Upheld, recommendations

Summary

Mr C had lived close to a semi-industrial property for a number of years without problems, but more recently the owners of the property had sought to diversify and to develop the site and their business. Work started on the site but without the necessary planning permission. Mr C and his neighbours complained to the council about this and about the noise coming from the site, and the council told the developer that he needed to obtain planning permission.

The developer took five months to make a retrospective application and meanwhile noise complaints continued. Although the council had a target to consider the application within two months, it took them nine months to do so. The application was then refused by a committee of councillors. Throughout this time Mr C had been complaining of noise and disturbance in his home.

We took independent advice from one of our planning advisers. Our investigation showed that while council officers were encouraged to support small businesses, they also had obligations to the wider public. In this case, there was no doubt that works had been undertaken without the necessary planning permission and that noise was affecting those who lived nearby. While the council advised the developer of this, they allowed him too long before he submitted his retrospective application. Although it was clear that during this time they were negotiating with the developer to mitigate the noise, matters took too long to resolve. We upheld Mr C's complaint.

Recommendations

We recommended that the council:

• make a formal apology to Mr C for their failures in this matter;
• ensure that officers involved in this case are made aware of our decision;
• make a further formal apology for the failures identified; and
• ensure that appropriate officers are informed of the circumstances and outcome of this complaint.

Summary

Ms C, who is an advice worker, complained on behalf of her client (Mr A) that the council had unreasonably failed to carry out repairs to prevent water coming into Mr A's council house. Ms C said that Mr A contacted the council many times about this and the council had failed to permanently resolve the situation.

Our investigation considered the council's policy on water ingress and whether they followed it. The policy said that for top floor flats such as Mr A's they would arrange a temporary roof repair to ensure the home was wind and watertight. The council indicated that, in such cases, temporary repairs should be carried out within one day.

The evidence showed that on eight separate occasions the council were advised of water ingress problems at Mr A's property. On two of these, they arranged repairs in accordance with their policy. However, on the remaining six, the evidence suggested that no temporary repairs were completed. We acknowledged that, during that time, the council organised more permanent repairs for the roof, but this did not remove the requirement for them to carry out temporary repairs to make Mr A's home watertight. Given the number of times Mr A reported the same issues, we also found that the council failed to identify the problem and to take appropriate action earlier.

We were also concerned that in their response to Ms C's complaint the council said they were not aware of a recent problem, when their records clearly showed that this had been reported to them no fewer than seven times. We were, therefore, critical of the council's failure to investigate Ms C's complaint properly.

Recommendations

We recommended that the council:

• feed back our decision on this case to the staff involved to prevent such failings occurring in future;
• review Mr A's compensation claim in light of their acknowledgement that they had previously failed to review their repairs system properly in this case and carry out sufficient repairs to rectify the water ingress problem and advise Mr A of the outcome; and
• provide Mr A with a written apology for the failings identified.

Summary

Ms C complained on behalf of her daughter (Ms A) about the care and treatment she received at the Western Infirmary for appendicitis. She complained that her daughter was not fully diagnosed soon enough, as there was a delay to her initial scan, and she was not monitored appropriately. She also said that a delay in operating to remove Ms A's appendix caused a rapid deterioration in her condition and a more complex operation. Ms A was operated on some 24 hours after she was admitted to hospital. Ms C also complained about the board's handling of her complaint.

The board had accepted that there was poor communication in relation to some elements of Ms A's care, and that the family were misled in relation to when the operation might take place. They apologised for the distress this caused.

After taking independent advice from two of our advisers - a consultant surgeon and a nursing adviser - we upheld both complaints. The surgical adviser was satisfied that Ms A's treatment was reasonable, and that the operation took place within a reasonable timeframe. However, the nursing adviser was concerned that Ms A was not monitored frequently enough, given that the reason for admitting her to hospital was to keep her under close observation. We were also critical of the communication between ward staff and Ms C. She was given inaccurate information on at least three occasions, increasing the family's distress.

