Upheld, recommendations

Summary

Mr C, who is a solicitor, complained on behalf of the owners of a farm. He said that the farm had received an abnormally high water bill despite being certain that they had not used the amount registered on their water meter. Mr C complained to Business Stream, suggesting that the meter was faulty. Business Stream arranged for the meter to be checked, but concluded that it was functioning normally and that the farm must have used the water.

We took independent advice from one of our water advisers. He said that the most likely cause of the high meter readings was air pockets or debris escaping from the water system following repairs to the water main near the farm. The farm's location and pipework made it particularly vulnerable to this. Although Mr C had provided several pieces of anecdotal evidence that should have highlighted these as potential causes of the high meter readings, we found no evidence to suggest that Business Stream had considered this. We concluded that they did not take adequate steps to fully investigate the cause of the high meter readings. We found it unreasonable that the farm should be expected to bear the full financial burden of something that seems likely to have been beyond their control, and made a recommendation to address this.

Recommendations

We recommended that Business Stream:

• re-calculate the farm's average daily consumption and credit their account with an amount equivalent to 50 percent of the over-consumption recorded on a particular meter reading.

Summary

A number of years ago, Mr C bought a field next to a farm. The field was served by a water trough. He said that although he considered the water bills to be high, it was only in 2010 that he established that the supply was a joint one with the farm. He initially complained to Scottish Water who told him the meter number that should have applied and Mr C continued to question his bills on this basis. However, he also complained as he said that Business Stream continued to bill him incorrectly.

We investigated the complaint and considered all the relevant documentation, including all the correspondence and invoices from Business Stream. We upheld the complaint because our investigation found that Scottish Water had not kept Business Stream up-to-date about the correct meter that served the trough in Mr C's field. When this was brought to their attention, they corrected the records, re-billed Mr C and made him an ex-gratia payment in recognition of the inconvenience he had suffered.

Recommendations

We recommended that Business Stream:

• make a formal apology for their failure to deal properly with letters of complaint.

Summary

Mr C, who is a prisoner, was being taken to hospital and he asked a prison officer to phone his sister to let her know. The prison officer agreed but another officer then told Mr C it could not be done. Mr C complained that the prison inappropriately failed to action his request.

The prison rules say that if a prisoner becomes seriously ill or is admitted to a medical facility outwith the prison, the governor must, where possible, ask the prisoner if any relative or friend should be informed. The rules also say that if a prisoners wants a relative or friend to be informed then the governor must notify them.

In responding to Mr C's complaint, the prison confirmed that such a request should be actioned but they also said the officer could not recall Mr C making it. We were unable to determine whether or not Mr C did make the request. However, even if he did not make the request, prison rules confirm that steps must be taken to ask a prisoner whether they would like a relative or friend to be informed. That did not happen in Mr C's case and because of that, we upheld his complaint.

Recommendations

We recommended that the Scottish Prison Service:

• remind prison staff of the requirements of the relevant Prison Rule (42).

Summary

Mrs C lives in an upper flat in a block of four council flats. Shortly before Christmas she reported water coming into her home from a leaking roof. The council responded after the new year, and provided plastic sheeting in the loft space. Nothing was then done to the roof until July when a scaffold was erected for one day (Mrs C disputes that any work was done on her side at that time). After she contacted the council again, a repair order was issued at the start of August, and roof works including the taking down of a chimney and other repairs were completed by late October. The scaffolding remained up for another six weeks and Mrs C says that at the time of its removal the roof leaks had not been completely attended to. She complained to us that the roof repairs were not carried out within a reasonable time.

Our investigation found that the council's communication was inadequate, as they should have told Mrs C what they intended to do and when. We found it difficult to see from their records exactly what they did plan to do to the roof, and why, but the evidence we saw suggested that repairs were not carried out in a reasonable timescale. We upheld Mrs C's complaint and made two recommendations.

Recommendations

We recommended that the council:

• apologise to Mrs C for the poor quality of their communication to her of the reasons for the delay; and
• if they have not already done so, carry out an inspection to determine whether the downpipes and guttering at Mrs C's home require repair and, if so, inform Mrs C of a timescale target for completion.

Summary

Mr C complained about the conditions imposed on his licensed premises, and about how the council handled his complaint about this.

We explained to Mr C that we could not deal with his complaint about the conditions, which had already been the subject of legal proceedings. We did investigate his complaint about the complaints handling, and found that there had been several shortcomings. The council did not adhere to their complaints procedure or inform Mr C of their intention to deviate from their usual process. They took far too long to respond to his complaints and on some occasions failed to acknowledge his letters. They also did not tell Mr C that he had a right to complain to the Standards Commissioner.

