Upheld, recommendations

Summary

Ms C complained that the council had not considered her complaints in line with the social work complaints procedure. Ms C had complained on behalf of her friend (Ms A) about the extent of Ms A’s involvement in the care the council were providing for her aunt (Miss B).

Ms C sent her complaint to the council in May 2013, enclosing a mandate signed by Ms A, authorising Ms C to complain on her behalf. She did not receive a response and wrote to the council again a month later. They responded towards the end of August. Ms C then emailed asking for her complaint to be considered by a complaints review committee (the final stage in the social work complaints procedure). Although the council acknowledged the email, Ms C then had to contact them again before they wrote to her some three weeks later. They explained that they would not be responding to Ms C directly, as Miss B had not appointed her to handle her affairs.

The council told us that they had responded appropriately to Ms C as she did not have the authority to complain on Miss B’s behalf. They also considered it unclear whether she had Ms A’s authority. They did not think that the law and guidance about the social work complaints process allowed either Ms C or Ms A to complain on Miss B’s behalf.

We could consider only the way the council had responded to the complaints Ms C had made on behalf of Ms A, not the underlying concerns she raised. We noted that when Ms C complained she had enclosed Ms A's mandate. Although, in line with the guidance around the social work complaints procedure, the council may not always have to take a third party’s complaint through that process, we considered that they could have responded to Ms C sooner and more clearly to explain their concerns. The paperwork indicated that their first response was sent over three months after she first complained and so, taking everything into account, we took the view that their handling of the matter fell below a reasonable standard.

Recommendations

We recommended that the council:

• remind social work staff to respond to complaints timeously and, where appropriate, to advise of the steps being taken in response to the complaint; and
• apologise to Ms C for the delay in responding to her complaints.

Summary

Mrs C, a private homeowner, complained to the council about a fence that they put up at her neighbour’s property. She complained that they had not consulted her about this, and her door now faced a six-foot fence. She had suggested other options that would not have impacted upon her, but said the council refused to consider these and had not responded adequately to her complaints. The council apologised for not involving her in discussions before they put the fence up and explained why they thought her suggestions were not practicable. Our investigation upheld Mrs C's complaints. As, however, the council had already apologised for not consulting her about the fence, we did not make a recommendation about this.

Recommendations

We recommended that the council:

• apologise to Mrs C for the delays in responding to her complaints.

Summary

Mrs C complained about how the council handled work that would possibly reroute sewerage infrastructure through her garden. The work was to be done as part of the council’s flood defence programme, which was originally the subject of public consultation.

The original plans had a minimal effect on Mrs C, but in 2010 the main contractor showed her a copy of a revised plan, which indicated that a new sewer was to be laid under her and her neighbour's gardens. This was the first Mrs C or her neighbour knew of the change. She was concerned that the new sewer would have significant consequences for her property and complained to the council. The council maintained that the flood prevention scheme was empowered by the Flood Prevention (Scotland) Act, which they said gave them the power to amend or deviate from (within a certain tolerance) the original plans without further consultation or provision of information to those affected. Considerable correspondence and meetings between the council, Mrs C, her neighbour, the design engineers, and the constructors ensued, ending in a meeting in March 2011. Mrs C and her neighbour considered that negotiations were ongoing at this stage as there were several action points from the meeting about further consultation or information to be provided to them. The next communication Mrs C received from the council was a formal 'Notice to Proceed' with the revised plans three weeks later.

At this point Mrs C felt that she had no option but to seek legal advice. After correspondence between her solicitor, the council and Scottish Water (who did not agree with the council's view) a compromise was reached that the new sewer would not be routed through the gardens. Mrs C then asked the council to reimburse her legal fees, but they refused.

Our investigation, which included taking independent advice from one of our planning advisers, focused only on consultation with and provision of information to those affected by the scheme, rather than the legal views of the various parties. We considered that it would have been reasonable for the council to have consulted with, or at least told, Mrs C at the point when the plans changed so radically. We were also disappointed that the council were giving mixed messages when they were corresponding and meeting with Mrs C and her neighbour in March 2011, but then without further warning issued the Notice to Proceed.

