Upheld, recommendations

Summary

Mr C lives in a small estate. When the council granted planning consent for the development they approved landscaping plans, and put in place a planning condition to control the date of completion of the landscaping and the replacement of diseased or damaged plants. They did not, however, include any provision for a scheme of maintenance.

Mr C told us that some of the open space next to his home had not been landscaped, and he was concerned that other parts of the estate appeared to be getting a more frequent grass cut and related maintenance. He complained that the council failed to take reasonable action to ensure that landscaping in the housing development was in accordance with approved plans.

We took independent advice from one of our planning advisers, and we upheld the complaint. The adviser said that while one approved drawing had included a landscape maintenance schedule, this had not been included in any of the relevant consents and this had given rise to Mr C's complaint. Mr C wanted the council to take enforcement action, but this was not possible.

Recommendations

We recommended that the council:

• review their use of planning conditions with regard to securing control over the management arrangements for long term maintenance of landscaping and open space; and
• ensure that all application documents on which such matters depend are captured by references to approved documents in the terms of the decision.

Summary

Mr C was unhappy that the council breached a Tree Preservation Order (TPO). He told us that, because a council officer made wrong assumptions about which tree was to be felled, the council had granted permission for the felling of a healthy tree that was the subject of a TPO. Before Mr C brought his complaint to us, the council had acknowledged their error and apologised to him for it. However, Mr C said that the council had given him unsatisfactory and confusing responses to his complaint.

We took independent advice from one of our planning advisers. He said that the council had focused on inadequate explanations for the errors, instead of reviewing their procedures as they should have done. As the council appeared to have given more weight to defending their actions than to reviewing procedures, inconsistencies had then emerged in their responses to Mr C. The council had acknowledged that the wrong tree had been felled, and that the tree had not been properly identified before permission was given, which was a relatively serious mistake. The adviser had concerns that the complaint was not investigated thoroughly enough, especially as the deficiencies related to planning procedures. We upheld Mr C's complaint, as we found that the council's investigation and complaints handling was inadequate and inconsistent.

Recommendations

We recommended that the council:

• consider the comments on the content of procedural guidance on tree works consent applications (in addition to matters already identified by the council) and advise the Ombudsman of their intentions with regard to carrying out a review of procedures and making the relevant staff aware of them;
• ensure that appropriate action is taken to avoid such an incident recurring and advise the Ombudsman of the action taken; and
• issue Mr C with a full and sincere apology for the failings identified in this complaint.

Summary

Shortly after being placed on the waiting list for a day surgery procedure in hospital, Mr C had a phone call offering him an appointment for the following week. He did not receive the pre-operative information leaflet in the post until two days after the surgery. On the day of the operation he was told that he had been moved to last on the theatre list. When he asked why, he was told it was because he previously had methicillin-resistant staphylococcus aureus (MRSA - a bacteria that is resistant to some common antibiotics, can cause infection and can be difficult to treat). This caused Mr C some distress. He complained that his history of MRSA had impacted on how his surgery was managed, although he had told staff - both at his pre-operative appointment and on the morning of the operation - that he had been given the all-clear a few years before.

In responding to Mr C's complaint, the board acknowledged that it was unfortunate that he did not receive the information booklet in advance. They also said that there was no requirement to screen day surgery patients for MRSA, and that their infection control policy did not require MRSA-positive patients to be last on the theatre list, as measures were in place to mitigate against cross infection risks. However, they then went on to say that the consultant had placed Mr C last on the list as he had a history of MRSA and there was nothing in his records indicating that he was clear of the infection.

As part of our investigation, we obtained independent advice from one of our medical advisers. Having done so, we upheld the complaint. We noted that the board had failed to provide pre-operative information to Mr C at the right time. We also found that they had deviated from their normal policy without properly explaining the reason for this. Their response to Mr C's complaint had been contradictory, in failing to explain why the consultant had not adhered to their policy.

Recommendations

We recommended that the board:

• bring their infection control policy to the attention of staff and highlight the importance of adhering to this;
• review their process for ensuring patients receive any relevant pre-operative information in a timely manner;
• remind staff who handle complaints of the importance of providing clear and consistent responses; and
• apologise to Mr C for the failures highlighted in our decision.

