Upheld, recommendations

Summary

Mr C complained that there was a failure to provide his elderly mother (Mrs A) with appropriate care and treatment during two hospital admissions. Mrs A was first admitted to University Hospital Crosshouse when she fractured her pelvis after a fall at home. Mr C complained about the length of time his mother spent in the emergency department before being transferred to a ward. He also complained that her medication was changed and that she was discharged to a rehabilitation centre suffering from severe jaundice.

After taking independent advice from one of our medical advisers and our nursing adviser, we found that the time taken by medical staff to assess Mrs A and admit her to a ward was reasonable, and we identified no failings in nursing care. There was not enough evidence for us to say whether her medication was changed but we were satisfied that there was no evidence that when Mrs A was transferred to the rehabilitation centre she was suffering from severe jaundice. However, we were concerned that Mrs A did not appear to have been reviewed by a consultant within 24 hours of admission. Although our adviser said that such an assessment would not have altered the outcome for Mrs A, we considered this to be a failure of care. We were also concerned that there was a failure to assess Mrs A's bone health for possible osteoporosis (a condition that affects the bones, causing them to become fragile and more likely to break) and the reasons why she fell and suffered a fracture. In view of these failures we decided that the board failed to provide appropriate care and treatment to Mrs A during her admission.

Mrs A was readmitted to University Hospital Crosshouse the following month because her sodium level was low and she had a slow pulse. Mr C complained that medication prescribed prior to admission was changed, and that when she was transferred to Ayrshire Central Hospital she received poor nursing care.

Our medical adviser explained that there were sound medical reasons why Mrs A's medication was changed, and our nursing adviser found no evidence of any failings in Mrs A's nursing care while she was a patient in Ayrshire Central Hospital. There had been issues in relation to Mrs A's clothing, but the board had already apologised for this and taken action to address the failings identified. We were, therefore, satisfied that the board dealt with this appropriately. However, we had a number of other concerns about Mrs A's care and treatment during this admission. There was insufficient documentation in her medical notes to suggest that the assessment of her condition was sufficiently detailed and her condition severe enough to merit the medication she was prescribed for vertigo (the sensation a person has that they, or the environment around them, is moving or spinning). Also, we did not find evidence that medical staff had discussed or explained the diagnosis of vertigo or the changes to medication with her, or with Mr C. We also found that Mrs A's GP was only given a very basic level of information about her condition and treatment, with no information about her sodium level at the time of discharge or the changes to her medication. Finally, we considered that Mrs A's medical notes for this period were difficult to interpret because of poor handwriting. Because of all these issues, we found that aspects of Mrs A's care and treatment fell below a standard that could reasonably have been expected, and we upheld this complaint too.

Recommendations

We recommended that the board:

• apologise to Mr C and to Mrs A for the failings identified;
• ensure there is appropriate consultant assessment, including at weekends, for patients admitted as an orthopaedic emergency in University Hospital Crosshouse;
• ensure that the reasons why a patient has sustained a fall and the consequences of the fall are both assessed;
• ensure that medication changes are discussed as appropriate with the patient or, where appropriate, a patient's carer prior to their discharge;
• ensure that a patient's discharge summary contains all relevant information; and
• remind staff of the need to ensure that entries in a patient's records are legible.

Summary

Ms C, who is an advice worker, complained to the medical practice on behalf of her client (Mr A) about his care and treatment. Ms C said she wrote to the practice several times, and phoned them, but they did not reply. Because of that, Ms C complained to us that the practice failed to adequately respond to the complaint.

The practice told us that they did not receive Ms C's initial complaint and only became aware of it a few months later when she submitted it again. They also told us that, after meeting Mr A, he told them he no longer wanted to pursue the complaint, and that they wrote to Ms C to tell her that.

The NHS guidance Can I help you? outlines what should happen when an NHS provider receives a complaint. In particular, it confirms that a complaint should be acknowledged within three working days and investigated, with a full response provided within 20 working days. If the NHS provider is unable to meet that timescale, they should provide a written explanation for the delay and an update on progress and when they expect to be able to reply. They should also tell a complainant that they have the right to seek a review from the SPSO if they are unhappy with the reasons for the delay. In this case, the practice clearly failed to comply with that guidance when handling Ms C's complaint.