Recommendations

We recommended that the council:

• apologise to Mr C for the shortcomings identified in our investigation in respect of the handling of his complaint that have not already been the subject of an apology; and
• draw our report to the attention of the head of legal services.

Summary

Ms C complained that the council failed to properly deal with a complaint made by her neighbour’s tradesman about the condition of Ms C’s property. She raised concerns about eight issues related to the council’s actions. She also complained that the council did not deal properly with her complaint about this.

Our investigation found that the council acted directly on a complaint from a tradesman about the condition of Ms C’s property without first carrying out their own investigations. They, therefore, did not act completely independently. We also found that the council unreasonably failed to tell Ms C about missing and leaking guttering and apparent water staining on the blind on one of her rooms. We were particularly concerned about the council’s lack of record-keeping in this case and addressed this in our recommendations.

On the issue of complaints handling, there was no evidence that the council investigated Ms C’s complaint in line with their own complaints procedure. The evidence also showed that Ms C raised 11 issues in her letter of complaint to the chief executive, which he did not address in his response.

Recommendations

We recommended that the council:

• provide a written apology for failing to test the veracity of the information provided by the tradesman before writing to Ms C, failing to act independently, and unreasonably failing to explain why they thought there was a suspicion of dampness in the property;
• feed back the decision on this complaint to the staff involved;
• take steps to ensure that, in future, records are made of phone calls from complainants and visits to properties in response to such complaints;
• provide a written apology for failing to investigate the complaint properly; and
• feed back our views on their complaints handling to the members of staff involved.

Summary

Mr C had to move from his previous council tenancy and, at short notice, was offered the tenancy of another house in a different town. Mr C said that he, his partner and several friends worked hard to clear his former tenancy and leave it in a tidy state, but admitted that they had left two plastic bags of rubbish in the bathroom. Some seven weeks after the move, the council sent Mr C an invoice for works carried out by a contractor to clear and clean Mr C's former home. Mr C disputed this through a firm of solicitors and then pursued a complaint through the council's procedures. In the interim, the council put the non-payment of the invoice in the hands of recovery agents.

Our investigation found, on balance, that the council had unreasonably issued the invoice. They had taken digital images some two weeks after Mr C moved out, but these were undated and did not conclusively identify the property. Mr C maintained that several of the images (which the council disclosed following an information request) were not of his former home. We also found that the council did not deal reasonably with Mr C’s complaints.

Recommendations

We recommended that the council:

• reconsider in the light of information from our investigation whether there are grounds to reduce the sum claimed in their invoice;
• ensure that when digital images are taken on termination of a tenancy, these are imprinted with the date and a means of verifying that date and identifying the property; and
• apologise to Mr C for their shortcomings in handling his complaint.

Summary

Ms C complained on behalf of her daughter (Ms A), an overseas student who was studying in Scotland. Ms A had developed abdominal pain, nausea and constipation. She was seen at home by a GP who examined her, carried out a urine analysis and advised her to take an over-the-counter painkiller. Five days later, Ms A’s condition had not improved so she went to the medical practice where she was seen by a different GP. Ms C was examined again and the notes record that a uterine mass (a lump in the area of the womb) was detected. The second GP diagnosed constipation, advised Ms A to take the same painkiller and a laxative (a drug to relieve constipation) and asked her to return to the practice in a week. The notes recorded that the uterine mass was to be investigated then.

Ms C was concerned about her daughter's condition, so she came to Scotland the following day and escorted Ms A home where she was seen by her local GP. An ovarian cyst (a lump or sac on the ovary) was diagnosed and Ms A had surgery to remove it. Ms C complained to us that the practice did not provide reasonable diagnosis and treatment for her daughter.

After taking independent advice from one of our medical advisers our investigation found that there were clear clinical signs that should have prompted further specialist investigation. The Scottish Intercollegiate Guidance Network (SIGN) issue guidance on the investigation, management and treatment of various medical conditions. SIGN 75 (which deals with ovarian cancer) says that any woman found to have an abdominal mass should be referred to a specialist for further investigation. The adviser said that the recommended diagnostic tool in such cases is ultrasound investigation (specialist imaging using sound waves) and that the GPs who saw Ms A should have referred her urgently for this. The adviser said that it was not appropriate to have advised Ms A to take a laxative and re-attend in a week's time.