We found that the board had delayed in responding to Ms C's complaint, and did not act on assurances they had given during that process. The board explained to us, however, what they had since done to ensure that this did not happen again, so we made no recommendation about this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• reflect on the failures in communication that our investigation identified, and consider how communication with patients and their families could be improved to ensure information is as accurate as possible; and
• ensure that nursing staff within the surgical unit are aware of the importance of carrying out vital signs observations as part of their role in the assessment and monitoring of surgical patients.

Summary

Mrs C attended A&E at Monklands Hospital in the early hours of the morning with her daughter (Miss A), who was given a liquid steroid to treat croup (an infection of the voice box and windpipe) before being discharged. Later that same day, and after speaking with NHS 24, Mrs C returned to A&E because she felt that Miss A's condition had not improved. Mrs C said she was advised that an out-of-hours (OOH) appointment had been booked for her daughter that evening but that she did not know about it. A nurse examined Miss A, and after a discussion with the duty consultant, advised Mrs C that she could take her daughter home. The following day, Mrs C visited her doctor for an unrelated issue and whilst there, the doctor examined Miss A and confirmed there was a slight wheeze so prescribed steroids. Because of this, Mrs C complained that the care and treatment provided to her daughter in A&E was unreasonable.

The board told Mrs C that because Miss A was well and had a normal set of observations, the duty consultant felt it would be best if she was allowed to attend her booked OOH appointment. They said this was because it was unlikely that she would be seen by an A&E doctor earlier than the time of the scheduled appointment later that evening. However, when we examined the evidence, we identified that the scheduled appointment had already been cancelled because Miss A was seen in A&E. When we asked the board about this, they told us that the appointment with the OOH service would have been cancelled when Mrs C arrived at reception in the A&E department. The board said the receptionists for both services sat side by side and would have liaised with each other about this.

We took independent advice from one of our medical advisers, but he said he was unable to say whether the care and treatment provided to Miss A by the A&E department was reasonable, given that the duty consultant made an incorrect assumption that her OOH appointment was still booked for later in the evening that day. We found that the consultant appeared to have taken the decision to allow Miss A to leave A&E on the basis of inaccurate information and because of that, we upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failure our investigation identified; and
• take steps to review what happened in Mrs C's case and ensure appropriate measures are in place to prevent the same thing from happening again.

Summary

Mrs C complained about the care and treatment of her late husband (Mr C). Mr C was diagnosed with lung cancer and over a five-month period had six appointments with five different consultants. At most of the appointments, which were at both the Beatson Cancer Centre and Royal Alexandra Hospital, Mr and Mrs C had to wait around one and a half hours beyond the appointment time, which was extremely stressful for them. Mr and Mrs C also attended one of the appointments expecting to receive the results of a scan. However, this was not available until 17 days after it was taken, when Mr C began to develop increasing weakness in his legs. He was admitted to hospital the following day and developed complete paralysis of his legs and lack of sensation up to his abdomen. The cancer was found to have spread to his spine, leading to spinal cord compression, and Mr C died shortly after. Mrs C complained that if the results of the scan been available earlier, there might have been a better outcome for her husband, had treatment been administered sooner.

After taking independent advice on Mr C's case from two of our medical advisers, we found that there was a delay in making the scan available, and that the radiologist failed to flag the risk of spinal cord compression when reporting the scan. While there was only a slight possibility that earlier information would have meant that the outcome would have been different for Mr C, these failings led to a significant personal injustice as the delay caused a great deal of distress and there was a missed potential opportunity to diagnose and treat Mr C's spinal compression earlier. We also found an error in the reporting of a previous scan, which might have affected treatment decisions relating to Mr C's pain. Finally, in relation to Mrs C's complaint about the board's appointment handling, we found that there was a lack of continuity of care because of poor record-keeping and the involvement of multiple consultants. This adversely affected the information available to the consultant at each appointment, potentially impacted on Mr C's care and was particularly distressing for both Mr and Mrs C, given the ongoing situation.

Recommendations

We recommended that the board:

• take account of our medical adviser's comments about reviewing report turnaround times and reporting radiology errors, and provide us with evidence on how they intend to avoid a recurrence;
• provide evidence that multi-disciplinary team meetings play a role in the management of patients with lung cancer, in line with the relevant guidelines;
• raise the failures our investigation identified with relevant staff, and ensure it forms part of their annual appraisal;
• provide us with evidence on how they intend to avoid a recurrence of the failures that our investigation identified in the complaint about appointment handling; and
• apologise to Mrs C for the failures our investigation identified.

