Upheld, recommendations

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.

Summary

Mrs C was referred to Aberdeen Royal Infirmary with pain on her left side, which her GP thought might be due to kidney problems. She was x-rayed, had an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) and was discharged with a diagnosis of constipation with no planned follow-up. Mrs C continued to be unwell and was treated by her GP for constipation (as advised in her hospital discharge letter). Mrs C collapsed at home and was readmitted to the hospital several months later. At that time a computerised tomography (CT) scan (a scan that uses x-rays and a computer to create detailed images of the inside of the body) was performed and a large mass, thought to be an ovarian cyst, was found. Mrs C had surgery to remove this mass and was advised that primary cancer had been found in her colon and it was this that had spread. Mrs C was offered chemotherapy but was advised that this was only to relieve symptoms as the diagnosis was terminal.

Following surgery to remove the primary cancer from the colon, Mrs C was told she was not terminally ill and that the spread of the cancer had not occurred as had been previously suspected.

We took independent advice from a medical adviser who said that the board's initial actions and their diagnosis of constipation were reasonable. Our adviser also considered that the treatment provided once the cancer was detected was reasonable and appropriate.

Nevertheless, our adviser said that it would have been good practice to have a bowel surgeon present during Mrs C's surgery given the known presence of abnormalities in the colon. Our adviser was also of the view that the pathology report following this surgery did not suggest a terminal diagnosis and he did not consider that the terminal diagnosis given to Mrs C had been appropriate. For these reasons, we concluded that the care Mrs C received was not reasonable.

Recommendations

We recommended that the board:

• apologise to Mrs C for incorrectly diagnosing her condition as terminal;
• ensure the staff involved in the diagnosis reflect on their diagnosis in light of our medical adviser's comments, in particular to ensure pathology reports are appropriately taken into account; and
• review the surgery carried out in light of our medical adviser's view that a bowel surgeon should have been directly involved.

Summary

Ms C, who is a member of parliament, complained about the care and treatment Mrs A received at Peterhead Hospital. Ms C brought the complaint to us on behalf of two of her constituents, the late Mrs A's daughter (Mrs B) and sister (Mrs D). Mrs A had been admitted to hospital after suffering from sickness and diarrhoea for several days. Ms C said that staff at the hospital failed to provide Mrs A with appropriate clinical treatment and nursing care. Ms C raised a number of concerns, including that there was an overall lack of concern or anxiety about Mrs A's condition shown by nursing staff and the doctor involved, and not enough was done to help her. Mrs A died whilst in hospital.

We obtained independent medical advice about the complaint from a GP and a nurse. Both of our advisers said that Mrs A's SEWS score (Standardised Early Warning System – a system which uses special observation charts completed by nursing staff to recognise deterioration in patients) was such that medical assessment should have occurred, but nursing staff failed to request a review by a doctor.

Our nursing adviser explained that Mrs A's oxygen reading was very concerning and, along with Mrs A being 'clammy' and her 'limbs discoloured', this indicated a very serious deterioration in her condition. She said nursing staff should have been aware of the significance of these signs of shock and should have acted immediately.

Our GP adviser said that when the doctor saw Mrs A, he did not carry out a reasonable assessment, did not record accurate observations and did not take action upon these. She said that the doctor failed to respond appropriately to the abnormal and deteriorating observations recorded on Mrs A's SEWS recording chart and arrange further investigation.

We concluded that there were clear failings in the clinical and nursing treatment provided to Mrs A by the staff at Peterhead Hospital.

Recommendations

We recommended that the board:

• ensure the failings identified by the adviser are addressed with the doctor;
• confirm that the doctor has discussed his full report with the independent GP appraiser and confirm the outcome to us;
• remind nursing staff involved in this case of the importance of SEWS and the reason for using this across Scotland;
• provide us with an update regarding the current use, monitoring and any relevant accuracy of completion of SEWS and response audits;
• provide us with evidence of their on-going assessment and training for medical emergency, including sepsis; and
• provide the family with a written apology for the failings identified.

Summary

Mr C asked the prison to cover the cost of providing him with contact lenses instead of glasses. The prison advised Mr C that the Scottish Prison Service (SPS) would not cover the cost of contact lenses, only glasses. Mr C complained that the prison failed to appropriately consider his request because they failed to seek any clinical advice about whether he needed contact lenses, and he said he had previously received them in a different prison.

We asked the SPS to tell us if steps had been taken by the prison to confirm whether an optician had recommended that Mr C receive contact lenses instead of glasses. We also asked whether steps had been taken to check whether the other prison had provided Mr C with contact lenses. In their response, the SPS provided a statement from the other prison which confirmed that they had not purchased contact lenses for Mr C. The SPS also received confirmation from the health centre that the optician had not recommended that Mr C wear contact lenses instead of glasses, and there was no medical reason why Mr C could not wear glasses. This information was only sought by the prison following our enquiry to the SPS about Mr C's complaint.

At the time of making his complaint, the prison did not take steps to check whether Mr C had previously been issued contact lenses. They also did not clarify whether Mr C did in fact require contact lenses. We considered that both of those steps should have been taken by the prison at the time of investigating Mr C's request and therefore we upheld the complaint.

We also upheld Mr C's complaint that the prison failed to handle his complaint appropriately. In particular, the information provided by the SPS indicated that the chairperson of the internal complaints committee (ICC) invited the health care manager to attend the hearing but she chose not to. We concluded that the chairperson considered that the evidence the health centre manager would have brought was of relevance and value to the ICC's consideration of Mr C's complaint. However, there is nothing contained within the prison rules which suggests that a witness can be compelled to attend an ICC hearing. Instead, the rules indicate that a witness can be called by the prisoner to give evidence in support of their complaint and the ICC chair can decide whether the witness will be permitted to attend. There is no suggestion that the witness must attend even if they are permitted to do so by the ICC chair. However, as noted earlier, we considered that steps should have been taken by the prison to explore whether the optician had recommended that Mr C wear contact lenses as opposed to glasses. The ICC could have, with Mr C's consent, obtained that information easily and without the health care manager's attendance at the hearing. Taking those steps would have ensured the ICC had access to the relevant information that the health care manager could have brought to the hearing before reaching their decision on Mr C's complaint. The SPS accepted that they did not respond to Mr C's complaint within the relevant timescale and offered an apology. Therefore, we upheld the complaint.

Recommendations

We recommended that the SPS:

• provide feedback to the relevant members of staff in relation to the handling of Mr C's request to ensure that all relevant information is obtained prior to taking decisions;
• explore what their position would be if a clinician recommended a prisoner be supplied with contact lenses instead of glasses; and
• apologise to Mr C for the failings our investigation highlighted about the prison's handling of his complaint.