Upheld, recommendations

Summary

C complained about the care and treatment provided by the board to their partner (A). A had a seizure and was admitted to hospital for further assessment. C reported their concern to staff that A had dislocated their jaw during the seizure, and advised that this had happened to A before.

A underwent x-rays and was referred to oral and maxillofacial surgery (OMFS, specialists in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) for review. OMFS concluded that no further treatment was required for A. C continued to report their concern about A's jaw and an urgent referral was made to ear nose and throat (ENT) for further assessment. This was later re-directed on vetting to OMFS, however no follow-up review by OMFS took place by the time of A's discharge some weeks later.

On discharge, C contacted A's GP who arranged for A to be seen by another health board. A was diagnosed as having a dislocated jaw and underwent emergency surgery.

The board said that there had been evidence of dislocation in the right jaw joint. They said that due to A's dementia and reduced mobility, they were unable to fully cooperate during their assessment and would not have been able to manage further x-ray procedures. They noted that A did not appear to be experiencing any pain and appeared to have a good range of movement of their jaw.

We took independent advice from an oral and maxillofacial surgeon. We found that A's initial assessment on arrival at the hospital and the decision to wait until the x-rays had been reported before referring A to OMFS for further assessment was reasonable. However, we found that the assessment of A's jaw by OMFS failed to elicit the clinical features of the dislocation and failed to consider other types of scan after concluding the diagnosis was unclear.

On the matter of the urgent referral to ENT which was later redirected to OMFS, we were critical that no follow-up review by OMFS took place prior to A's discharge. We considered that the board failed to provide A with reasonable care and treatment and upheld C's complaints.

We also noted that, at the point of C complaining to the board, it was known that A had in fact dislocated their jaw during their admission. The board confirmed in their response to our enquiries that no internal processes for reporting or learning or improvement had been followed on becoming aware of this harm. While the board had responded to C's complaint, we were critical that they failed to initiate or follow other processes to record the event, or to elicit learning and improvement outcomes at the point of becoming aware of it. Therefore, we made a recommendation to the board on this matter.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably assess and diagnose A's dislocated jaw, the referral to ENT being inappropriately accepted, and the unreasonable delay by ENT in reviewing A which did not take place during their admission. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The findings of this investigation should be fed back to relevant clinical staff in a supportive way for reflection and learning, and to inform future decision making regarding assessment processes.
• Referrals to other specialties for review should be made appropriately and accepted only when it is reasonable to do so. Referrals should be seen within a reasonable timescale.
• When the board becomes aware of a harm through the complaint process, processes should be followed to ensure reporting and learning and improvement takes place. This should be in line with both statutory duties and in keeping with any additional internal processes relevant to the incident type.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C’s child (A) was assaulted at school by other pupils. C complained that the council had failed to protect their child, failed to provide appropriate first aid and failed to provide a reasonable level of support to them following the incident. C also complained that the council failed to safeguard A from the bullying they subsequently experienced.

In their response to C’s complaint, the council provided details of the first aid provided and the steps taken to notify C’s spouse of what had happened. They said that the school had introduced a number of measures to help keep child A safe after the incident. The council initially said that C had refused to take part in restorative meetings, which they considered would have helped to resolve matters. After C complained about the council’s response, the council conceded that C had not been invited to a restorative meeting and apologised for this inaccurate information in their response.

We reviewed the council’s actions with reference to the relevant council policies. We considered that the assault had been taken seriously and acted upon swiftly. However, we found that although the council endeavoured to put in place a number of arrangements aimed at keeping A safe, these did not appear to have been fully implemented. We found that certain aspects of the council’s policies were not followed, that the council acknowledged that no restorative meetings took place and that counselling was not available to child A. We found that the council failed to ensure A was sufficiently supported after the incident and we also found shortcomings in the council’s complaints handling. We therefore upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and C’s family for the reliance on inaccurate information when reaching conclusions in the stage one response, with an acknowledgement of the impact this had on them. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the issues highlighted in this decision notice. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• That the council consider creating a structured procedure and guidance for dealing with serious unacceptable behaviour and ensuring that the parties involved receive a full suite of support if required.