Summary

Mr C complained about a number of aspects of the care and treatment the practice provided for his late mother (Mrs A). This included that there was a delay of six weeks in the practice referring Mrs A to a specialist, after a doctor at the practice told Mr C at a home visit that this would be done. Mr C also complained that when another doctor at the practice saw Mrs A at home on a later date, he failed to arrange for her to be admitted to hospital and made an inappropriate reference to her condition. Mr C said the practice failed to take his mother's deteriorating condition seriously and provide her with appropriate care and treatment.

After obtaining independent advice on this case from one of our medical advisers, who is a GP, we upheld Mr C's complaints. Our adviser said that he would have expected the first GP to have set a time to see Mrs A to go over blood test results and to review her condition. This did not happen. The referral, which was eventually made more than six weeks after the home visit, appeared to have been prompted by Mr C and was made to a psychiatrist for the elderly, rather than a consultant geriatrician. It appeared that the practice might have taken some reassurance from tests that had suggested there was no sinister cause for Mrs A's long-term problems. The adviser said, however, that as Mrs A had red flag (warning) symptoms that could suggest underlying cancer and as some time had passed since the tests were carried out, a referral to a consultant geriatrician should have been made.

The second doctor accepted that, at the later home visit, he had referred to Mrs A inappropriately. In our view, the term he used was insensitive and would likely have added to the distress Mr C was experiencing at that time. Having correctly decided not to admit Mrs A to hospital, it then appeared that this doctor failed to assess Mrs A's social situation at the visit, although we accepted that, overall, the practice acted reasonably in trying to get social work involved in her case.

Recommendations

We recommended that the practice:

• feed back the failings identified to the staff involved to ensure that a similar situation does not happen in future; and
• provide Mr C with a written apology for the failings identified.

Summary

Mr C’s water consumption went up steadily over several years, and when he started to enquire why this might be, he was told that he had a shared supply. Mr C investigated which property he shared a supply with, but was unable to establish this, partly due to difficulties accessing a neighbouring vacant property. However, when Business Stream’s surveyor was shown a meter in the neighbouring property, they continued to say that Mr C had a shared supply. After seven months of investigation, Mr C started to investigate the possibility of a leak, and one was found in the pipe between his property and the meter, underneath some pavement. It took about a week to find and fix this.

Mr C applied for a ‘burst allowance’ (a refund of some of the costs for the last six months of the leak). He was granted an allowance, but the calculation for the rebate was based on average water consumption during a period including when the leak was still being found and fixed. It did not, therefore, reflect the standard water consumption. Mr C complained that, had Business Stream highlighted the increased consumption earlier, and had they suggested the possibility of a leak when the issue was first raised with them, he would not have had to pay such high bills for so long. He also complained that the burst allowance was inappropriately calculated.

We found that Business Stream could not have known about Mr C’s raised water consumption level until he identified this, as the increase in usage was at a level that could have reflected changes in his business. However, we decided that they should have discussed the possibility of a leak with Mr C. Had they done this, he could have investigated and fixed the leak seven months earlier. We also decided that the burst allowance was inappropriately calculated, as the baseline for Mr C’s water consumption should not have included the period when the leak was still being fixed.

Recommendations

We recommended that Business Stream:

• refund Mr C the cost of the excess water consumption on his account for a specified period, based on an average water consumption relating to a period after the leak was fixed;
• refund Mr C the difference in the burst allowance, based on a lower average consumption for the period after the leak was fixed; and
• apologise to Mr C for the time and effort he incurred due to poor information and advice from Business Stream.

