Upheld, recommendations

Summary

Ms C's child was a pupil at a school and was the target of a bullying incident. The school investigated, and suspended two pupils as a result of their enquiries. Ms C's child continued to feel intimidated by one of the pupils and became unwell, resulting in an absence from school. Ms C, the school and the council were all involved in trying to find a way to help her child return to school, and a number of measures were introduced to stop further bullying. Ms C's child went back to school but, after further incidents, Ms C was not satisfied that the measures protected her child and decided to request a place at another school.

Ms C complained to us that the council failed to respond reasonably to her concerns about engagement and communication with her and her child. She also complained that they did not follow anti-bullying policies and procedures. Our investigation upheld both of Ms C's complaints. We found that, although the council were willing to engage with her and had suggested positive steps such as mediation, they had not always taken her child's views into account and had not adequately documented their decision-making process. We also found that they failed to record bullying incidents in line with the anti-bullying policy.

Recommendations

We recommended that the council:

• keep a clear record showing what factors have been considered when making decisions such as inviting to meetings parents with whom children have no contact;
• ensure that staff at the school are aware of the Scottish Government's GIRFEC (Getting It Right For Every Child) policy and its aims;
• apologise to Ms C and her child for failing to record reported incidents in line with the relevant policy;
• carry out an audit of the school's recording of bullying incidents to establish whether all incidents are being appropriately recorded in line with policy; and
• ensure that, at the next revision of the anti-bullying policy, the national approach to anti-bullying is referenced and taken into account.

Summary

Ms C, an advice worker, complained on behalf of her client (Mrs A) who had concerns about her late husband (Mr A)'s, treatment at the Royal Alexandra Hospital. Ms C complained to the board about numerous issues including a breakdown in communications from staff about Mr A's deterioration, and inadequate treatment. Ms C also said the board had not addressed all of Mrs A's concerns. The board, when considering Ms C's complaint, decided that there were grounds to conduct a significant clinical incident review (SCI) and on completion forwarded a copy of the report to Ms C.

We found that, while the board's decision to hold a SCI was an indication they had taken the complaint seriously, they failed to address all the concerns Ms C raised. They simply referred her to the SCI report and apologised for other failings, but did not specify what they would do to prevent this happening again. We also had concerns about the time taken to provide a final response to the complaint.

Recommendations

We recommended that the board:

• apologise to Mrs A for the failings in communication which we have identified; and
• revisit this complaint and issue a further response which specifically addresses the issues raised with appropriate explanations, and provide information about actions which will be taken to prevent a similar occurrence happening again.

Summary

Miss C was party to legal proceedings. She complained to the Scottish Court Service (SCS) that she had not received within a reasonable timescale a copy of documents relating to the decisions taken at the proceedings. She then submitted a claim for compensation due to the consequences of the documents not being provided within a reasonable timescale. At the conclusion of this correspondence the SCS told her that her complaints had been considered under their complaints procedure. Miss C was dissatisfied with this and complained to us that the response to her complaints had not been reasonable.

Our investigation found that it was reasonable that there was some confusion about what Miss C wished the SCS to consider, given the context of her communication with them. However, because their complaints handling guidance highlighted the importance of clarifying matters with the complainant, and because Miss C had eventually made reasonably clear what she wished the SCS to consider, we upheld her complaint.

Recommendations

We recommended that SCS:

• apologise to Miss C that they did not respond reasonably to her complaint; and
• highlight to all relevant staff the importance of clarifying the matters that a complainant wishes to be considered at all stages of the complaints handling process.

Summary

Mr C was unhappy with the council's lack of action in dealing with three large trees outside his home, which he said were not only dangerous, but also overhung his garden. Mr C also said that the trees, which had broken branches hanging from them, had caused damage to cars in his driveway. Mr C reported the matter to the council in January 2013 and again in October 2013. In December 2013 he was told this would be dealt with as an emergency and a council representative called at his home in January 2014 to look at the trees. As the work had still not been undertaken in June 2014 he again contacted the council. He told us in August 2014 that the trees had still not been trimmed.

We found that a works order was put in place with effect from October 2013 with a completion date of October 2014 so, technically, the council still had time to complete the work by their target. However, we found that they did not tell Mr C what that target date was. This failure to pass on information led to Mr C's belief that there was a delay and, for that reason, we upheld his complaint.