In relation to complaints handling, we recommended:

• Information contained within complaint responses should be accurate. In terms of good practice, complaint responses should be person-centred and non-confrontational.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the council’s handling of their council tax account. They had applied for a single person discount and a council tax reduction. C complained that the council failed to manage their account properly, did not communicate with them and issued warning notices for payment while the account was in dispute. C said that the council’s handling of their account amounted to discrimination.

We found that there were significant delays throughout the council’s assessment. However, we noted that this took place during the COVID-19 pandemic when services were disrupted. We found nothing to suggest the council were discriminating against C but considered that their communication was generally poor.

We were satisfied that C’s council tax reduction entitlement was assessed reasonably, but we considered more could have been done to obtain the relevant information for the purposes of assessing C’s application for single person discount. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Invite C to provide evidence of the date that they moved into the property and reassess the start date for their single person discount accordingly. The council should confirm to C what type of evidence they would accept as proof of the date of entry.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the council unreasonably assessed that a property was in a safe and lettable condition when they handed the tenancy over, that the council failed to make, or communicate, reasonable arrangements for carrying out repairs, and that the council failed to provide a reasonable response.

In respect to the aspect of the complaint that the council had unreasonably assessed that their property was in a lettable condition when the tenancy was allocated, we found that the capacity of the council’s systems to record safety and quality checks led to the council being unable to evidence that the property met the lettable standard at the time the tenancy was allocated. We therefore upheld this complaint.

C also complained that the council failed to make, or communicate, reasonable arrangements for carrying out repairs. We found that C was put to having to arrange repairs that could have been carried out before the property was let. We also found that the council did not communicate effectively with C when appointments were cancelled or had to be rearranged. We therefore upheld this aspect of the complaint.

C also complained that the council did not provide a reasonable response to their complaints. We found that the responses to the complaints did not address all of the concerns raised and failed to recognise the impact the issues had on C. We therefore also upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to ensure that repairs were carried out to the required standard prior to letting the property, for failing to check that the heating and smoke alarm systems were in full working order, for failing to make or communicate reasonable arrangements for appointments and for failing to provide a reasonable response to their complaints. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Where the council have informed a tenant that they will carry out repair work, officers should keep the tenant updated about any delays.
• The council should have effective systems in place to ensure the Lettable Standard is met and that records are well maintained and easily accessible. Tenants must have a satisfactory provision for heating their property.

In relation to complaints handling, we recommended:

• Complaint responses should comply with the Model Complaints Handling Procedure and council staff should be familiar with the Complaints Handling Procedure. Responses should address each point of the complaint, providing a clear explanation of what occured and describing action that will be taken where something has gone wrong. The information in responses should be supported by the evidence in the relevant records.
• Complaint responses should recognise the complainant’s experience and demonstrate empathy for their situation.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C reported concerns to the council’s environmental services department about smoke pollution over a number of years as a result of their neighbour burning bonfires and a wood-burning stove. C was dissatisfied with the lack of action taken by the council and submitted a complaint. C considered that the council’s investigation of their concerns was insufficiently detailed, failed to take account of available evidence, and dismissed factors which C considered important. C also complained that the council’s response contained a number of inaccuracies.

We found that the council did not meet the timescales set out in their complaints procedure. However, the complaint was raised and investigated during the COVID-19 pandemic and C was advised from the outset that timescales were being affected. The council also apologised for this delay. We considered the overall time taken to have been understandable in the circumstances. However, we did note that the council failed to communicate to C that their complaint was being considered at stage 2 of the complaints procedure, despite initially advising that it would be reviewed at stage 1 and that C was not provided with updates when they asked.

It is also clear that there was ongoing communication between C and environmental services throughout the investigation period, correspondence sent and received via a councillor on C's behalf and Freedom of Information requests made. This all contributed to an overall confused chain of correspondence.

Generally, we were satisfied that C’s complaints were taken seriously and an investigation was carried out before the council’s response was issued. However, we found that the investigation sought mainly to respond to the complaint, rather than get to the root cause and attempt to resolve C’s dissatisfaction. The council’s response to C’s complaint reiterated their previously-stated position on whether they considered statutory nuisance had been witnessed. However, C’s complaint referred to the way that the officers had reached their decision, and the lack of objective measurement of the problem or use of official monitoring tools and the apparent disagreement as to which legislation was relevant. We considered that the council’s response should have explained matters such as why the smoke was not considered to be a statutory nuisance, what would be considered a statutory nuisance, why no equipment was deemed necessary to establish that no nuisance existed, and how the officers assess such situations.

