Upheld, recommendations

Summary

Mr C complained about the care and treatment provided to his late brother, Mr A (who had a significant mental health condition), when he was admitted to University Hospital Ayr with internal bleeding. Following treatment, Mr A was transferred to East Ayrshire Community Hospital with a view to discharging him home a few days later. However, when Mr A's support workers came to the hospital to take him home, they raised concerns about his condition and he was readmitted to University Hospital Ayr. Mr A had further internal bleeding and several weeks later a scan showed that he had had a stroke. He was later discharged to a nursing home, where he became severely disabled and in need of constant attention before his death some six months later.

Mr C complained that if it were not for Mr A's support workers querying his discharge, he would have been sent home and died. Mr C also believed that the result of the stroke would not have been as serious if Mr A had received adequate care and treatment sooner. Mr C was also unhappy with communication from a stroke consultant about the possibility of stem cell treatment, and the board's response to the complaint, saying it was not an accurate reflection of what happened.

We took independent advice from one of our medical advisers after which we upheld Mr C's complaint. Our investigation found that Mr A was clinically unstable when he was transferred to the community hospital, that healthcare professionals failed to check a blood test before the transfer, and that the stroke consultant's discussion with Mr C unreasonably raised his hopes for curative treatment. However, we found that healthcare professionals had diagnosed Mr A's stroke within a reasonable time. In relation to Mr C's complaint about the board's response to his complaint, we found shortcomings in the board's response and made a recommendation to the board about this.

Recommendations

We recommended that the board:

• inform us of how they intend to ensure the safety of transfers to community hospitals, particularly for vulnerable adults with severe mental health problems such as Mr A;
• provide a copy of the latest audit of the appropriateness of admissions to the community hospital;
• feedback the failings identified in relation to checking a blood test and communication about stem cell treatment to the relevant healthcare professionals;
• bring the failures identified to the attention of relevant complaints staff; and
• apologise to Mr C for the failings this investigation identified.

Summary

Mr C complained about the university's actions, after he had a period of ill health while studying there. He complained that they did not do enough to support him through a difficult time, and did not make reasonable adjustments to enable him to continue his studies. He said this led to him having to withdraw from the course.

We found that Mr C had had a number of absences, despite the expectation that he attend all elements of the course. We reviewed what the university expected of Mr C in order for him to continue to the next year of the course, and noted the meetings he had with staff and the support that he was offered in trying to overcome his situation.

We sought independent advice from an equality and diversity specialist, who noted that the university had referred Mr C to sources of support. However, she said that Mr C's department did not take reasonable steps to inform and assist him. They had not implemented the university's policies about equality of access and fees refunds. She took the view that had they done so Mr C might have been able to agree an approach with the university that would have enabled him to continue his studies. She also noted that they had not sought advice from occupational health before making a decision about Mr C's future studies.

We noted the difficulties for Mr C and the university in predicting how the year would progress, and in deciding what he could best do to overcome these challenges. However, we considered that the university could have done more to discuss the options with him, highlight their concerns, and review any alternative approaches available to him. We noted that an occupational health referral could have assisted with this, and we were critical of the lack of notes or minutes of meetings.

Mr C also complained about the number of people that he had to inform about his health issues, saying this breached his privacy. Our review of the university's policies and procedures identified who he was required to tell about his sickness absence. We noted that, on occasion, Mr C chose to share personal health information with staff when he was absent due to ill health, beyond the requirements of the university's procedures. However, we found that there was a lack of procedures in relation to situations other than reporting illness. We were critical of this, as it meant that information could have been shared with more people than was necessary.

Recommendations

We recommended that the university:

• apologise for their handling of Mr C's poor health in the academic session 2012-13, for the stress this has caused him, and the potential impact on his career;
• consider applying their refund policy to Mr C's fees for the academic session 2012-13;
• undertake a full review of the events that led to the curtailment of Mr C's studies, to identify what they could have done differently, and how their policies and practices could be improved in future;
• review their policies regarding the provision of support and adjustments for students, and consider consolidating them into one document, to ensure clarity for students and staff in relation to what support is available and how it is implemented;
• ensure staff are aware of the need to minute meetings with students, particularly where performance is in question, and that these minutes should be shared with the student;
• apologise to Mr C for their handling of his sensitive personal information; and
• review their policies relating to the provision and sharing of personal sensitive information, to ensure that they clearly indicate why such information is required and who needs to have access to it.