Recommendations

We recommended that the practice:

• provide a fuller response to the issues raised by Ms C;
• apologise for failing to deal with the complaint appropriately; and
• review their complaints handling procedure to ensure it complies with the requirements of the Can I help you? guidance.

Summary

Mr C and Mr D owned a restaurant and the upstairs residential flat. They complained to Business Stream that the restaurant's water meter also measured the flat's consumption. Although Mr C and Mr D knew that they had to pay commercial rates for their restaurant's water consumption, this meant that they were paying for the water in both the restaurant and the flat at commercial rates.

In response to their complaint, Business Stream explained that where a property has both a commercial and residential element (and a corresponding rateable value and council tax banding) it is classed as 'dual use'. In such cases, their policy says that all consumption (including that of the flat) is charged commercially and the restaurant can recharge the flat for its proportionate share. Business Stream also explained that Mr C and Mr D could request that the water charges be removed from the flat's council tax, and that they were satisfied that they had billed them appropriately, based on the information they had.

Although our investigation showed that Business Stream had billed Mr C and Mr D in accordance with their policy, when we took all the evidence into account we did not consider that the policy applied in this case. This was because the flat and the restaurant were two separate properties (as opposed to one property with a commercial and a residential part). We, therefore, took the view that they should not be classed as a 'dual use' property. We upheld the complaint and made two recommendations.

Recommendations

We recommended that Business Stream:

• contact their customers to explain their reassessment process; and
• consider, if their customers amend their pipework and apply for reassessment, backdating any reduction in their charges.

Summary

Mr C, who is a prisoner, told us that the prison did not investigate his complaint appropriately. Mr C had complained that his parole dossier (the documents prepared by the Scottish Prison Service (SPS) for the parole board) contained inaccurate information. In particular, the dossier said that Mr C had assaulted a prison officer, which Mr C said was untrue.

In responding to his complaint, the prison had suggested that the information referred to stemmed from one of two possible incidents. However, when we made enquiries with the SPS, they confirmed that no such incident had taken place and said the inaccurate information was contained within a report prepared by an assessor for another purpose. We upheld Mr C's complaint, because we found that the prison's response to his complaint was inaccurate and misleading.

Recommendations

We recommended that SPS:

• apologise to Mr C for failing to adequately investigate the circumstances of his complaint.

Summary

Ms C, who is a prisoner, complained to the prison governor that an officer had discussed her personal information with another prisoner. The governor acknowledged that the other prisoner had tried to discuss Ms C's circumstances, but indicated that the officer had only responded with a dismissive comment, and had not disclosed any of Ms C's personal information. Nonetheless, the governor arranged for a reminder to be issued to staff to exercise caution in future, to guard against potential breaches of confidentiality.

Ms C complained to us that the governor had not fully investigated her complaint. She said that he had spoken with the officer but not to the other prisoner. We asked the governor why he had not spoken with that person, and he explained that he did not feel that the prisoner would have offered a balanced or accurate account of events. He was also concerned that discussing the complaint with her might have had a negative impact on her relationship with Ms C.

We were not persuaded, however, that the reasons offered by the governor provided sufficient justification for choosing not to interview a relevant party to the complaint. We did not consider it appropriate for the governor to simply have accepted the officer's account without obtaining the other side of the story. We, therefore, upheld the complaint.

Recommendations

We recommended that Scottish Prison Service:

• ensure that, where possible, all relevant parties to a complaint are interviewed prior to a definitive finding being reached on that complaint.

Summary

Mr C, who is a prisoner, complained because he said the prison failed to handle his complaints appropriately. In particular, Mr C said his complaints had not been responded to or appeared to have gone missing.

We examined several complaints that Mr C had submitted and asked the prison about their handling of them. As well as explaining what had happened with those complaints, the prison said that they were now operating a pilot whereby all prisoners in that hall of the prison would be issued a receipt after they submitted a complaint. The prison said they planned to roll this out to the whole prison, apart from for confidential complaints submitted directly to the governor (PCF2 complaints).

