Upheld, recommendations

Summary

Mr C (an MSP) made a complaint on behalf of his constituent (Mrs B) about the clinical treatment and nursing care provided to Mrs B's late mother (Mrs A). The complaints included a delay in undertaking a CT scan (a specialised type of x-ray using a computer); the insertion and monitoring of a drain to remove fluid from Mrs A's abdomen; and failures in communication.

We upheld Mr C's complaint and made a number of recommendations. Our investigation included taking independent advice from two of our medical advisers - an oncologist (a cancer specialist) and a senior nurse. Both advisers were critical that there was a lack of documentation about Mrs A's care and treatment, and noted that this made it difficult to know what had or had not been done for her. Our investigation also found that there were many failures in communication between staff and Mrs A and her family. This was particularly difficult for the family when Mrs A was nearing the end of her life and was placed on the Liverpool Care Pathway (a tool used to assist clinicians and nursing staff to support patients and their families as the patient is dying. The aim is to address the patient's symptoms rather than aggressively pursue a cure for the underlying terminal condition.)

We also noted that there was a delay of some four weeks before the radiology department received an urgent CT scan request made by Mrs A's GP, and then it was a further two weeks before the scan took place. The board could provide no explanation for this delay other than human error in not following it up. While the delay was unlikely to have altered the eventual outcome for Mrs A, we found it unacceptable.

Recommendations

We recommended that the board:

• remind all staff involved in processing requests for referrals and investigations of the importance of arranging appointments to meet the two-week NHS target time;
• ensure that all relevant staff are made aware of the revised medical protocol for the management of ascites (fluid)/drainage;
• ensure that all relevant staff are made aware of the requirement to seek informed consent for any invasive procedure to be undertaken, and where necessary provide appropriate training;
• conduct an audit of record-keeping in the ward concerned, and address any learning issues identified;
• remind all relevant staff of the need for effective communication with patients, relatives and/or carers, and provide refresher training where necessary; and
• apologise for all of the failings identified during our investigation.

Summary

Mr and Ms C complained about the care and treatment given to their late mother (Mrs A) while she was a patient in hospital. Mrs A had been admitted with a history of diverticular disease (disease of the colon) and schizophrenia (a long-term mental health condition that causes a range of different psychological symptoms) but her immediate symptoms included a possible gastro-intestinal bleed. After admission, Mrs A experienced increasing confusion and showed signs of dehydration. Mr and Ms C said that staff failed to address these growing problems, together with the problem with which she had originally presented, to the extent that Mrs A became dangerously ill and died. Mr and Ms C were shocked at their mother's swift deterioration and death. They said that no proper intervention had been made until the day she died and they believed staff paid more attention to Mrs A's mental health than to the physical problems she was experiencing. They complained to the board, who said that they were satisfied that the care and treatment given to Mrs A was appropriate to her needs.

We obtained independent advice from a medical adviser and nursing adviser, and gave careful consideration to Mrs A's medical records and the complaints correspondence. We upheld the complaint, as our investigation found that although the board had tried to address Mr and Ms C's concerns by holding a number of meetings and by writing, their initial letter failed to mention that intravenous fluids were not started when they had been suggested or that a deteriorating renal function was a key part of Mrs A's condition.

Recommendations

We recommended that the board:

• consider the use of cognitive function screening and assessment tools as routine in similar circumstances;
• ensure that nursing care plans are in place for patients; and
• review their initial letter to Mr and Ms C and consider what steps could be taken to improve the quality of future responses.

Summary

Mrs C complained that there were delays in providing dental treatment to her profoundly disabled daughter (Ms A). Mrs C said that after Ms A attended a dental appointment it was some seven months before she received treatment under general anaesthetic. Mrs C alleged that Ms A received a standard of care which was less than that given to the general population, because of her disability, and that the delay was unreasonable. Mrs C also complained that the board failed to deal with her complaint properly.

We took independent advice from our dental adviser on Ms A's care and treatment, and took all the complaints correspondence and relevant medical records into account. Our investigation found that Mrs C had questioned both the treatment and the approach recommended by Ms A's dentist. Because of this, the board were placed in the unusual position of having to have two dentists with Ms A during her treatment. The board also had to satisfy themselves that what was being agreed with Mrs C was in accordance with the policies with which they had to comply. The adviser confirmed that the complex discussions and additional arrangements that were necessary to provide Ms A's treatment created a delay which was understandable, and did not consider this unreasonable. However, an internal time line tracking events over a three month period between the date when an approach to treatment was agreed and the date the approach was confirmed to Mrs C was too long and showed no urgency. In the circumstances, we upheld the complaint of delay. We also found that the board showed a similar lack of urgency in responding to Mrs C's complaint.