On this basis we considered that it was reasonable for Mrs C to feel that she had no option but to take legal advice, and that the direct intervention of her solicitor led to the compromise finally agreed. For this reason we took the unusual step of recommending financial redress for the reimbursement of Mrs C's legal fees.

Recommendations

We recommended that the council:

• issue a written apology for the failings identified; and
• reimburse Mrs C's legal fees, following production to the council of confirmation of the fees directly incurred in relation to the maladministration and service failure identified during our investigation.

Summary

After Mr C's daughter (Miss A) was in a road traffic accident, paramedics took her to A&E at Ninewells Hospital strapped to a spinal board (a specialised stretcher, designed to protect patients with spinal damage). Mr C complained that the board then failed to adequately assess and treat Miss A, and said that she was not x-rayed at any point before she was discharged. Following her discharge she remained in significant pain and discomfort and Mr C took her to the family GP who, after a brief examination, referred her as an emergency to a different hospital. An x-ray taken there revealed a fractured vertebrae in Miss A's back and a CT scan (a scan that uses a computer to create an image of the body) revealed two further fractures.

We took independent advice from one of our medical advisers. He said that while the initial examination of Miss A was of a reasonable standard, a second more comprehensive examination should have identified the need for an x-ray of the spine. The adviser also said there was no record of Miss A's mobility having been assessed and that, as she was suffering pain in her abdomen, she should have been assessed for liver damage, given the speed at which the vehicle was travelling immediately before the crash.

In light of this advice we upheld Mr C's complaints, as we concluded that the board had failed to adequately assess and treat Miss A and had unreasonably failed to arrange for x-rays or scans to be taken of her spine.

Recommendations

We recommended that the Board:

• apologise for the failings identified in the care provided; and
• provide evidence that they have addressed the failings our investigation identified with the doctor responsible, through the staff appraisal process.

Summary

Miss C complained about her care and treatment when she was admitted to St John's Hospital for planned surgery. In particular, Miss C said that she had left hospital with an open wound, and was given inadequate post-discharge advice and care. She also complained about the care and treatment she received after being re-admitted nine days later with a severe wound infection, and said that her wound packing had been removed on the ward without adequate pain relief, and that packing was left in it.

During our investigation, we took independent advice from two of our advisers, one who is a specialist gynaecology consultant and another who is a plastic surgery consultant. The gynaecology adviser said that the operation appeared to have been straightforward but that Miss C was at high risk of infection. He found no evidence that prophylactic antibiotics (drugs that treat bacterial infection, given in advance of a procedure to reduce the risk of infection) had been given to Miss C during surgery, although he accepted that there might have been a reason for not doing so. He also said that she should have been given antibiotic therapy on discharge. However, he said that there was no evidence that she was discharged with an open wound.

After Miss C returned to hospital she had a further surgical procedure. The plastic surgery adviser was satisfied that the initial assessment and surgery were carried out to a high standard. He also indicated that it was routine practice to remove the wound packing on the ward, but noted that Miss C had not been given any additional pain relief for this procedure which can be traumatic and that this should have been considered. He also advised that it was unlikely that the full extent of Miss C's wound was observed during the procedure and that it was likely some of the large gauze swabs used as packing were left in the wound. We were critical of these apparent failures by the board.

We found nothing in Miss C's clinical records to indicate that at her pre-operative assessment she was given the information the board said she should have. There was also nothing to indicate whether it had been explained to Miss C that she was responsible for passing a discharge letter to her GP. We noted, however, that the board said they had already taken steps to remind staff of the importance of providing appropriate information and advice.