The evidence we saw showed that Mr C's complaints were not responded to by the prison within the relevant timescales; a confidential complaint was incorrectly placed in the external mail; another complaint was misfiled along with Mr C's legal correspondence; and Mr C had to submit a new complaint to chase up an existing one. In addition, we found the prison's ability to log prisoners' complaints was restricted to certain members of staff. In light of this, we upheld Mr C's complaint and made recommendations.

Recommendations

We recommended that Scottish Prison Service:

• apologise to Mr C for the failings identified with the handling of his complaints;
• communicate the findings of the pilot to the Ombudsman; and
• consider implementing a similar process for PCF2 complaints in light of the failings identified with the handling of Mr C's complaints.

Summary

Mrs C had made an insurance claim against the council following work carried out as part of a flood prevention scheme. Although her claim now appeared to be in the process of being properly addressed, she was unhappy about how her complaint about the delays in doing so had been handled. She complained to us about this, explaining in detail the ways in which she said the council had failed to deal with the complaint properly.

We upheld Mrs C's complaint, as our investigation found that the council had handled her concerns poorly. We found evidence of failures to honour commitments and assurances they had given, over-reliance on standard acknowledgements of emails, timescales that were largely meaningless, and a failure to properly investigate and respond to the handling issues and complaints which Mrs C had very clearly set out. The council also failed to discuss Mrs C's complaint with her, and in their correspondence they failed to address, or respond to, the complaints handling issues she had raised. They also did not give her the 'upheld' outcome that she deserved based on the evidence that should have been available to them, had they looked at her complaint properly. Despite acknowledging to Mrs C that there appeared to be a need to review their administrative procedures, the council's response to our enquiries did not say if any review has taken place, or if a review was planned. We made a recommendation specifically about this, relating it to the model complaints handling procedure (CHP) provided for local government by our Complaints Standards Authority.

Recommendations

We recommended that the council:

• apologise to Mrs C for their poor handling of her complaint to include specific mention of their failure to properly investigate the complaint and their failure to follow their complaints handling policy and procedures;
• review their administrative procedures in relation to dealing with complaints correspondence;
• provide the Ombudsman with a report which gives an assurance from senior management that they are satisfied that their complaints handling procedures meet the requirements of the CHP; and
• update Mrs C on the current situation on the underlying issue of the delay in her insurance claim, which was the cause of her complaint.

Summary

Mr C had lived in his parents' council house for many years with his wife (Mrs C), but did not become the tenant until after his father died in February 2007. This was after the modernised right to buy a council house was introduced in the Housing (Scotland) Act 2001. This reduced the maximum discount that could be given (to people who became tenants after September 2002) to 35 percent or £15,000, whichever was less. When Mr C took over the tenancy he asked a council officer if he could apply to buy the house. She wrongly told him that as a new tenant with a modified right to buy, he would have to wait five years. Four years later, in 2011, Mr C wrote to a senior housing officer asking again about this. In replying, the senior officer repeated the first officer's error that Mr C had to wait five years before applying. Seven months after that, Mr C discussed the matter with a housing manager, but they did not correct the previous misinformation. The council then began a consultation exercise on designating the whole of the council's area as having pressured area status (removing a tenant's general right to buy under the modernised scheme) and this came into place on 1 February 2012. Under these circumstances, should they wish to sell a house, the council have to apply to Scottish Ministers for consent for a voluntary sale.

Mr C then found out that he could have applied to buy his home as soon as he became a tenant. He formally complained to the council that he had been given incorrect information three times, and that the general right to buy had since been removed. They upheld his complaint; and eventually agreed with Mr C that he would allow access to have his home valued, and that they would be prepared to make the case for consent to sell to him at the £15,000 maximum discount with an allowance for rent paid from March 2011. Mr C, however, thought that the remedy for his complaint did not go far enough and that the allowance for rent should extend back to when he became the tenant, and brought the complaint to us. We upheld his complaint, and our recommendation reflects Mr C's concerns about the redress he had been offered.

