Upheld, recommendations

Summary

C complained about The City of Edinburgh Council’s administration of their council tax account. C complained that the council issued reminders for council tax arrears and threats of legal action when they had paid their council tax in accordance with a payment arrangement. C also complained that the council failed to respond to the their complaint in accordance with their Complaints Handling Procedure (CHP).

The council apologised for delay in responding to C’s complaint. They said that a council tax payment reminder had been sent to C as they had made a payment without using their reference number. This had meant that the payment hadn’t been allocated to C’s account.

C remained unhappy and asked us to investigate. C complained that the council had failed to respond to their correspondence and had failed to take the fact that they are a vulnerable person into account.

We found that the council had repeatedly failed to engage with C’s correspondence over a significant period of time. We found serious and repeated failures by the council to adhere to their CHP. We considered that the council acted without any consideration or accommodation of C’s vulnerability. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in the administration of C’s council tax and in the handling of their complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Enquiries about council tax payments, especially where the council is claiming no payment has been made and the customer is stating the contrary, should be dealt with and responded to promptly.

In relation to complaints handling, we recommended:

• The necessary systems and procedures should be in place to ensure that complaints are handled in line with the council’s complaints policy and procedure and that all staff are aware of the complaints handling policy and procedure.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about Fife council's handling of a complaint that they made regarding an incident involving their child (A) at their school.

C said that A was a victim of sexual assault and harassment during a playground game in which another child forced A to kiss them, touched A inappropriately and encouraged other children to chase and catch A. C said that, as a result of this, A felt unsafe and was unable to return to the school.

C complained that the council’s staff failed to carry out a reasonable investigation, including that A’s teacher’s account of events was accepted without any further scrutiny.

We found that the council’s initial investigation of concerns raised verbally by C was reasonable and highlighted the school staff’s conclusion at that time that this had been a matter that could be dealt with in the classroom. When new information became available indicating that the events may have been more serious, the council left the investigation to the police. Following completion of the police’s investigation, the council issued their response to the complaint, which reflected the situation as they understood it.

However, C’s complaint clearly included mention of their concern that a few weeks before the specific incident complained of they had reported to the teacher that a similar incident had occurred. Due to the lack of records available of the council’s investigation it is unclear whether, or to what extent, that these concerns were taken into account or investigated. These concerns were not responded to by the council. It is unclear, therefore, whether the council reasonably considered the implications of the teacher having been aware of potentially inappropriate behaviour taking place among the children for a few weeks before the reports that led to action being taken. These implications may have included what weight the school and council gave to the teacher’s statements, whether evidence or corroboration should have been sought for when the teacher or other staff first became aware of the children’s actions in the playground, and whether the outcome of the investigations would have been the same. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for their failure to investigate and respond to C’s concern that they had reported to the teacher. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Complaints are properly investigated and responded to in line with the Model Complaints Handling Procedure for Local Authorities.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the council’s planning department with respect to a section 75 agreement (a contract that is entered into between a landowner and a planning authority). In particular, C complained that the council had failed to adhere to a clause of the section 75 agreement requiring them to adopt open space and woodland areas within, and bordering the housing development on which C lives. C noted that some of the land in question had now been sold to a property developer. C believed that the council’s inaction could result in development adversely affecting C and other residents’ properties and a failure to maintain the playpark and communal spaces. Additionally, C was dissatisfied with the council’s response to their complaint due to missed timescales, and the response having been issued by an officer closely involved in the matters complained about.

We took independent advice from a planning adviser. We found that many of the significant events related to this complaint were now historic. In particular, the fifth clause of the section 75 agreement required prior action be taken, adoption of the land by the council, before occupation of a number of homes in a phased development. However, a number of years previously the council had failed to monitor and discharge this condition allowing occupation. While in theory enforcement action remained a possibility at the council’s discretion, due to the passage of time the owner of the land likely now had deemed planning permission. On this basis, we upheld C’s complaints about these matters. We also upheld C’s complaint that the complaint had not been handled in line with the council’s complaints handling procedure.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing in their duty to ensure that all the conditions and schedules of the decision notice and the Section 75 Agreement were discharged. Apologise for failings in relation to enforcement action which due to the passage of time and failings outlined appeared to no longer be a reasonable option available to the council. Additionally, apologise for the failings in complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information leaflets.