Summary

Mrs C's husband (Mr C) cut his hand in an accident at home. She dialled 999 and asked for an ambulance. The ambulance service's call handler took details of Mr C's injury but concluded that an ambulance was not necessary. Mrs C had to ask neighbours to help transport Mr C to hospital, where his injury needed surgery. Mrs C complained that the ambulance service's refusal to dispatch an ambulance was unreasonable, and was dissatisfied with their handling of her subsequent complaint.

We took independent advice from one of our medical advisers, who is a paramedic, and after considering their advice we upheld Mrs C's complaints. Our investigation found that the call handler used a nationally recognised system of scripts to obtain information about the severity of Mr C's injury. During the call, they also asked for help from a clinical adviser, who could ask questions that were not included on the script to obtain additional information. An appropriate script was chosen and largely followed, which determined that no ambulance was required. However, we considered that the decision-making process was skewed because the call handler input inaccurate information. Assumptions were made about the severity of the bleeding and the clinical adviser asked questions that demonstrated a lack of knowledge of hand injuries. Furthermore, changes in Mr C's condition during the course of the call were not acted upon appropriately. We concluded that an ambulance should have been dispatched to take Mr C to hospital.

We found that the ambulance service's handling of Mrs C's complaint was generally reasonable. However, they failed to follow their own complaints procedure as they did not contact her to advise that their decision would be slightly delayed.

Recommendations

We recommended that the service:

• apologise to Mr and Mrs C for failing to provide an ambulance;
• take steps to ensure their call handlers are able to identify and act upon changes in patients' conditions during the course of a call; and
• share this decision with the clinician involved.

Summary

Mrs C's late father (Mr A) saw a GP at his medical practice about, amongst other things, a cough. He had a chest x-ray, the results of which were normal. Some seven months later, in June 2012, he had three further consultations at the practice about chest problems and a persistent cough, and a further chest

x-ray, taken after the third appointment showed an abnormality in the lung. After collapsing and being admitted to hospital, Mr A went to the practice again in July and was referred urgently to the respiratory clinic because of his persistent cough. Mr A also attended a cardiology (heart) clinic where a scan was arranged. The clinic told the practice that the scan showed that Mr A might have a pulmonary (lung) tumour. The respiratory clinic then found that the scan showed metastatic malignancy (cancer that had spread) in his lung. They wrote to the practice about this and said they had not discussed the potential diagnosis with Mr A but had told him that there was a shadow on the lung that needed investigation. Several weeks later Mr A saw a GP, who did not explain the result of the scan but wrote in the medical notes that Mr A was aware that cancer was a possibility. Mr A was then referred to oncology (cancer specialism) and at the end of October a cancer nurse told the practice that Mr A had now been told his diagnosis. After this Mr A asked the practice for an appointment but they told him they could no longer treat him because he had moved out of their area. Mr A died shortly afterwards.

Mrs C complained that the practice did not provide reasonable care and treatment to her late father. She said that they did not carry out appropriate investigations and/or tests within a reasonable time and failed to communicate with him and his family about his diagnosis. Mrs C was also concerned that the practice refused to treat him after he moved house, although he had been a patient there for over 25 years and they were well aware of his medical history.

We took independent advice on this case from one of our medical advisers, who is a GP. Our adviser said that the failure to refer Mr A for a chest x-ray after his first two consultations in June 2012 was not reasonable and did not follow the guidelines for referral in such cases, although his care after the chest x-ray was eventually carried out was of a reasonable standard. The adviser also said that the practice's communication with Mr A was reasonable, and that it was the responsibility of hospital doctors to tell him about test results and treatment plans. We recognised how distressing it must have been for Mr A and his family waiting for results and a definitive diagnosis, but noted that the practice was not responsible for telling Mr A about these. Turning finally to the practice's decision not to treat Mr A after he moved house, our adviser said that while the practice acted correctly as far as the terms of the GP contract were concerned, they did have discretion to keep Mr A on their list on compassionate grounds if this was geographically feasible. In the circumstances, while accepting this was for them to decide, we took the view that the practice should have given more consideration to keeping Mr A on their list. Given this, and the failure to arrange a chest x-ray within a reasonable time, we upheld Mrs C's complaint.

