Upheld, recommendations

Summary

Mrs C complained about a number of matters related to her caesarean section (c-section - an operation to deliver a baby, which involves cutting the front of the abdomen and womb) and her subsequent care. Mrs C experienced a combination of complications including heavy bleeding and deep vein thrombosis (DVT) requiring hospitalisation.

After taking independent advice from a medical adviser, we found that most of Mrs C's medical and nursing care was reasonable. However, we upheld her complaint as we considered that the board did not take all possible precautions to reduce the likelihood of her developing DVT and heavy bleeding. We identified that Mrs C was given a combination of drugs that was likely to have caused her bleeding to worsen. We also considered that Mrs C should have been given compression stockings before and after the c-section until she regained full mobility. This did not happen in line with national guidelines on thrombosis and embolism in pregnancy. Mrs C also developed pressure sores following her c-section - the board acknowledged that she had not been properly assessed in this respect and agreed that this was unacceptable.

Recommendations

We recommended that the board:

• provide evidence to show that they have updated their policy on DVT to include the use of compression stockings;
• provide evidence to show that they have reminded relevant staff of the importance of assessing those mothers at risk of developing pressures sores following c-section;
• consider developing a template for documenting pressure sore risk assessments; and
• apologise to Mrs C for the failings we identified.

Summary

Mr C complained on behalf of his son (Mr A). Mr A had mental health problems but although he was twice on the waiting list for treatment for this, the board removed him from the list because he was either being investigated by the police or was awaiting trial. Mr C complained to the board, who confirmed that as there were outstanding charges against Mr A, his name had been removed. They said that this was in accordance with their usual protocol.

As part of our investigation we obtained independent advice from one of our medical advisers, a consultant forensic psychiatrist. Our adviser said that the board's protocol was contrary to the NHS policy of individualised care according to need. Mr A had been removed from the waiting list without due consideration for his needs and circumstances. We upheld the complaint as Mr A had received no treatment, and had significant psychological needs that went unmet.

Recommendations

We recommended that the board:

• formally apologise to both Mr C and Mr A for failings in this matter;
• look again at their protocol in terms of the Healthcare Quality Strategy for NHS Scotland 2010; and
• assure themselves that any outstanding mental health needs for Mr A are now addressed.

Summary

Mr C had been diagnosed with dyslexia and visual stress. He complained that the university had not provided him with the support he needed for his additional learning needs and that his support had been reduced. This caused him great anxiety as he approached his final exams. He complained to the university but they did not uphold his complaint, and he felt that it was not reasonably handled.

Our investigation found that there were a number of areas, including assessment and agreed support hours, where his needs were not addressed and reasonable adjustments were not made. We also found that his additional needs were not addressed throughout the complaints handling process, including how support records were used, and that his recognised difficulties in processing information were ignored. We upheld Mr C's complaint and made a number of recommendations to address this.

Recommendations

We recommended that the university:

• apologise for not providing the support required to meet Mr C's needs;
• review how any failure to meet Mr C's support needs may have had a negative impact on his final year assessed work;
• review all instruments of assessment to ensure they are suitable for students with support needs; and
• review the Enabling Support ES15 form and how the Enabling Support activity log is used to ensure that students know and understand the recorded detail.

Summary

Mr C's business was identified as occupying premises that were receiving water services without being charged (known in the water industry as a gap site). As the default licensed provider for commercial water services, Mr C's business's details were passed to Business Stream who created an account in July 2012 and backdated their charges to the date Mr C's business moved into the premises. Mr C complained that Business Stream issued his company with bills and aggressive reminders without any introduction or information about who they are. He also complained that he was not given any option other than to use Business Stream.