What we said should change to put things right in future:

• Where as a condition of planning permission being granted, the council and the developer have entered into a Section 75 Agreement, the said Agreement and the conditions attached there too require to be monitored by the council to ensure that they are complied with and discharged. The council should therefore ensure that they have a systematic and robust system of monitoring in place.

In relation to complaints handling, we recommended:

• The council should ensure that they comply with the process and time limits set out in the complaint handling procedure. Where the council are unable to meet their time limits for responding to a complainant they should notify the complainant and explain the reasons why. The council should also ensure that their final response to a complaint signposts to this office in line with their complaints handling procedure.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the council failed to provide support to them and their child (A), who had a severe and debilitating mental illness, and that the council unreasonably failed to respond to all of their concerns.

We took independent advice from a social work adviser. In relation to the council’s failure to provide support to C and A, we found that there were unreasonable delays by the council at each stage of this case. We found that there appeared to be a lack of appropriate management oversight of the case, and a lack of follow up to ensure the best possible outcome for A was met. We also found that the overall communication with C was poor.

In relation to the council’s failure to respond to all of C’s concerns, we found that the actions which the allocated social worker said that they would undertake to progress the case had led C not to make a complaint. We found that the council’s complaint response lacked detail and clarity as to what went wrong and how this could have been avoided. In particular there should have been a clearer acknowledgement and explanation as to why their own guidelines on timescales were not adhered to. We also found that the council failed to fully acknowledge the impact on C, A and their family from those delays and that if the council considered it was not possible or appropriate to issue a joint response on behalf of the council and other partnership organisations, the reason(s) why should have been explained to C and C should have been signposted accordingly. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in providing support to C and A. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Complaint responses should be informed and accurate. The council’s complaint handling monitoring and governance system should ensure that failings (and good practice) are identified and that learning from complaints is used to drive service development and improvement. The council should ensure that they carry out a robust investigation of a complaint when things go wrong. This should include examining the management and decision-making processes of a case to ensure that they have an understanding of all aspects of a case.
• Contact and referrals to social work services should be handled in a timely way and, where appropriate, allocated to a social worker without delay. Children and Young Persons’ assessments should be completed wherever possible in accordance with the timescales set out in the council’s policy. Where this timescale cannot be met, the reasons for this should be fully documented and there should be regular and proactive communication throughout the process.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about South Lanarkshire Health and Social Care Partnership's handling of supported living arrangements for their adult child (A) with severe learning difficulties and significant support needs.

The partnership approved an assessment of A’s needs that included supporting them to move into their own tenancy with one-to-one support. It was noted that, long-term, the preferred option would be for A to move into a shared tenancy. C said that they worked with A’s care provider to find a suitable two-bedroom (to accommodate care staff) tenancy for A. The partnership were advised that this work progressed to the point where the care providers were looking to purchase a property for A to live in, and they told C a three-bedroom property should be the focus of the property search to achieve the ultimate aim of A securing a shared tenancy with room for another individual and care staff.