We found no evidence that the council’s response to C’s complaint was inaccurate, or that a more detailed investigation would have altered the outcome in terms of the environmental services' assessment of C’s reports.

C also appears to have been given conflicting explanations as to why video evidence was not considered. However, this was clarified in response to our enquiries. We considered that this highlights the importance of collating a single clear explanation before responding to an individual’s enquiry.

Taking all the evidence into account, we found that the council did not reasonably respond to C's complaint. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to address some of the issues C raised, that their communication with C regarding the complaints procedure was poor and their general communication was confusing. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Write to C to provide a more comprehensive response to the outstanding issues we have identified in this decision.

What we said should change to put things right in future:

• The council should consider how they could have better managed correspondence from C to ensure that, where individuals communicate through multiple channels or across multiple departments on the same issue, all points are responded to fully and consistently.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C, an adult with autism, was receiving treatment from the Partnership as a new patient after moving into the area and was unhappy with their psychiatrist. C felt that the Partnership did not have appropriate staff who specialised in treating adults with autism.

C complained that the psychiatrist questioned the diagnoses and treatment plan already in place, that the psychiatrist told them that the treatment plan was wrong, that they asked questions in an unstructured way and made unreasonable remarks about C’s personal life. Further, during an online consultation the psychiatrist allowed a second person to be present without having made C aware this would happen and ignored their request for an adjustment to have a doctor of the same gender as them. C also complained that the Partnership accused them of being misogynistic by asking for a same-gender doctor.

The Partnership said that the psychiatrist did agree to provide the prescription C was seeking as C was very fixed on the recommendations made by their previous psychiatrist. The Partnership also said that C was derogatory towards the psychiatrist due to their gender and questioned their ability.

We took independent advice from an adult consultant psychiatrist. We found that the evidence showed that the Partnership provided elements of good care and treatment to C. However, their response to C’s request for a same-gendered doctor was unreasonable, the consultation deviated significantly from recognised good medical practice and it was unreasonable to have an additional person present without C having been told or asked for consent beforehand. In addition, we found that there was no evidence that would support the Partnership’s position that C was derogatory towards the psychiatrist due to their gender, and there was no evidence to suggest C was significantly hostile. Therefore, the Partnership’s assertions about C’s manner were unreasonable. As such, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Complaints should be investigated in line with the Model NHS Complaints Handling Procedure. Particularly they should identify and clarify all points to be investigated at the outset of the investigation, address all of the points raised and be person-centred and non-confrontational.
• New patients should receive initial appointments with clinicians that are conducted reasonably and in line with good practice. Particularly these should ensure questioning and summarisation of clinical information is structured, appreciate the importance of establishing a therapeutic relationship between the clinician and new patient and establish the patient’s expectations from the outset.
• Observations and opinions on a patient’s manner and motivations should be fair, accurate, and evidenced in so far as possible.
• When student or trainee clinicians sit in on appointments for training, the Partnership should introduce the person and explain why they are there, where possible, the patient should be informed in advance of the appointment and the patient's consent should be sought. When a patient does not consent to a trainee/student being present they should leave the appointment.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C was sent to hospital by the GP with a diagnosis of severe cellulitis (an infection caused by bacteria getting into the deeper layers of your skin). Prior to being sent to hospital, C received paracetamol, intravenous fluids and intravenous antibiotics. On arrival at hospital, C had a long wait until being treated and C complained that the delay in admission and treatment was unacceptable.

The board apologised that C had to wait in their car and explained that patients were seen on a clinical priority basis. They advised that C's clinical priority was not deemed to be urgent as C had received paracetamol, fluids and antibiotics before arrival.

We took independent advice from an acute and general medicine adviser. We found that at the time, there was no clear system for prioritising patients. However, since then the board have improved their practice. We found that the triage which had been undertaken after admission had not followed guidelines. Additionally, we found that the waiting time to receive antibiotics was longer than the recommended maximum wait between antibiotic doses. As such we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in admission and treatment, specifically that clinical priority was not appropriately assessed, that the triage decision was not in line with the guidance and that there was a delay in administering medication. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Staff should triage patients in line with the relevant guidance.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment that they received during their labour and delivery of their baby (A). In particular, C complained that the standard of care and treatment they received had been unsafe, that there had been a lack of communication in relation to their requested position during labour, the use of forceps and the provision of pain relief. C also complained that they had been unable to give their informed consent for the use of forceps.