Recommendations

We recommended that the practice:

• ensure that the GP who saw Mr A at his first two appointments in June 2012 discusses this complaint and findings as part of their annual appraisal and that the diagnosis and management of lung cancer forms part of their learning needs;
• consider their approach to de-registering patients in light of this case; and
• apologise to Mrs C for the failures identified.

Summary

Mr C, who is a prisoner, complained that on three separate occasions the prison health centre supplied his medication late. He was also unhappy with the way in which his complaint about this was handled.

We took independent advice on this complaint from one of our medical advisers. Our adviser said that, although he might potentially have suffered some pain, the delays would not have had a negative impact on Mr C's medical condition. We noted this, but decided that the overall delays he experienced were unreasonable. In addition, although Mr C was given an extra supply of medication in case this happened again, we made recommendations as we took the view that the board should take further action.

Our investigation also found that the board did not follow Scottish Government guidance on the NHS complaints procedure when handling Mr C's complaint. He was told he had to complete a feedback form before being allowed access to a complaints form. By not providing a complaints form on request, the board made Mr C go through an unnecessary additional stage before he could complain. In a separate complaint that we determined last year, we recommended that the board ensure that local complaints processes were in line with the Scottish Government guidance. The board provided us with evidence to show that they had since implemented this (from 1 November 2013) so we did not make a recommendation about that in this case.

Recommendations

We recommended that the board:

• review their procedures for acquiring and supplying prescribed medications, to reduce the likelihood of delays occuring in the prison; and
• apologise to Mr C for failing to handle his complaints appropriately.

Summary

Mr C complained that his wife (Mrs C) sustained injuries while she was a patient in Wishaw General Hospital. Mrs C suffered from dementia and normally lived at home. She was in hospital for some seven months, during which she fell several times, sustaining minor injuries, and was involved in a series of incidents with other patients or visitors to the ward. Towards the end of her stay in hospital, Mr C was helping his wife to change when he noticed bruising on her back, which he considered could only have come from punches. When he reported this to a staff nurse, it became apparent that no staff member had reported these injuries. One nurse had seen - but had not reported - them, assuming someone else would already have done so.

Our investigation found that there were failings in the assessment and monitoring of Mrs C's falls risk; vulnerable adult safeguarding; record-keeping and communication with the family. Although staff took appropriate action after Mrs C fell, there was no evidence that they told her family on these occasions, and it was entirely inappropriate that no-one reported the bruising on Mrs C's back. Mrs C was a vulnerable adult and staff should have taken appropriate action to report and record this, as reflected in the board's own guidance. It was not, however, possible during our investigation to establish how Mrs C had sustained these injuries.

Our investigation found that the board had investigated Mr C's concerns and had acknowledged the failings that our investigation confirmed. They had already taken some reasonable remedial action so we made recommendations aimed at confirming that this had been effective.

Recommendations

We recommended that the board:

• provide the Ombudsman with evidence that all aspects of the remedial action plan formulated after the internal investigation have been implemented or are progressing within reasonable timeframes; and
• provide the Ombudsman with reassurance that all staff involved with caring for vulnerable adults have the knowledge, skills and training to recognise, raise and respond appropriately to safeguarding issues.

Summary

Mrs C complained on behalf of her family about the care and treatment given to her late aunt (Mrs A) by a medical practice. She told us that there was a delay in providing a diagnosis and appropriate treatment, which affected Mrs A's prognosis and led to her consequent suffering.

We took independent advice on this complaint from one of our medical advisers, and took all the relevant documentation, including all the complaints correspondence and Mrs A's medical notes, into account. Our investigation found that the care and treatment that the practice gave Mrs A was not reasonable. After the results of a magnetic resonance imaging scan (a scan used to diagnose health conditions that affect organs, tissue and bone) raised concerns, the practice had referred Mrs A to hospital for further investigation. However, they had marked this referral as 'routine'. Our adviser said that, in the circumstances, they should have marked it as 'urgent' and the referral letter should have contained more detail, particularly about the scan's abnormal results. We also found that Mrs A's clinical notes were insufficiently detailed and it was unclear whether GPs had physically examined her.

The practice had carried out a significant event analysis (SEA) into what had happened, but our adviser pointed out that it did not reflect on what had gone wrong. There was also no recognition on the part of the practice that the abnormal findings of the scan should have been considered.