We took independent advice from a social work adviser. We found that the partnership’s assessment of A and C’s needs was reasonable. We were satisfied that the partnership’s reasoning was clear and appropriate in determining that a shared tenancy was the preferred long-term option for A, that the benefits of this (if delivered appropriately) were agreed by all involved, and that the partnership’s communication with C and other involved parties was clear and frequent throughout. We did not find that A’s assessed needs changed following the reassessment. However, it was decided at that point that the focus had to switch from providing A with a single tenancy to a shared tenancy. This decision was in line with the agreed long-term plan for A but was also, as the partnership described it, a material change from the initial proposal. It was also a change made without any prior preparation by the partnership in terms of finding a suitable joint tenant or three-bedroom property. We found that this caused an unreasonable delay to A being able to move towards independent living given plans were already advanced to secure a single tenancy that would have met A’s assessed needs. With this in mind, on balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that the partnership’s decision caused an unreasonable delay to A’s move to independent living. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The partnership review their handling of A’s case with a view to identifying how they may better investigate the viability of all options for independent living and progress these before reaching decisions that effectively reduce those to a single option.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C presented to the medical practice with nausea and weight loss. Following blood tests, a significant drop in haemoglobin levels was noted and anaemia (deficiency of healthy red blood cells in blood) was diagnosed. C complained that they were not referred on to secondary care for admission or investigation at this point. A few days later, C collapsed and suffered internal bleeding as a result of a large gastric ulcer (a perforation or hole in the lining of the small intestine, lower oesophagus or stomach).

The practice advised that C was a new patient to the practice and had recently been in hospital with acute kidney injury. On first presentation they had a urine infection, which was treated with antibiotics. Following the blood test results, examinations were carried out to check for internal bleeding. No signs of bleeding had been found but C had a bladder full of urine and their catheter was bypassing. The doctor referred to district nursing for a catheter change and a repeat blood test. This was to check whether C was experiencing further kidney injury. There were no obvious signs of dyspepsia (a condition where digestion is impaired) as no heart burn was recorded.

We took independent medical advice from a GP adviser. We found that it would have been appropriate to make an urgent cancer referral based on the symptoms, but that it was reasonable not to have suspected a gastric ulcer. We also found that there was no record that the causes of the anaemia had been fully explored or that a treatment plan and safety netting advice had been considered or communicated.

We upheld the complaint as we considered that although many of the actions had been reasonable, it did not appear that a cancer referral, a treatment plan or safety netting had been properly considered, recorded or communicated. We did not consider that this had changed C’s outcome and acknowledged that the practice had taken steps to learn from the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not fully exploring C’s symptom history and medication, for not communicating a treatment plan and for not providing worsening advice in case of deterioration. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflet.

What we said should change to put things right in future:

• The practice should consider scheduling regular peer reviews to ensure that consultations are fully recorded including treatment plan and safety netting advice. Staff should be aware of NICE Guidelines and Scottish Referral Pathways for suspected cancer.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their late parent (A). A underwent surgery to treat hypertension (high blood pressure). A few days later, A’s condition deteriorated with the cause thought to be sepsis (a life-threatening reaction to an infection). A’s condition worsened further and they were transferred to the High Dependency Unit (HDU). A died later that day.

C complained that there had been a failure to administer antibiotics that A had required and that there had been unreasonable delays in transferring A to the HDU, which resulted in A being left in a state of distress. C also complained about the conclusions that the board had reached about A’s care following a Significant Clinical Investigation (SCI).

The board stated that A had been monitored every 30 minutes and that there had been no delay in providing antibiotics to A. The board accepted that there had been a failure in communication between nursing and porter staff which had led to a delay in A being transferred to HDU. However, the board considered that this would not have resulted in a different outcome although it was acknowledged that this would have reduced A’s family’s distress.