The board, when responding to C’s complaint, accepted that some aspects of C’s care did not meet the standard that they would expect in terms of communication and C’s requested positioning throughout the labour and delivery of A. As a result of C’s complaint, the board had shared the complaint with the midwifery staff responsible for C’s care. The board asked them to reflect on C’s experience and consider ways of improving care for the purpose of providing person centred care. The board also accepted that they had failed to arrange C's postnatal review clinical appointment. The board said they had taken action to review and amend the process for appointing consultant led postnatal follow-up. The board indicated that, while the event had not been recorded as an adverse incident and a Datix (an incident/risk management reporting system to collect and manage data on adverse events) had not been submitted, a review had been carried out and action had been taken as a result of that review.

We took independent advice from a consultant obstetrician (a doctor who specialises in care during pregnancy, labour and after birth). We found that during C’s labour there were significant periods of loss of contact (LOC) during the recording of the foetal heart rate. However, we also found that, while labour would have been complicated by the LOC there was no evidence that C or A were put at risk. We also found that the actions of staff during this period were reasonable and proportionate to the needs of C and the clinical circumstances which occurred at the time. We found that safe care and delivery had been provided to C. However, we also found that there had been a material change in C’s birth plan and that there had been a failure to communicate these changes with C.

The board accepted that there was no documentation in the medical records of a discussion with C in line with Royal College of Obstetricians and Gynaecologists guidance on obtaining verbal consent on assisted vaginal births. We found that obtaining consent is an important aspect when providing care and treatment to a patient, and completing the appropriate documentation is a professional standard. The event should have been recorded as an adverse incident and a Datix should have been submitted. We upheld the complaint and provided feedback to the board in relation to the use of the adverse event process and the submission of a Datix.

Recommendations

What we said should change to put things right in future:

• Patients should receive clear explanations and appropriate information where there are changes to their birth plan. Where discussions have taken place with a patient, this should be documented.
• Staff should be aware of the relevant Royal College of Obstetricians and Gynaecologists (RCOG) guidance on documenting consent.

In relation to complaints handling, we recommended:

• Complaint responses should be informed and accurate and address all aspects of the complaint.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the council had unreasonably failed to carry out an adequate assessment of their parent (A)'s personal care needs and made an unreasonable decision that A did not meet the criteria for free personal care funding.

We found that the council's records did not evidence that thorough assessments of A's needs were carried out. There was no evidence that A's needs had changed, or that they no longer met the criteria for free personal care funding when the funding stopped. Although there was some evidence that A's needs were considered when the decision to stop funding was challenged, there was no evidence of an adequate assessment. Therefore we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to complete an adequate assessment of A's needs, for failing to work in partnership with A and their family and for stopping free personal care funding. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Provide financial redress for an amount equal to the payment of free personal care funding that A should have received between the dates specified in our decision notice.

What we said should change to put things right in future:

• Assessments and reviews should be fully and accurately recorded within a reasonable timeframe.
• Funding decisions should be based on robust assessments that are completed and recorded in accordance with council procedures.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the council's handling of reports they made about their neighbours' antisocial behaviour. They reported a number of incidents to the Police and to the council's Antisocial Behaviour and Private Sector Services teams. Although C's reports were investigated, they were dissatisfied with the action that was taken by the council. C complained that the council failed on multiple occasions to respond to their contacts or took an unreasonable length of time to respond. C submitted a formal complaint to the council. Again, they considered that the council took an unreasonable length of time to respond to their concerns and inappropriately assigned an individual who was involved in the matters they complained about to conduct the investigation.

We found that although the council communicated clearly and regularly with C regarding their ongoing reports of antisocial behaviour, more could have been done to explain their assessment of the situation and the reasons why no formal action was being taken. We found that the council failed to follow their complaints handling procedure. There were delays in responding to C's complaint and it would have been better practice for the complaint to be investigated by someone with no involvement. On balance, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Staff should handle complaints in line with the Model Complaints Handling Procedure, ensuring that wherever possible the complaint is investigated by someone not involved in the complaint.
• The council should ensure that when customer contact is escalated to a formal complaint, it is dealt with under the complaints handling procedure.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.