Recommendations

We recommended that the practice:

• provide a formal apology for the shortcomings identified;
• complete a reflective SEA to address the inadequacy of the previous report;
• ensure that the GPs concerned undertake audits of the quality of information contained in referrals and advise the Ombudsman of the findings; and
• ensure that the GPs concerned audit the quality and completeness of their clinical notes and advise the Ombudsman of the findings.

Summary

In December 2010 Ms C invited her elderly father to her home in England to spend Christmas with her. While he was there, he became ill and was not able to return to his home in the council's area. Ms C had to become her father’s main carer. He was assessed in February 2011, after which the council made free personal nursing care payments for him. Ms C then had considerable contact with the council over details of the care package, the number of hours awarded, the degree of retrospection of the award, and issues about respite care.

Ms C first considered complaining to the council in October 2011, and eventually did so in February 2012. After completing its initial stages the complaint was considered at a complaints review committee (CRC) in August 2012, with Ms C participating through a video link. The recommendations of the CRC were reported to the council’s leadership panel in October 2012 and Ms C was informed of the outcome two days later.

Ms C complained to us that the council’s handling of her complaint was unreasonable. Our investigation focused on five complaints handling issues. One related to information about the complaints procedure in October 2011, three were about delay (in dealing with an initial internal complaint, in supplying a form to request a CRC and a delay in convening that CRC and making recommendations to the appropriate committee) and the fifth was that a summary report did not include a full minute of the proceedings of the CRC.

Our investigation found that there had been delay, and we upheld the three complaints relating to this, but we did not find evidence to support the other two complaints.

Recommendations

We recommended that the council:

• apologise for the delays in dealing with the complaint submitted to them.

Summary

A firm of solicitors complained on behalf of their clients (Mr and Mrs A) that the council did not act reasonably and correctly when they withdrew school transport. The council had introduced a revised home to school travel policy, in line with national guidelines, which meant that Mr and Mrs A's children no longer qualified for free transport to school. They also said that proper procedures had not been followed when the council dealt with the case and the appeal. Mr and Mrs A were told they could not complain as the decision of the sub-committee was final.

Our investigation found that the appeal sub-committee that took the decision did not have full, accurate and relevant information about the route in question. Additionally, as there was no statutory right of appeal, Mr and Mrs A should have been signposted to us, as they were entitled to an independent review of their concerns. We upheld both complaints and made recommendations.

Recommendations

We recommended that the council:

• review their decision about the provision of transport in this case;
• review their policy wording to reflect advice on signposting for internal appeals procedures; and
• apologise for not signposting to SPSO at the end of the appeal process in this case.

Following a review, this report was changed on 25 February 2015. The full revised version of the report is available below.

Case:              201303605: Comhairle nan Eilean Siar

Sector:           local government

Subject:         school transport

Outcome:       some upheld, recommendations

Summary

A firm of solicitors complained on behalf of their clients (Mr and Mrs A) that the council did not act reasonably and correctly when they withdrew school transport. The council had introduced a revised home to school travel policy, in line with national guidelines, which meant that Mr and Mrs A's children no longer qualified for free transport to school. They also said that proper procedures had not been followed when the council dealt with the case and the appeal. Mr and Mrs A were told they could not complain as the decision of the sub-committee was final.

Our investigation found that the appeal sub-committee applied the revised policy correctly in considering Mr and Mrs A's appeal. We did not uphold the first complaint although we made two recommendations about how the clarity of the process could be improved. However, as there was no statutory right of appeal, Mr and Mrs A should have been signposted to us, as they were entitled to an independent review of their concerns and we upheld the complaint that the council failed to follow proper procedures in dealing with the case and subsequent appeal and made recommendations.

Recommendations

We recommended that the council:

• review their policy wording to reflect advice on signposting for internal appeals procedures;
• apologise for not signposting to SPSO at the end of the appeal process in this case;
• amend the appeal application form to include a section for parents to complete detailing why they are not able to act as an accompanying adult/meet the parental responsibilities outlined at Paragraph 6.1 of the home to school transport policy; and
• give consideration to giving clearer guidance around the statement in the school transport guide for parents that pupils should be accompanied 'until they can confidently and safely walk the route'.