Recommendations

We recommended that the board:

• make a formal apology to Mrs C and Ms A for the delays in providing treatment;
• confirm that a relevant protocol is in place;
• apologise to Mrs C for the delay in dealing with her complaint; and
• remind the appropriate staff of the importance of adhering to their stated complaints policy.

Summary

Mr C, who is a prisoner, complained that he was not seen by the prison dental hygienist after being advised that he would be seen again in three months. He was also unhappy that it took nearly four months for him to see the dentist after he reported that a tooth had broken, causing him pain and increasing difficulty in eating and sleeping.

The board told us that when they took over responsibility for providing NHS care for prisons in their area in April 2012, there were no guidelines in place aimed specifically at the treatment of prisoners but this was now underway. They also said that since Mr C complained, the prison had audited its practice against the board's new dental services standard statement.

Although we recognised that the prison's dental resources were going through a transitional period, we were unable to clearly identify why Mr C's hygienist appointment did not go ahead until 11 months after it was recommended he be seen again. We took independent advice from our dental adviser, who said that from the evidence in the dental records it would have been reasonable for Mr C to see the hygienist around every three months. We, therefore, took the view that the delay was likely to have affected the progression of Mr C's gum disease, which the records show got worse during the months he was waiting to be seen. In addition, we found that the time it took before Mr C saw the dentist was unreasonable and not in accordance with the guidance in place at the time, or the draft guidance due to be published. We were concerned that the board did not identify this while investigating his complaint. We found that the delay was likely to have contributed to his tooth decay and the possibility that he may lose a tooth.

Recommendations

We recommended that the board:

• apologise to Mr C for the delay he experienced in being seen by the hygienist and the dentist; and
• provide the Ombudsman with evidence to show that the prison has audited their practice against the board's dental services standard statement.

Summary

Mr C's business moved into their current premises in 2005, and Business Stream created a water account for them in December of that year. In 2013, Mr C noticed that his water bills had suddenly increased. He was advised to check for a leak, but none was found. Eventually, it was discovered that his premises' pipework was shared with a number of residential properties, and Business Stream's policies required that his premises be treated as 'dual use premises'. This meant that Mr C could not install a second water meter to separate his water usage from that used by the residential properties. Although Mr C did not own or manage any of the residential properties, he would be billed for the water for all the properties and would have to sub-charge the residential properties for their share of the water charges. As they were already paying for water through their council tax, it would be up to Mr C to arrange for them to cancel the water charges from their council tax and to have any amounts paid refunded to him.

We found that, historically, Mr C's premises had been part of a larger property attached to the residential properties with a shared address and rateable value. However, at the time of Mr C's water account being created, the properties had been split and the assessor had given Mr C's property its own rateable value. As such, we did not consider that his property fitted the 'dual use premises' model. We noted that Business Stream's policies did not address circumstances such as Mr C's and there was no mechanism for customers in his position to have their water meters relocated or a secondary meter fitted. We considered it unfair that the result of this was that the customer was required to make complex arrangements with unrelated residential property owners to charge for water that was already being paid for through council tax. We upheld his complaint, as we found that Business Stream and Scottish Water did not do enough to find a common sense solution to the situation to ensure that Mr C's business was charged fairly for its water consumption.

Recommendations

We recommended that Business Stream:

• and Scottish Water jointly reconsider Mr C's case to ensure that his business's billing arrangements reflect that his premises are no longer 'dual use';
• and Scottish Water reconsider their policies to allow for situations similar to Mr C's; and
• consider backdating the revised billing arrangements for Mr C's business to December 2005.

Summary

Mr C operated an accounting business from a room in his house. This meant that the room was listed on the Scottish Assessors Association’s website and that Mr C would be eligible for certain water charges, even though the room had no direct water connections. Business Stream became aware that Mr C was eligible for water charges in March 2010 but did not issue their first invoice (with charges backdated to that date) until well over two years later.

Mr C complained about this delay and also the level of the invoice. He also told Business Stream more than once that the business had ceased more than a year before they issued the invoice. In addition, he said that Business Stream misadvised him that he would qualify for relief from their charges if he supplied proof that he received 100 percent small business rates relief.

Mr C had received a reduction in his council tax, and we had to consider whether it was reasonable to, therefore, expect him to have made enquiries about whether he should pay a commercial water supplier. However, we upheld both of his complaints as, on balance, we considered Business Stream’s delay of over two years in issuing their invoice to have been unreasonable. In addition, although they had met their timescales in responding to Mr C’s complaint, they failed to address the significant matter of Mr C’s company having been liquidated.

Recommendations

We recommended that Business Stream:

• apologise for the delay in issuing their invoice, revisit the liquidated company point with Mr C and waive their charge for overdue payment of the disputed balance;
• confirm the internal steps taken to ensure staff give accurate advice regarding exemption from their charges; and
• confirm the steps they will take to ensure initial invoices are issued more promptly.