Recommendations

We recommended that the council:

• apologise to Mr C for their failure to tell him the target date for work to be carried out on the trees;
• take steps to ensure that the work is completed by the target date; and
• remind staff in the arboricultural team of the importance of logging visits and phone calls.

Summary

Mr C complained that the governor at his prison did not investigate his confidential complaint, which included an allegation Mr C made about the actions of a member of prison staff.

Prisoners can make complaints about routine matters. They can also make complaints about exceptionally sensitive or serious matters, which are treated as confidential complaints that go directly to the prison governor. We found there was no guidance for governors on what matters could be considered exceptionally sensitive or serious and thus appropriate to be dealt with under the confidential process. There was also a lack of clarity about which process should be used to deal with prisoners' allegations against prison staff. We found that the governor failed to provide Mr C with reasons for deciding that his complaint was not about a confidential matter; and that the prison did not keep a proper record of his confidential complaint, as they were supposed to.

We took the view that an allegation made by a prisoner about a member of staff would appear to be a matter of serious concern for a governor, even if such an allegation later proved to be unfounded. In addition, we did not think it was reasonable for a member of staff's peers to investigate, consider the evidence, and reach a conclusion about an allegation against that member of staff. We decided that the governor should have either given Mr C reasons for not investigating his complaint, or should have investigated it. We upheld Mr C's complaint.

Recommendations

We recommended that Scottish Prison Service:

• remind relevant prison staff of the need to record and file a copy of confidential complaints, as well as providing reasons for the governor's decision when a confidential complaint is considered not to be of an exceptionally sensitive or serious nature;
• provide guidance to governors on the types of complaint which might be considered to be of an exceptionally sensitive or serious nature and, therefore, should be dealt with under the confidential process; and
• amend the complaints guidance so it is clear which process should be used to deal with allegations against staff that are made by prisoners.

Summary

Mr C raised a number of concerns regarding the care his father (Mr A) received in Ninewells Hospital. Mr A had existing diagnoses of lung cancer and diabetes when he was admitted to the hospital with an infection. Mr C said that his father's initial treatment was excellent, but when he was later transferred to another ward, the standard of care dropped. Mr C raised a number of concerns regarding the standard of clinical and nursing care on that ward, where Mr A died three days after his admission. Mr C complained that family members were not made aware of Mr A's deterioration. He also complained that staff failed to adequately manage Mr A's diabetes and food and fluid intake. Mr C believed his father's death was caused by a failure to identify and treat hypoglycaemic shock (severely diminished blood sugar levels), rather than as a result of his underlying cancer and infection as the board suggested.

After taking independent advice from a nursing adviser and a medical adviser, we upheld Mr C's complaints. We were satisfied that Mr A's condition was appropriately assessed upon admission and that the proposed treatment with intravenous antibiotics was appropriate. That said, we were concerned by the ward staff's management of his blood glucose levels. Mr A's diabetes was clearly recorded when he was admitted to hospital, but we found evidence to suggest that the ward was not equipped to react to significant changes to his blood glucose levels, and the board's own procedure for managing hypoglycaemia was not followed. We also found that medication was omitted from the list of existing medications for Mr A and that this likely contributed to his hypoglycaemic episode. However, we accepted medical advice that the hypoglycaemic episode was ultimately dealt with appropriately and that there was no evidence to suggest that this contributed to the decline in Mr A's condition, or to his death. We were, however, critical of the board for failing to contact the family when Mr A deteriorated, and for their poor handling of Mr C's complaint.

Recommendations

We recommended that the board:

• provide us with an update on their plans for electronic palliative care summaries;
• conduct an audit of the ward staff's compliance with their obligations in terms of maintaining full, accurate medical records;
• provide us with an update on all of the actions taken to improve their performance as a result of Mr C's complaint;
• conduct a review of their approach to catering for in-patients with diabetes;
• share our decision with the clinical staff involved in Mr A's care; and
• apologise to Mr C and his family for the issues our investigation highlighted.

Summary

Mr C complained on behalf of his father (Mr A) who lives in a care home. Mr C was unhappy that Mr A's GP did not visit his father there, but instead spoke to care home staff by phone. He was also unhappy with the GP's responses to his complaint about this. We looked at Mr A's medical records, as well as the GP's file on the complaint, and took independent advice on the complaint from one of our medical advisers, who is a GP.

We found that on two occasions the GP did not take sufficient time to fully assess and clarify the situation after Mr A had collapsed. Instead, the GP made an assumption about why he had collapsed. We also found that the GP did not take account of key aspects of Mr A's medical history when considering how to manage his situation. In addition, we found that it was inappropriate for the GP to use the fact that Mr A was being seen as a day patient at a local hospital as a reason not to visit him.