Recommendations

We recommended that the Board:

• apologise to Miss C for the inadequate care and treatment we identified, that she was not given adequate information about post-operative care at her pre-operative assessment, and that it was not properly explained to her that she was responsible for passing on the discharge letter to her GP;
• make relevant staff members aware of our adviser's comments and give them an opportunity to reflect on these for their future practice - in particular in relation to consideration of the use of prophylactic antibiotics both during surgery and prior to discharge, and the issue of pain relief and wound observation at dressing change; and
• provide us with evidence of the steps taken to remind staff of the importance of providing appropriate information and advice as stated in the board's response to Miss C's complaint.

Summary

Mrs C complained that communication from staff and the care provided to her husband (Mr C) in Caithness General Hospital were inadequate. Mr C had been taken to A&E after collapsing, and although Mrs C thought he had symptoms of a stroke, he was discharged. The board said that this was because Mr C did not want to stay in hospital overnight. He suffered a significant stroke shortly afterwards. Mrs C also complained about the nursing care after her husband was admitted to hospital, saying that when visiting him the next day she found him in a side room, lying on a mattress on the floor. She was distressed that Mr C's dignity was compromised, as he was not wearing pyjama bottoms.

After taking independent advice from one of our medical advisers and our nursing adviser, we upheld all Mrs C's complaints. We found that the junior doctor and the consultant physician involved did not give enough consideration to Mr C's diagnosis, particularly to the likelihood that he had suffered a minor stroke. Had they done so, it might have led them to have assessed the risk of this happening again and provided treatment if appropriate. However, our medical adviser pointed out that the outcome for Mr C might not have been different even had he been admitted to hospital at the start.

Although both the nursing staff and the doctors had indicated in the clinical records that Mr C did not want to stay overnight, there was no clear written information to show that they had recommended that he should be admitted before having an urgent scan in the morning. As the doctors had not indicated what they thought was wrong with Mr C, he would not have been aware of any potential risks in being discharged. We considered that the communication with Mr and Mrs C fell below a reasonable standard. We also found that the nursing staff should have told Mrs C before she visited that they were nursing Mr C on a mattress on the floor, to reduce the likelihood of him falling out of bed. The board had acknowledged that his care in terms of his dignity was unreasonable and had taken steps to address this with relevant nursing staff.

Recommendations

We recommended that the Board:

• draw to the attention of the junior doctor and the consultant physician our findings in relation to the lack of consideration given to Mr C's initial diagnosis;
• draw to the attention of the junior doctor and the consultant physician the importance of ensuring that communication about likely diagnosis is clearly explained to patients and their families where appropriate; and
• apologise to Mr and Mrs C for the failings we identified in Mr C's care.

Summary

Ms C, who suffers from mild cerebral palsy and epilepsy, complained that when she attended the Western Infirmary Glasgow following a fall, staff failed to take her concerns seriously and discharged her without taking an x-ray of her left knee. Ms C says she was told to carry out exercises, which she did, but the pain worsened and she returned to the hospital three days later to be told, following an x-ray, that her left knee had suffered a fracture.

In response to Ms C's complaint, the board apologised for the delay in the diagnosis of a left knee fracture and told Ms C that the member of staff involved had been asked to reflect on her practice and attitude. We contacted the board and were told that they had upheld Ms C's complaint that staff had not carried out an x-ray when Ms C first attended the hospital and that advice should had been sought from a senior member of the medical staff. The board also said that the member of staff involved did not follow recognised protocol and that all staff are required to have an up-to-date Knowledge and Skills Framework and a Personal Development Plan, both of which are used to ensure that staff are kept up to date in their clinical practice. We found that the board's response to Ms C was lacking in specific detail and did not make clear that her complaint had been upheld. The board's response also failed to include information about what action had been taken to prevent a repeat occurrence.

Recommendations

We recommended that the Board:

• apologise to Ms C for failing to make clear that her complaint was upheld and that appropriate action had been taken to help prevent a similar situation occurring in future.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mrs A), whose late brother died during an investigative procedure in Glasgow Royal Infirmary. The complaint was about the way the board investigated Mrs A's complaint about her brother's care and treatment.