Summary

Mr C complained that the Scottish Prison Service (SPS) delayed in repairing a phone that he reported broken. We found that the SPS had not taken any action to repair the phone for over two weeks after Mr C complained about it and we upheld his complaint.

Mr C also complained about the way in which the SPS had handled his complaint about this. In their initial response, they said that the fault had been reported. When we investigated this, we found no evidence that this had happened. When we asked for an explanation, the SPS told us that they had confused this with another problem that was affecting phones in the prison. Mr C then made a further complaint about the matter. In their response to this, the SPS again confused the two problems and told him that the fault had been reported and resolved. This was incorrect and we found that there had been a clear failure by the SPS to investigate and address a relatively straightforward complaint. Their responses to Mr C were clearly inaccurate and we also upheld this aspect of his complaint.

Recommendations

We recommended that the SPS:

• take steps to ensure that there is an effective process in place for identifying phones in the prison, logging reports of phone faults and ensuring that they are investigated and repaired;
• issue a written apology to Mr C for the failures we identified in relation to the handling of his complaint; and
• issue a reminder to the staff involved in handling Mr C's complaint that the issue complained about should be adequately investigated in line with the prison rules and the SPS's staff guidance on prisoner complaints and disciplinary appeals.

Summary

Mr C complained that when he transferred from prison 1 to prison 2 some of his property went missing and that this was not properly investigated, although he submitted a claim form in December 2012. He told us that prison 2 had made several attempts to contact prison 1 to have his claim fully investigated but the matter remained unresolved.

We found no record of Mr C having submitted a claim form in December 2012. We did find, however, that in January 2013 prison 1 had forwarded various items belonging to him to prison 2, which suggested that there was an issue with his property around this time. We noted that although in August 2013 prison 2 sent prison 1 a claim form that Mr C completed, and made attempts to follow this up, prison 1 did not reach a decision on the claim until April 2014. Although the SPS have no national timescales for resolving lost property claims forms, we concluded that prison 1 delayed unreasonably in responding to Mr C's claim. Furthermore, they did not provide sufficient information to show how they investigated the claim or any reasons to justify their initial compensation offer. As there was evidence of various items having gone missing, we upheld Mr C's complaint and made recommendations.

Recommendations

We recommended that the Scottish Prison Service:

• review their initial offer of compensation to better reflect the loss of the missing items identified; and
• ensure prison 1 review their lost property claims procedure with a view to ensuring details of the investigation are documented and timely decisions are made.

Summary

Mr C applied for planning permission in 2007, which was granted with conditions. Mr C began works on the site a couple of years later. In July 2013 the council contacted Mr C and informed him that he had not satisfied all of the conditions of the planning permission prior to work starting, and they had not been formally discharged. They invited him to submit the information regarding the conditions for them to be discharged.

Mr C said he had been given verbal approval by the planning officer at the time, but did not recall getting anything in writing. Mr C submitted further information in August 2013. In November that year, the council wrote to Mr C to inform him that as the conditions had not been discharged within the five year period in which the permission had been granted, the application had lapsed and he would have to submit a new application and pay the associated fee for doing so. Mr C complained about this and came to us.

We took independent advice from one of our planning advisers, who was of the view that the council, by its own standards for discharging conditions, had not followed the proper procedure. Our adviser also noted that the council had not specified in all the conditions that they needed to be satisfied in writing. We accepted our adviser's view and in light of the evidence we found we upheld Mr C's complaint and made recommendations to address the issues identified. We also recommended the council apologise to Mr C.

However, our adviser also noted the responsibility of the applicant to ensure they have all the proper permissions before starting works on site. In considering this, we recommended that the council reduce the new application fee by half, to reflect the shared responsibilities of both parties.

Mr C had also complained about the way the council handled his complaint. We were satisfied the appropriate person had investigated it, but it had taken six weeks for a response to be issued to Mr C. For this reason, we upheld this complaint and made a recommendation to remind staff about the timescales on complaints.

Recommendations

We recommended that the council:

• apologise to Mr C for the failings identified;
• find a mechanism to reduce the cost of the application fee by 50 percent, in recognition of the failings identified;
• remind relevant staff of the procedures regarding the discharging of conditions;
• consider being more specific in requiring written approval, in wording conditions; and
• remind relevant staff of the importance of monitoring timescales on complaints.