We upheld both of Mr C's complaints. We found that, in the main response to Mr C's complaint, the GP appeared to have given up responsibility for Mr A's primary care, as they had said there was little they could do because he was being supervised by various hospital departments. The GP also made general statements about the workload of modern medical practices, and said that other patients in residential care visited the surgery. We concluded that, while this may be contextual information, it did not explain why the GP failed to visit Mr A. We found these responses unreasonable and highlighted that the GP may not have recognised the serious nature of Mr A's situation.

Recommendations

We recommended that the practice:

• ensure that the GP apologises to Mr C for failing to assess and care for Mr A appropriately, and for not visiting Mr A in the care home;
• ensure that the GP apologises to Mr C for failing to provide reasonable responses to his complaint;
• ensure that the GP apologises to the care home manager and nursing staff for failing to respond appropriately to their requests for help; and
• ensure that the GP reflects on our adviser's comments and informs us of how they would deal with similar events in future.

Summary

Mr C, who is an independent advocate, complained on behalf of his client (Mrs A) that the board did not take reasonable steps to prevent Mrs A's husband (Mr A) from developing a pressure ulcer (bed sore) during his stay in Inverclyde Royal Hospital. Mr A had terminal cancer and was admitted to hospital for palliative care (care provided solely to prevent or relieve suffering). He was there for ten days, and was then discharged home with no mention of a pressure ulcer. Later on the day of his discharge from hospital, a district nurse examined Mr A and found that he had a pressure ulcer.

We took independent advice from our nursing adviser, who said that the board had not thoroughly assessed Mr A during his admission and so had not recognised his increased risk of developing a pressure ulcer. If this had been done then Mr A's condition would have been more regularly assessed. The adviser was critical that staff relied on the assessments made when he was admitted, and said they had not exercised good clinical judgement. The adviser also said that the record-keeping was poor. In light of these failings, we upheld the complaint. As, however, the board had already taken positive steps to stop this happening again, we made only one recommendation.

Recommendations

We recommended that the board:

• provide Mrs A with information about steps taken to address the shortcomings identified.

Summary

Ms C, an advice worker, had written to her client (Mr A)'s medical practice to seek clarification about whether a request that Mr A made to his GP for a referral had been carried out. She received no response. After two follow-up letters were also ignored and two months had gone by, Ms C complained to us.

The practice told us that they did not consider that entering into correspondence with Ms C would serve any practical purpose as the issues Mr A was concerned about had been dealt with some years previously. We decided, however, that the practice should have explained this to Ms C. We, therefore, upheld her complaint that the practice did not reasonably respond to her correspondence.

Recommendations

We recommended that the practice:

• apologise to Ms C and Mr A for the failure to reply to correspondence; and
• review their communication policies to ensure that they clearly advise correspondents when a decision is taken that correspondence will not be responded to, and explain the reasons for that decision.

Summary

Ms C complained that the council failed to cut back trees outside her property. Ms C told us the trees were overhanging her house to the extent that they were nearly touching her roof. Ms C said her television reception had been affected, and she was living in constant darkness on the side of her house facing the trees, which meant she had stopped using her living room due to the lack of natural light. Ms C said her roof was black with moss from the trees, and she had to clean up leaves and bird droppings regularly.

We found that the council had told Ms C the trees would be dealt with; however, nearly a year later, the work had not been carried out. The council said there was a breakdown in communication between work teams, which led to confusion between shifts and, as a result, there was a delay in the work being started. We upheld Ms C's complaint as it was unacceptable that the work had not been carried out.

In our recommendations to the council, we had asked them to arrange for Ms C's roof to be cleaned. The council refused, and so we asked them to make her a goodwill payment of £100 to Ms C instead. The council again refused. Their reason, in both instances, was that payment or any works other than the actual tree works was disproportionate to their failure to deal with the trees. We were disappointed by the council's intransigence as, in our view, it was entirely reasonable for the council to make a tangible expression of regret, in line with our office's guidance on apology, given the effect that their very poor service had on Ms C.

Recommendations

We recommended that the council:

• apologise to Ms C for failing to deal with the trees outside her property;
• provide Ms C, in writing, with a date for the work to be carried out on the trees, and copy that communication to us;
• draw up an action plan to ensure that such delays do not happen again, and copy the action plan to us.