Upheld, recommendations

Summary

Mrs C lived in a small residential development. The site consisted of multiple plots and various planning consents were in place for individual developments. It was served by a shared access track with planning conditions in place requiring the developer to upgrade the track surface and drainage before building work started.

Mrs C complained that development progressed at the site without the access track being upgraded. The council took a pragmatic view that it was appropriate for the final surfacing work to be done after all work on the site was completed. However, in the meantime, the track surface became badly damaged and no interim maintenance work was carried out. Initially the council had worked with the main developer to ensure the track was maintained, but the developer sold on a number of their plots and no longer considered themselves liable for the access track.

We took independent advice from one of our planning advisers and found that the pragmatic view taken by the council about final completion of the track was reasonable. However, we were critical of their failure to ensure that interim maintenance work was carried out. In particular, we found that the original planning conditions were poorly worded and made no provision for interim maintenance of the track. Furthermore, we considered that the council did not fully explore who was liable for the planning conditions after the developer sold on their plots and failed to take steps to work with the responsible party to ensure access to the site was maintained.

Recommendations

We recommended that the council:

• review their use of planning conditions in cases involving unadopted road access to multi-owner developments to ensure that a clear record is obtained as to the proposed construction, the council's approval, and the timing of the work;
• consider using conditions to ensure that satisfactory schemes of long-term maintenance of private access roads are submitted and approved by the planning authority;
• review their position as to who is responsible for discharging the outstanding conditions relating to the access track, with reference to the adviser's comments on section 145(2) of the 1997 Act; and
• having clarified who is responsible for the access track, work with the responsible party to ensure interim maintenance work is carried out on the access track.

Summary

Mrs C complained to the council that her son's school had not responded appropriately to a playground incident. She said she should have been contacted but instead her son was sent home with a note in his bag. The council investigated but did not uphold Mrs C's complaints, and she was not satisfied with their response.

Our investigation reviewed how the council had investigated and responded to her complaints. We found that, although they provided a reasonable explanation to Mrs C's initial complaint, their final response (at stage two of their complaints process) was confusing and the conclusions reached did not clearly follow from the explanations given. We upheld Mrs C's complaint.

Recommendations

We recommended that the council:

• apologise for incorrectly stating that the council did 'not uphold' elements of the complaint at Stage 2 of the complaints procedure.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mrs A), who experienced a sudden and severe headache while on holiday visiting her daughter. Mrs A's daughter arranged for an ambulance to take Mrs A, who has a history of migraines, to A&E at Dr Gray's Hospital.

A junior doctor reviewed Mrs A and referred her to a senior doctor to determine whether a CT scan (a scan that uses a computer to produce an image of the body) would be necessary. The senior doctor reviewed Mrs A a few hours later, decided this was not required and discharged her, advising her to seek help if her condition worsened or did not improve. Mrs A said the doctor told her that it would be safe for her to fly home the next day, but the doctor did not recall saying this. Mrs A flew home the next day and arrived feeling very ill. A few days later she was admitted to hospital where, after further investigations, she was diagnosed with a brain aneurysm (a bulge in a blood vessel in the brain).

Mrs C complained about the care and treatment Mrs A received at A&E. She said that Mrs A was misdiagnosed and her symptoms were not taken seriously due to her history of migraines. She also complained that the doctor inappropriately advised Mrs A that it was safe to fly.

After taking independent advice on this complaint from a medical adviser, we upheld Mrs C's complaint. We found that the senior doctor had failed to properly investigate Mrs A's symptoms in line with relevant guidance and so missed the diagnosis of a brain aneurysm. In relation to whether the doctor had advised Mrs A that it was safe to fly, there was no evidence of this in the medical records and so we could not make any finding.

Recommendations

We recommended that the board:

• issue a written apology to Mrs A, acknowledging the failings our investigation identified; and
• raise the failings we found with the doctor involved for reflection and learning as part of their annual performance review.

Summary

Mr C complained that he waited too long to see a prison dentist after a crown fell out. He said that he had twice asked to see the dentist and had explained that he was suffering some pain. In response to Mr C's complaint, the board said that they did not consider his dental problem to be an emergency and that his needs would be met by a routine appointment, for which he was placed on a waiting list. Mr C then complained to us as he was concerned the root would be beyond repair if he waited any longer for an appointment. Although he then received treatment, Mr C continued to pursue his complaint with us as he felt he had waited too long for treatment and did not want this to happen again.

We took independent advice on this case from a dental adviser. Although Mr C had asked for an emergency appointment, our adviser considered that he had been appropriately categorised as needing routine dental care even though he had some pain. We found this to be in accordance with guidance to which the board referred when treating prisoners. However, we upheld his complaint as we found that it was four weeks before the crown was re-cemented. We considered this wait to be unreasonably long, and not in accordance with the seven day timescale set out in the guidance for treating routine patients. We also found that there was no documented information to show that Mr C was given advice about pain management while waiting for his appointment. We noted that the Scottish Government will shortly be publishing national guidance for a robust framework for oral health improvement and dental services in Scottish prisons, and made our recommendations in the light of this.

Recommendations

We recommended that the board:

• apologise to Mr C for the unreasonable delay in being seen by the dentist and for the lack of pain relief advice; and
• consider developing a policy for dental care within the prison when the Scottish Government's national guidance is published.

Summary

Mrs C had a hip replacement a few years ago which initially seemed to be successful. In early 2013, Mrs C attended her medical practice with pain in her thigh that was preventing her from bending to put her shoes on or driving. She was prescribed painkillers for a possible muscle or ligament injury and advised to rest. Mrs C's pain continued and she was sent for an x-ray which was reported as normal by a radiologist (a specialist in x-rays). The pain got no better and Mrs C was referred to a specialist. Some months after initially attending the practice, Mrs C contacted them to ask for a referral to a private hospital. Later that month, the practice arranged crutches for Mrs C as she was struggling to walk, and she was seen by the private consultant a few days later. He considered that the x-ray showed a possible issue and made suggestions for further investigations at an NHS hospital. These were carried out the following month and showed that Mrs C's replacement hip had become loose, causing the thigh bone to fracture. Mrs C complained that the practice failed to diagnose the cause of the pain in her thigh.

We took independent advice from one of our medical advisers, who is a GP. The adviser reviewed Mrs C's medical records and said that although the x-ray was normal, the fact that she continued to suffer from pain and visited the practice on several occasions should have prompted them to carry out further

x-rays, particularly when she had to be given crutches to walk. We, therefore, upheld her complaint.

Recommendations

We recommended that the practice:

• ensure that GPs familiarise themselves with the diagnosis and management of hip fracture, paying particular reference to the need to reassess patients who may clinically present with a fracture but have a negative x-ray;
• carry out a significant event meeting to discuss this clinical incident and any lessons that can be learned; and
• apologise to Mrs C for failing to take reasonable steps to diagnose the cause of her pain.

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.