Summary

A planning application was submitted for land next to Mr C's property. Mr C viewed the available documents and made representations to the council. He also asked for copies of information that would have made clear the proposed heights of the dwellings being proposed, but was not given this information. The planning application was approved. When work began, Mr C was concerned about the height of the ground being prepared for the dwelling to be built closest to his home. He complained to the council that the height of the proposed dwelling had not been clear from the information available to the public during the consultation period. In response the council advised that clear indications of the heights of the proposed dwelling had been available when the decision to grant permission had been taken. Mr C brought his complaint to us.

We took independent planning advice, and found that the documents that the council said made clear the heights of the proposed dwelling were not available to the public during the consultation period, and that this was not in line with the terms of relevant national policy. In light of this, we upheld Mr C's complaint.

Recommendations

We recommended that the council:

• provide written apologies to all those to whom they gave notice of the application under the neighbour notification provisions of the Planning etc (Scotland) Act 2006 for their failure to reasonably ensure that the heights of the dwellings proposed in the application were clear to the public during the consultation period; and
• review their planning procedures to ensure that the information available to the general public during the consultation period for planning applications indicates clearly when substantial changes to the height of land are proposed.

Summary

Miss C was served with a bus lane enforcement charge notice for an incident that occurred within days of her selling her vehicle. The notice said that if she considered she should not have received it, she could make representations, and if the council rejected these, she could appeal to the Scottish Parking Appeals Service. At first, Miss C did not have details of the new owner, but after she got information from the DVLA (for which she had to pay), the council withdrew the notice. They turned down her request for the costs, and said they reserved the right to send her a further notice if the new keeper denied responsibility. Miss C complained that the council failed to deal with the issues and her queries satisfactorily, and unnecessarily put her to the expense of pursuing the matter.

We upheld all Miss C's complaints. Our investigation found that the council’s decision not to pay her DVLA expenses was based on a misinterpretation of the regulations. The notice omitted part of the regulation saying that it was only ‘if’ that information was in the recipient’s possession that they must provide it. We found that the council had misunderstood their obligations and had no right to demand this information from Miss C. We also found that the council continued to correspond with Miss C after the DVLA confirmed that she was no longer the registered keeper. The council had accepted this but failed to explain to us why they then continued to deal with Miss C, even after the new keeper had accepted liability for the contravention. They also failed to investigate Miss C’s complaint that email was acknowledged but not replied to.

Although the council told us that they carried out all procedures in terms of the Transport (Scotland) Act 2001, they failed to make clear to Miss C which section of the regulations gave them the authority to ‘withdraw’ the notice rather than cancel it. There was nothing wrong with the council testing out the information about the new keeper. However, they should not have issued Miss C with a notice of acceptance until they had done so. By doing so, they denied Miss C a right to appeal, and she was only able to obtain confirmation that the notice would not be re-issued by pursing a formal complaint to the final stage of the council’s complaints procedure.

Recommendations

We recommended that the council:

• review their handling of Miss C's expenses claim, in the light of the omission of an integral part of the Regulation from the Penalty Notice;
• review the handling of this case to ensure an improvement in future dealings with their customers;
• apologise to Miss C for their failure to address her complaint promptly and clearly;
• investigate why Miss C's email was not recorded and processed, and notify us of their findings;
• apologise to Miss C for the failure to investigate this matter; and
• review their procedures for imposing charges for bus lane contraventions and the standard letters issued to the public.

Summary

Mr C complained to us about the council's handling of his tenant's application for Local Housing Allowance (LHA). When his tenant failed to pay the rent, Mr C phoned the council. He was told that there were delays in processing the application, but that when it was done, he would receive a payment directly. The council finished processing the application some four months after it was submitted. However, a computer system fault meant that the first payment went directly to the tenant's bank account, instead of Mr C's. Mr C did not know this, and when he had still not received payment several weeks later, he made a further enquiry. It then became apparent what had happened, but by this time a further rent payment had gone to the tenant.

We found that the council gave Mr C inaccurate information about applying for direct payments. They 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, and 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 respond within their stated timescales, and 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, in their decision-making and their use of evidence - they relied too heavily on unreliable evidence from the tenant. We also found that they did not provide Mr C with consistent information.

Recommendations

We recommended that the council:

• pay Mr C the cost of the first payment which was sent in error to the tenant;
• ensure that all staff involved in processing LHA applications are fully aware of the timescales in the council's complaints handling procedure; and
• apologise to Mr C for the errors in handling his tenant's LHA application, and for the time and effort involved in this complaint.