Summary

Mr C, who is a prisoner, complained that the prison would only allow him to purchase a Playstation 2 instead of a Xbox games console. The prison advised Mr C that Xboxes were not allowed as they can be modified for internet provision, which was a security risk. Mr C said that the prison were acting unreasonably because, to enable internet connectivity, a phone line, modem router and high speed broadband would all have to be installed in the cell.

Our investigation found that although prison governors have the discretion to refuse certain items in a prisoner's cell for the security and good order of the prison, Scottish Prison Service headquarters had issued advice to all prisons in March 2010 and May 2013 that certain Xboxes could be allowed but not the Xbox 360, which has wireless connectivity capabilities. In view of this, the prison reconsidered their original position and now allow prisoners to purchase Xbox consoles (with the exception of Xbox 360).

Recommendations

We recommended that Scottish Prison Service:

• provide the Ombudsman with a copy of the prison's revised 'articles in use' policy.

Summary

After his partner died, Mr C notified the council of this change in his circumstances. He complained to us that it was then discovered that there had been an error in the handling of his benefit claims, which meant that for over a year he had been in receipt of a payment that he was not due. When he brought his complaint to us, the council had investigated the matter, and we were satisfied that this had been undertaken fully, so we decided reinvestigation of the circumstances behind the error was not required. However, Mr C told us that he was still unhappy because he believed he missed out on the opportunity to apply for a discretionary housing payment and of receiving council tax benefit for a period of four months, and because he had received a number of notices from the council with different information about what he owed.

When the council investigated Mr C's complaint, they upheld it and found that a longstanding error in recording had resulted in him receiving an overpayment of benefit. They had apologised to him for this, and had said that they would not ask him to repay the benefit paid in error. The council also told him that they would improve their processes and procedures to prevent a repeat.

Our investigation found that, despite this, Mr C had received notice shortly afterwards that his rent account was in arrears and that the council were asking him to repay an overpayment of council tax benefit from the date that the Department of Works and Pensions (DWP) told them of a further change in his benefit entitlement.

When we investigated, we found the situation very confusing and we were not surprised that Mr C had been similarly affected. We established that he had not missed out on a discretionary housing payment, as he had feared, because the rent arrears he had were not due to council error but a more recent change in his benefit entitlement, but we found that the council had failed to consider his request for this. We also found that it was unreasonable, having written off the overpayment of benefit for rent up to the end of the financial year, that he was being pursued for an overpayment of council tax benefit for this period, when it was the council's error that had affected his benefit.

Recommendations

We recommended that the council:

• should cancel or write off the council tax arrears for 2012/2013 on Mr C's account;
• write to Mr C with a clear, simply set out explanation of how his rent and council tax accounts currently stand, and of any arrears and how these are made up;
• write to the DWP confirming that the error in Mr C's benefit claim arose on the council's part and was not attributable to him in any way; and
• make him a payment as a goodwill gesture to reflect that they failed to meet a reasonable standard of service.
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Summary

Mr C complained that the council unreasonably refused to carry out work to his bathroom wall despite previously agreeing to do so. The council had told him that the offer of work was being withdrawn because he had made an abusive phone call to a member of staff. Mr C complained that the council had never told him what the abuse consisted of, or when it was meant to have taken place.

We upheld Mr C's complaint, as we found that the council did not conduct an adequate investigation into his concerns, and their responses had been confused and at times contradictory. There was also confusion about the possible involvement of a councillor. Council officers were unclear about the policies and procedures to be used when dealing with difficult phone calls, and we found that the withdrawal of the offer of the work was neither proportionate nor reasonable. We also found that the council's record-keeping was inadequate and that there was no proper audit trail of the decision-making process.

Recommendations

We recommended that the council:

• provide Mr C with a written apology for the failings identified by our investigation;
• complete the outstanding work in Mr C's bathroom;
• provide evidence that they have put in place written guidance on managing unacceptable behaviour and drawn this to the attention of all council staff; and
• review their policies for recording contact between staff and councillors to ensure that a formal record is kept.

Summary

Mr C complained about the way in which the council handled his complaint about a planning matter. We found that the council failed to deal with the subject of his complaint at the earlier stages of the complaints procedure. When they did finally respond to the matter he was complaining about, they acknowledged some, but not all, of their failings and apologised to Mr C for them. However, in later correspondence, the council appeared to change their position and said that they regarded the first stage response to the complaint as their final response on the matter.

We concluded that the council’s handling of this matter was confusing and of poor quality, and upheld Mr C’s complaint.

Recommendations

We recommended that the council:

• apologise to Mr C for the poor handling of his complaint, and for not acknowledging their failings in dealing with it;
• feed back to the planning department that they should acknowledge incoming emails, and clearly explain why they might not provide a response to the substance of an email; and
• review how this matter has been dealt with, in order to learn lessons in identifying the substance of a complaint and providing appropriate explanations and apologies in complaint responses at the earliest opportunity.