Mrs A complained to the board in July 2012 and two weeks later she and a friend met with members of the clinical, nursing and complaints team staff to discuss her concerns. Mrs A expected to receive a copy of the meeting notes shortly afterwards, but this did not happen. She chased this up over the next few weeks but did not receive the notes until October that year.

When Mrs A reviewed them, she found several inaccuracies and omissions according to her recollection of the meeting and sent the board a list of these in early November. She asked them for a final written response, so that she could escalate her complaint to us if necessary. This did not happen, although she had several more contacts from the board. Mrs C eventually complained to us in October 2013. The board eventually, and only after our intervention, provided an amended copy of the notes. Mrs A still thought that there were inaccuracies and omissions, and was confused by conflicting information about the board's process for investigating significant clinical incidents and how they are reported on the NHS system (known as Datix).

In response to our enquiries, the board said that the complaint file was closed in error after the meeting, so no automatic reminders were sent to the complaints team or the clinical staff involved in the complaint about the outstanding meeting notes.

Our investigation found that the board had not complied with the timescales in their own complaints handling procedure. We were concerned at the time taken, firstly to produce the meeting notes, and then to correct them. We were particularly concerned that we had to intervene before the amended notes were issued. It was also of concern to us that when Mrs A contacted senior members of staff because she had not received any response from the complaints team, they did nothing to progress this or assist Mrs A. We noted that the members of the clinical team that Mrs A contacted did not respond to her because they assumed the complaints team would do so.

Recommendations

We recommended that the Board:

• issue a written apology for failing to notify Mrs A of her right to complain to this office and the inconsistent explanations she received about the significant clinical incidents policy;
• take steps to review their procedures for preparing and issuing notes of complaints meetings to ensure they are issued to complainants as soon as possible after the meeting and that they address any concerns about accuracy appropriately at the time; and
• review the current Datix form and consider how best to reflect the outcomes for incidents which, following initial review, do not escalate to full investigation.

Summary

Mr C, who is a prisoner, complained that the prison health centre had unreasonably failed to explain why his complaints were being managed in line with NHS Scotland's policy for dealing with habitual and vexatious complaints. In response to our enquiries, the board confirmed that the prison health centre inappropriately applied the incorrect version of a national policy and said that the decision to manage his complaints in line with that policy had now been revoked.

In addition, Mr C said the board failed to respond appropriately to his complaint about the decision to manage his complaints in line with the policy. In response to our enquiry, the board said that they were not in a position to confirm that the steps taken by the prison health centre in responding to Mr C's complaint were appropriate, given that the prison health centre had implemented the incorrect policy.

In light of the information available, we upheld Mr C's complaints.

Recommendations

We recommended that the Board:

• take steps to ensure staff within the prison health centre are fully aware of the correct complaints policy and its procedures.

Summary

Ms C complained that Business Stream calculated her water charges using the historic rateable value (RV) of her premises. She explained that they had been revalued since then and the RV was now at a lower figure than that used by Business Stream. In Ms C's view, Business Stream's invoices were incorrect and too high.

Our investigation found that Business Stream's policy is to use the RV from 31 March 2000 unless the property has been built or modified since then. The RV may also be adjusted if the official RV has been successfully appealed. Business Stream took the view that, as Ms C had not provided evidence that her property had been altered, the default RV was being correctly applied.

We found evidence to suggest that structural modifications to Ms C's property led to an increase in the building's RV in 2005 and Business Stream were using this, as permitted by their policy. However, our investigation also established that the RV was significantly reduced in 2009 after a successful appeal by the landlord. We were critical of Business Stream for not checking and confirming this with the assessor, and for failing to amend Ms C's account so that charges were based on the lower RV.

Recommendations

We recommended that Business Stream:

• apologise to Ms C for calculating the drainage charges for her business incorrectly; and
• confirm the date that the rateable value appeal was upheld with the assessor, recalculate Ms C's account using the lower rateable value from that date and issue a refund for any overpayments.