Our investigation also revealed an issue which was not known to Ms C and so was not raised in her complaint. In reviewing Ms A's medical records we found reference to the complaints letters and responses. This is contrary to the guidance issued by NHS Scotland which states that information on complaints should be kept separate from a patient's clinical records unless there is a valid clinical reason for mentioning this. There was no clinical reason to record complaints information in Ms A's records.

Recommendations

We recommended that the practice:

• issue a written apology to Ms C and Ms A for the failings identified during this investigation;
• conduct a significant event analysis (SEA) on this case and reflect on the lessons to be learned;
• ensure that the second GP is prepared to discuss the lessons from the SEA at their next GP annual appraisal, including any learning needs regarding SIGN 75; and
• familiarise themselves with the NHS guidance on complaints handling, in particular in relation to the recording of complaints in patients' records.

Summary

Miss C's mother (Mrs A) was admitted to hospital for surgery. Her recovery took a long time and she developed pleural effusions (fluid that gathers around the outside of the lung). After about four months she was transferred to another hospital. At this time she was still very unwell, being tube-fed and having a urinary catheter (a thin tube used to drain and collect urine from the bladder). Tests showed abnormalities in her abdomen. At the end of that month, Mrs A was transferred to a third hospital but returned to the second hospital several days later when tests indicated a chest infection. She was diagnosed as having contracted clostridium difficile (a common healthcare-associated infection). A line to provide better access to her veins for intravenous fluids and antibiotics was inserted but became dislodged. Her condition continued to worsen and she died a few days after being transferred.

Miss C complained that during her mother's time in the second hospital the board did not reasonably attempt to address her chest condition, and failed to help with eating or to consider her dietary requirements. She also complained that the board inappropriately transferred Mrs A to the third hospital, given her chest condition, and that they failed to take reasonable steps to ensure that the access line did not become dislodged. Finally, Miss C complained about the board's complaints handling.

We took independent advice from a medical adviser and a nursing adviser. The medical adviser said that before Mrs A's transfer to the third hospital there were shortcomings in diagnosing and managing the inflammation that Mrs A had and that the decision to transfer her was, therefore, questionable. The nursing adviser said that the nursing care in relation to nutrition was reasonable. However, given our concerns about the shortcomings in medical care we upheld the complaint. We were satisfied that in their complaint response the board provided a reasonable explanation for the cause of Mrs A's pleural effusions. However, we upheld the complaint about this because although they acknowledged that Mrs A's care could have been better managed, they failed to provide any further details. We also noted that they did not respond to her second letter of complaint for 14 weeks.

Recommendations

We recommended that the board:

• ensure that the failures identified are raised with the relevant clinicians during their next appraisal;
• review their complaints handling process in light of our findings; and
• apologise to Miss C for the failures identified.

Summary

Miss C's sister (Miss A) fell at home and was admitted to a hospital. Although she injured her back in the fall, her health had already been deteriorating for around two months. Miss A had a history of alcoholism and was underweight, and her GP had been treating her for urinary and lower respiratory tract infections. While in hospital, Miss A became lethargic and developed symptoms of liver disease. Although she initially responded well to treatment, her condition deteriorated and she was transferred to the care of liver specialists at a second hospital in a different board area. By that time Miss A was also suffering from pneumonia and increasing confusion, and she died two weeks after falling.

Miss C complained about the quality of nursing care at the second hospital, and the level of communication with family members. Specifically, she complained that she was not told that she could visit her sister outwith the standard visiting times, and that she was not contacted during the night when her sister's condition deteriorated. Miss C visited Miss A the following morning and found that she had died. She was unattended, with unconsumed medication on and around her bed.

We found the level of nursing care to be below an acceptable standard. Miss C should have been given clearer information about visiting times and should have been contacted when her sister's condition deteriorated. We accepted advice that, although Miss A's condition was closely monitored, staff should have identified that her deterioration was indicative of a terminal decline. Their failure to do so meant that Miss C was not able to be with her sister when she died. We also found that staff failed to provide adequate supervision of Miss A's medication intake.

Recommendations

We recommended that the board:

• apologise to Miss C for failing to make her aware of their flexible visiting arrangements and for failing to contact her when her sister's condition deteriorated;
• review their visiting policy to ensure that relatives are provided with information about visiting arrangements for patients who are critically ill;
• apologise to Miss C for failing to act on the changes to Miss A's vital signs during the night before she died;
• consider whether their nursing staff would benefit from refresher training on end of life care; and
• remind nursing staff of their responsibilities in line with section 2.10 of the Nursing and Midwifery Council Standards for Medicines Management.