Recommendations

We recommended that the council:

• after first obtaining Mr C's agreement and a supporting statement from him, present a case to Scottish Ministers for consent for a voluntary sale based on the estimated 26 February 2007 market value, with discount of £15,000 and an allowance for rent paid to date of completion of sale; and
• in the event that the Scottish Ministers do not consent to any sale of the property as outlined in recommendation one above, that the council make an ex-gratia payment to Mr and Mrs C to reflect the terms of the loss they have incurred financially, this being the rent paid from 26 February 2007 to date.

Summary

Mrs C was expecting a baby. When she was 35 weeks pregnant, a routine scan raised concerns about her baby's heart rate and it was suggested that she be flown by air ambulance to the mainland for an emergency caesarean section (an operation to deliver the baby). Mrs C's husband (Mr C) and young child were with her at the appointment, and she asked if they could travel with her. She was told that, whilst Mr C would be permitted to travel with her as an escort, the board would not agree to provide travel arrangements for their child. As there was no-one available locally to look after their child, Mrs C had to travel alone in the air ambulance while her husband and child followed separately on a commercial flight. Because of this, Mr C was not with her for the birth. Mr and Mrs C's baby died three days after being born.

Mrs C complained about the board's decision about the travel arrangements. She said that for the return journey, whilst the board arranged return flights for her and Mr C, they could only provide her with the phone number of the airline and a booking reference so that she could make her own arrangements for their child to travel back with them. She did not feel that the board took account of her circumstances or the physical and emotional stress she was under at the time. She also raised concerns about their handling of her complaint.

We upheld both of Mrs C's complaints. We found that the board's decisions were made with reference to their patient travel policy, which is primarily designed to reclaim relevant expenses incurred when travelling to and from mainland hospital appointments. This was appropriate for the return element of the travel, and we were satisfied that the policy was correctly applied for that journey. However, the policy specifically says that it does not apply in emergencies, or cases where the patient is being transferred between hospitals. Both of these criteria applied to the outward journey in Mrs C's case, and we concluded that it was not appropriate to refer to the policy for decisions about the air ambulance journey. Our investigation found that it was the board's patient transport staff who took the decision not to allow Mr and Mrs C’s child to travel in the air ambulance. Although the ambulance service specifically asked if Mrs C would be accompanied by an escort, they were told that she would be travelling alone. The ambulance service told us that they would have tried to take Mr C and the child, had they been asked to do so and had there been capacity on the aircraft. However, we noted that they were not asked to decide this. We considered that, under such circumstances, there should have been scope for the patient transport staff to use their discretion. This would have meant referring the decision to the ambulance service, so that they could decide whether they could carry all three passengers in the air ambulance.

We found that the board's complaints handling was reasonable in most regards. However, they failed to properly investigate who had reached the decision that Mrs C’s husband and child could not travel on the air ambulance. This led to inaccurate information in the board's response to her complaint.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for failing to pursue the option of their child travelling in the air ambulance with them;
• refund to Mrs C all reasonable costs incurred for her family’s outward flight; and
• consider introducing a policy to cover situations such as that encountered by Mrs C.

Summary

Mr C, who is a prisoner, had a stomach ulcer for which he had emergency hospital treatment in January 2012. Helicobacter pylori (a stomach infection) is the most common cause of ulcers and the hospital arranged for him to be tested for infection in March 2012. The results were negative, but Mr C was not made aware of this. He complained that the prison health centre team had not done anything about his ongoing stomach pain and that he had not received his test results or a hospital appointment despite having being referred there in June and October 2012.

We took independent advice on this complaint from one of our medical advisers. We upheld Mr C's complaint, as although we found that the health centre team had prescribed appropriate medication for his symptoms in line with national guidance, we concluded that they had unreasonably delayed in following up his test results with the hospital. We also found that there was a failure in sending a further referral to the hospital requesting that Mr C be re-tested when the hospital apparently told staff that they had no record of a test being done in March 2012. We were unable to clearly establish why Mr C was not told the results of the test carried out in March 2012, nor why it took so long for him to be re-tested.

Recommendations

We recommended that the board:

• ensure the prison has procedures in place to follow-up test results in a timely manner and, where appropriate, arrange prompt re-testing if necessary; and
• apologise to Mr C for failing to follow-up his March test results in a timely manner along with prompt re-testing.