Summary

Mr A suffered from advanced cancer, and was admitted to Ninewells Hospital for treatment to control his pain. While there, he fell and a fractured hip was suspected, although it was established this was not the case. He was transferred back to a palliative care centre (a place providing care to prevent or relieve suffering only), but was semi-conscious on arrival, and died shortly afterwards.

Mr A's daughter (Ms C) complained that her father had not received adequate care. She said Mr A's mobility problems had not been properly addressed, which had contributed to his fall. His pain had not been properly controlled and staff had failed to communicate properly with the family. The family felt Mr A was not properly assessed after his fall and should not have been transferred.

The board accepted that there were failings in Mr A's care, and apologised for these, explaining that changes had been made to procedures as a consequence. They said the decision to transfer Mr A was appropriate, although he had deteriorated during the transfer. They also said that he was properly assessed after his fall and his pain had been adequately managed. The board told the family they had an action plan to improve care, and this would be shared with them.

We took advice from a palliative care adviser, a nursing adviser and a geriatric medicine adviser. The palliative care adviser said Mr A had suffered a reaction to his medication. His dosage had been reduced, but it had later been increased again. She was also critical that Mr A was not medically reviewed before transfer. Our nursing adviser criticised the standard of nursing care, but noted that the board had taken action to remedy the majority of the failings. The geriatric medicine adviser agreed that the decision to transfer Mr A was appropriate, but was critical of the failure to review him immediately prior to transfer, or to discuss the decision with the family.

We found the decision to transfer Mr A was reasonable, but that he should have received a medical review immediately before being transferred. The transfer should also have been discussed with the family before it took place. We found serious failings in the nursing care provided to Mr A, noting that the board had addressed these, although they had failed to evidence this to the family. We upheld Ms C's complaints, and made several recommendations.

Recommendations

We recommended that the board:

• apologise for the failings that our investigation identified;
• review their complaints procedure to ensure that where appropriate complainants are provided with copies of action plans drawn up in response to their complaints;
• remind staff of the inappropriateness of the use of the term 'cotsides' when discussing patient care;
• review their procedures for transfer of patients, to ensure that patients are appropriately reviewed by medical staff immediately prior to transfer;
• remind staff of the importance of reviewing a patient's clinical notes prior to prescribing opiates; and
• remind all staff of the importance of providing accurate information to relatives in relation to the medical care being provided.

Summary

Mrs C complained that the board failed to take reasonable steps to mobilise her father (Mr A) during his stay in the Western General Hospital.

During our investigation, we took independent advice from three of our medical advisers, a consultant physician, a physiotherapist and a nursing adviser, after which we upheld Mrs C's complaint. The consultant physician said that the medical care Mrs C's father received was generally of a high standard and that the decision to discharge him had been reasonable. However, we were concerned that there was no reference in Mr A's medical records to the decision to prescribe him a second antidepressant. In addition, the physiotherapist said that Mr A did not appear to have received much in the way of mobility input during his first month in hospital and that physiotherapy care fell below what would be considered an acceptable standard. Physiotherapy treatment received later was, however, appropriate and acceptable.

There also appeared to be a lack of communication between physiotherapy, the medical team and the nursing team and a lack of coherent mobility planning involving the whole multi-disciplinary team. Our nursing adviser said that, while some aspects of Mr A's nursing care were reasonable, there were some failings in relation to record-keeping which made it difficult to establish some key aspects of the care provided, particularly in terms of his mobilisation and his confusion.

Recommendations

We recommended that the board:

• ensure that relevant staff members are made aware of our adviser's comments in relation to the use of a formal depression score to aid decision-making around antidepressant treatment, and given the opportunity to reflect on these for their future practice;
• bring the issues raised in this complaint to the attention of the physiotherapy staff involved to see if lessons can be learned and report back to us;
• consider including a section on mobility on the standard care plan;
• ensure that our adviser's comments about the lack of communication between physiotherapy and the medical and nursing team and a lack of coherent mobility plan involving the whole multi-disciplinary team are brought to the attention of the relevant staff;
• provide evidence of the systems in place to monitor the standard of record-keeping in relation to nursing and physiotherapy care, to ensure that assessment, care planning and evaluation of care delivery does reflect individual care needs; and
• apologise for the failings identified.