Upheld, recommendations

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.

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.