We took independent clinical advice from an acute medicine and nursing adviser. We found that there were a number of failings in the care provided to A following the initial deterioration in their condition. This included failure to initiate tests to identify sepsis, failure to commence intravenous fluids (medical technique that administers fluids, medications and nutrients directly into a person's vein) and failure to perform necessary blood tests, as had been outlined by A’s consultant. There was also no evidence that A had received antibiotics nor had been monitored with the frequency stated by the board. We also found that nursing staff failed to escalate a further deterioration in A’s deterioration and that there had been an unreasonable delay of around two hours in transferring A to HDU. In addition, we found that several aspects of the nursing records fell below the professional standards required by the Nursing and Midwifery Council and that the board’s SCI had failed to identify areas of learning arising from this case. For these reasons, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Significant Clinical Incident reports should:
• (i) be reflective and learning processes that consider events against relevant standards and guidelines,
• (ii) ensure failings are identified and any appropriate learning and practice improvements are made and,
• (iii) be in line with Learning from adverse events through reporting and review - A national framework for Scotland: December 2019 (healthcareimprovementscotland.org)
• Treatment plans should be comprehensive and document the working diagnosis. Patients should receive the treatment plan recorded in the medical records following consultant review unless there is a change of plan. If this happens this should be clearly recorded.
• Where the cause of a patient’s deterioration is suspected to be due to sepsis, the sepsis bundle should be initiated.
• Patients should be assessed, in accordance with the NEWS guidance relative to the patient's NEWS score. Where there is deviation from this, this should be recorded. In addition, patients who are assessed to have a NEWS score of five or greater should be escalated urgently for further assessment in line with NEWS guidance. NEWS scoring documentation should be fully completed and recorded.
• For patients where there is the presence of red flags indicating an ECG, this should be acted on without delay.
• Where blood tests are requested in order to investigate a deterioration in patient's condition they should be processed and reviewed as soon as possible. Patients should receive the appropriate blood tests to adequately assess the cause of deterioration and any tests that have been specifically requested by clinicians.
• Where a deteriorating patient requires to be transferred from the ward for more intensive treatment, the transfer should take place as soon as possible and without undue delay. A record should also be made showing which member of staff has requested the transfer, the time at which the transfer was requested and to whom the request was made.
• Nursing records should be documented in real time, as far as it is reasonably practicable to do so. They should also include a clear timeline of events, the actions taken by nursing staff (including in what order) and details of all communication with relatives and other healthcare professionals.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the actions taken by Borders NHS board in relation to diagnosing their child (A) with attention-deficit hyperactivity disorder (ADHD, a condition that affects people's behaviour, including restlessness and impulsiveness). C said that A’s initial referral was rejected and when an assessment did take place it failed to diagnose A’s ADHD. Requests for second opinions were then refused. C said that A was diagnosed with ADHD but not until some years after the initial referral and this was an unreasonable length of time.

We took independent advice from a consultant child and adolescent psychiatrist. We found that while the initial refusal of the referral and first assessment were reasonable, the decision to refuse the request for a second opinion and further assessment was not. This led to an unreasonable delay in diagnosing A with ADHD. As such we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Where a request for a second opinion is made and the initial assessment demonstrated some indicators of a developmental disorder e.g. ADHD, then a second opinion should be carried out, particularly for developmental disorders where changes may have occurred in the intervening time period.

In relation to complaints handling, we recommended:

• Responses to complaints should be clear and accurate.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about how the university handled their complaint that related to their disability and housing. We found that the university's decision to request further information from C about their disability to be reasonable and in line with their policy. We also considered it reasonable that the university asked C for further information about some serious allegations that they had made.

However, we found that the complaint should have been progressed to stage 2 of their complaints handling procedure from the beginning, with the delay of 18 days, which in the specific circumstances here appeared unreasonably inflexible.

On balance, we upheld this complaint as we did not believe it was properly processed and the university's communication with C could have been better.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to progress their complaint through the proper process, at the proper stage. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• The university are aware of the emphasis on them to ensure a complaint progresses through the correct process. We also need to be satisfied that the university are aware of the characteristics of a stage 1 and 2 complaint and finally that they exercise reasonable discretion when a request to progress a complaint to stage 2 is submitted out with the normal time limits.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C is a parent who lives with their partner (B). An allegation was made that C had used physical punishment to discipline their children and the children were removed from C and B's care. C complained that the children were removed without any evidence of wrongdoing on C's part.

We took independent advice from a social work adviser. We found that the reason for the removal of the children was justified on the basis of the evidence available at the time.

However, we considered concerns about the apparent lack of investigation into allegations which were made about B, incomplete forms, and the decision to return the children to C and B's care in advance of the outcome of the case. For these reasons we upheld the complaint.

Recommendations

What we said should change to put things right in future:

• Staff should complete all relevant sections of paperwork. Staff should reflect on the outcome of this case.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.