Summary

Mrs C owned a property, which she ran as a self-catering holiday let. In 2009 Scottish Water contacted her and explained that a water meter should be installed so that the business's water usage could be properly managed and charged. A meter was installed, but Mrs C was led to believe that her business used insufficient water to merit charges. In 2012, and again in 2013, Business Stream identified her property, through routine audits, as receiving water services without being charged (this is known as a gap site). Although Mrs C responded to their enquiries, they did not create a water account for the property until July 2013. Mrs C complained that she was firstly misled into believing there would be no water charges and that Business Stream then delayed setting up her water account, leading to a large unexpected water bill backdated to 2009.

We found that Mrs C was given appropriate information in 2009 about changes to the non-domestic water industry and the need to select a licensed provider to manage her business water usage. She missed an opportunity to select a provider at that stage, which contributed to the overall delay in the account being set up. However, when the property was identified as a gap site, we found there was then a clear delay on Business Stream's part in creating an account and starting to charge her for water. We were critical that there was also a lot of confusion about whether or not there was a meter in place, when there clearly was.

Recommendations

We recommended that Business Stream:

• apologise to Mrs C for the delay to setting up her water account and the confusion surrounding the amounts that should have been charged; and
• reimburse Mrs C 50 percent of the property's total water charges for the stated period.

Summary

Mrs C complained that Business Stream's water charges were incorrect. Her business premises shared a water supply with two neighbouring businesses. She had the main water meter and the usage through the two sub-meters was deducted to calculate her water usage. Although she tried hard to use minimal amounts of water, Mrs C found that her bills were disproportionately high compared to the neighbouring businesses. She, therefore, suspected a problem with her water meter and queried her bills with Business Stream. Investigations were carried out to check for leaks and Business Stream's engineers inspected the pipework in Mrs C's premises, but found no cause for her high bills. Mrs C complained to us that Business Stream did not do enough to identify the cause of these.

Based on the evidence submitted to us, there was no clear cause for Mrs C's high water usage and we upheld her complaints. We were satisfied that the sub-meters' usage was deducted correctly in all but a few cases and Business Stream agreed to review her account to ensure that her bills were accurate in this respect. There was, however, a significant spike in Mrs C's water usage at one stage, which coincided with a period where Business Stream failed to take the required two meter readings per year. Had they done so, the spike might have been identified sooner and Mrs C could have investigated and addressed this. There was no obvious evidence of a fault with Mrs C's meter, but we considered that Business Stream should have offered her a meter accuracy test, which they did not do.

Recommendations

We recommended that Business Stream:

• investigate the removal of one of the sub-meters from Mrs C's account and ensure that the correct deductions have been applied;
• issue a credit for an amount equivalent to 50 percent of Mrs C's volumetric water and waste water charges for the period between two specified dates; and
• provide Mrs C with details of their meter accuracy test procedure should she wish to pursue this in the future.

Summary

Mr C, who is a prisoner, complained that the prison governor did not handle his complaint appropriately. He had complained to the governor that language used in an email suggested untruthfulness on his part. He also complained that the staff member who wrote the email recorded inaccurate information in a note of the outcome of one of his complaints, and he asked for an explanation of this. The governor had interviewed the staff member about the language in the email exchange and had concluded that it was open to individual interpretation. In addition, the governor noted that Mr C had previously complained about the error in the note and that a manager had responded in writing apologising for the mistake and assuring him that the note would be amended and re-issued. The governor acknowledged that this had not at first happened, but confirmed that it had since been done.

We examined the information that the governor considered while investigating these complaints. We found that, by speaking directly with the staff member, the governor had taken proper steps to investigate Mr C's concerns about the email. However, although we considered it unreasonable to expect the governor to decide whether untruthfulness was implied, we took the view that the language used could be perceived as biased, whether or not that was the intention. It would, therefore, have been reasonable for the governor to assure Mr C that staff had been reminded to avoid using language that could cause offence or be misinterpreted. We also found that the error in the written note had been acknowledged but was not at first corrected and that, when responding to Mr C's complaints, neither the manager nor the governor had explained why this happened. We took the view that they should have done so and, because of the failings identified, we upheld Mr C's complaints.

Recommendations

We recommended that the Scottish Prison Service:

• apologise to Mr C for the failings identified following our investigation of his complaint;
• remind staff involved with complaints handling that they should avoid using language that could be misinterpreted; and
• explain to Mr C why the error occurred in the written note.