died in May 2014.

Mr C questioned why early tests and investigations given to Mr A failed to show evidence of his illness and said that there had been delays in providing him with treatment. Mr C said that as a consequence, Mr A had lost time with his family. Mr C also complained that there had been delay in issuing correspondence to Mr A. On behalf of the hospital, the board said that it had been very difficult to diagnose Mr A's illness and that while tests showed that something was wrong, this could have been for a number of reasons; there had been a delay in getting biopsy results but this had been unavoidable. Similarly, they said that there had been a delay in sending out letters because of administrative problems but that this had not affected Mr A's treatment overall.

We took independent advice from a consultant clinical oncologist and found that it had been very difficult to diagnose Mr A's cancer and to establish information by biopsy to determine the type of treatment he needed. This was not unreasonable in the circumstances. However, it had not been reasonable not to have treated Mr A as a suspected case of cancer from the outset and thus provide him with this care and treatment at an earlier date. Because of this delay and confusion in correspondence sent to Mr A, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• provide a formal apology to Mrs A;
• provide a formal apology for the delays in correspondence;
• inform us of the outcome of their administrative review and the steps taken to avoid a similar situation; and
• ensure that the advice provided for this complaint is brought to the attention of those clinicians involved in the case.

Summary

Mr C complained about his treatment when he attended a stroke clinic. He was unhappy that he was sent home the same day, having been assessed and a stroke diagnosis made. He said he lived alone in a third floor flat and the board did not ask how he would get home or check that there was someone there to look after him. He also complained that no follow-up was arranged, particularly in relation to the psychological impact of the stroke, noting that he previously suffered from mental health difficulties.

The board responded indicating that they carried out appropriate investigations to arrive at the diagnosis and sent a results letter to Mr C's GP with a care plan. They noted that Mr C was independent both before and after the stroke and that he had made his own way to the stroke clinic. They assumed, therefore, that he was able to make his own way home. They assured Mr C that a referral would have been made to the appropriate services had the clinical team believed there to be any ongoing physical or psychological problems arising from his stroke.

We took independent advice from one of our medical advisers, who said there was no evidence to suggest that Mr C required admission following his attendance at the stroke clinic. Our adviser considered that the assessment carried out was reasonable in terms of how thorough it was, noting that appropriate recommendations were made to Mr C's GP regarding his future treatment and monitoring. However, our adviser did not agree with the board's position that there were no ongoing psychological difficulties, stating that there was clear evidence of Mr C's previous and current mental health problems at the time of his attendance at the clinic. Our adviser, therefore, considered that Mr C should have been referred to psychology services by the clinic doctor and considered that the care he received in this regard was unreasonable. We also identified a later breakdown in communication which resulted in the neuropsychology department appearing not to have made an onward referral to the mental health team. On balance, we upheld the complaint and made some recommendations.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings that this investigation has identified;
• arrange for Mr C to be seen again in the stroke clinic for review of his symptoms; and
• highlight to relevant staff the importance of referring stroke patients to psychology services, where appropriate.

Summary

Ms C complained on behalf of her daughter (Ms A) about the treatment Ms A received at the Western General Hospital. She said that the reporting of a scan was unreasonable, and that the arrangements for follow-up appointments after this scan and an operation carried out some nine months later were unreasonable. Finally Ms C was unhappy with the board's handling of her representations.

During our investigation, we took independent advice from a consultant neurosurgeon and a consultant neuroradiologist, after which we upheld Ms C's complaints. In responding to the complaints, the board had accepted that the written report prepared after the scan failed show that there was a significant abnormality and they had apologised for this error. They had suggested improvements as a result, and our adviser said that these should be implemented.

We also found there was a delay in Ms A receiving a follow-up appointment after the scan, for which the board had also apologised. The advice we received was that Ms A's clinical pathway had not changed as a result of this, but it did lead to a considerable delay in telling her about her new diagnosis. The adviser also said that there was no delay in the follow-up appointment after Ms A's operation but we were concerned that she was not provided with the findings reported at the time of her operation during her in-patient stay in hospital. We were satisfied that there was no delay in arranging a further scan after her operation.

The board had apologised that Ms A had not received details of the oncology (cancer) team including the clinical nurse specialist in a timely manner. As a result of these communication problems the board had taken action to improve coordination of neurology patients and their care by establishing a new multi-disciplinary team. Finally, they had accepted failings in their handling of Ms C's complaints and had taken action as a result.

Recommendations

We recommended that the board:

• report back to us on the action taken to implement the improvements proposed; and
• ensure the staff involved in this case are made aware of the importance of ensuring findings reported at the time of the operation are appropriately reported to patients and/or their relatives.