We accepted Business Stream's position that Mr C's business had occupied the premises since June 2011 and had used water, waste water and drainage services without charge. As such, we considered it appropriate for Business Stream to recover the amounts due for the period between June 2011 and July 2012. Businesses are required to arrange their water services through a licensed provider and Business Stream are the default provider for customers who have not chosen an alternative. We considered it appropriate for Mr C to be contacted by Business Stream and advised of the water charges that had accrued against his property. However, we were concerned by the nature of that contact. We did not consider it reasonable for the first contact to have been a bill for a substantial sum with no explanation enclosed. Furthermore, the market code, which all water companies are required to follow, required that Mr C be given an initial period to choose his preferred licensed provider. He was denied this opportunity.

Recommendations

We recommended that Business Stream:

• apologise to Mr C for the failure by them, and Scottish Water, to contact him with a proper explanation as to the need to pay water charges and the process of selecting a licensed provider.

Summary

Mr C was the owner of a trough in a field. In 2008, he had experienced an increase in water consumption. He explained that at that time some work had been undertaken locally on water mains, so it was accepted that the increase was caused by that and the amount due was reduced. Mr C experienced a second increase during 2010. He again identified that work had been undertaken nearby during the relevant period. Business Stream, however, considered a number of possible causes for this increase in consumption and decided there was no evidence that there had been any error or problems with the meter readings. Mr C could not find a leak on the short length of pipe between the public pipe and his trough.

There are a number of possible causes for an increase that occurs over a period of time and then goes back to normal without any leak being fixed. It is not always possible to identify the precise cause and some of the causes are not in the control of Business Stream but the person receiving the supply. Therefore, when a dispute occurs, we assess whether Business Stream has reasonably considered whether there is any evidence of a cause of the increase which could be in the public network. While, in Mr C's case we found they had ruled out most problems that could have been caused by the public network, there was no evidence that they followed up on a particular issue about the recent work that Mr C said had been carried out. Mr C had provided the name of a road, contractor and the location of the relevant development. On this basis, we upheld Mr C's complaint and asked Business Stream to look again at that particular information.

Recommendations

We recommended that Business Stream:

• clarify with Mr C the position on the work allegedly undertaken by Scottish Water before pursuing the bill.

Summary

Mr C, who is a prisoner, complained that when he submitted a complaint, the prison's hall manager did not offer him the opportunity to discuss it. When Mr C escalated the complaint to the prison’s internal complaints committee (ICC) they acknowledged that the manager should have offered an initial discussion. In bringing his complaint to us, Mr C acknowledged that the prison had recognised the failing but expressed concern that they had not taken any action to stop this happening again. He noted that the failing had occurred again in other complaints he had submitted.

The prison told us that following Mr C’s complaint, the chair of the ICC had approached the manager involved and discussed the requirement to discuss complaints with prisoners. We noted that the prison rules say that within 48 hours of receiving a complaint managers must allow the prisoner the opportunity to discuss this with a view to resolving it.

We had previously investigated a complaint about the failure to comply with this rule and, on that occasion, we recommended that a reminder be issued to staff, highlighting their duties in this regard. Despite this, we observed that this was apparently continuing, and so we looked at the relevant section of the prisoner complaint form. We noted that this did not contain a prompt for managers to record their attempts to discuss the complaint with the prisoner. In the circumstances, we upheld the complaint and made a recommendation.

Recommendations

We recommended that the Scottish Prison Service:

• revise Section 2 of the Prisoner Complaint Form (PCF1) to prompt residential first line managers to record that a meeting has been offered to the prisoner and whether the offer was accepted.

Summary

Mr C represents a number of local residents opposed to an ongoing planning application. He wrote to the council with concerns about the lack of a transport assessment in relation to the application. Mr C did not believe the council had responded to his letter. When the council clarified the items of correspondence that they believed responded to the letter, Mr C was dissatisfied and brought his complaints to us.

After discussing this with Mr C we decided that the only matter we could consider was the failure to address points in his letter. We tried to resolve this with the council, but Mr C remained dissatisfied and resubmitted his complaint to us. We decided that the council had not reasonably addressed some of the concerns Mr C had raised and that it was unreasonable that they had not identified this until we became involved.

Recommendations

We recommended that the council:

• apologise to Mr C that their responses to his letter and subsequent related contact were not reasonable;
• provide a reasonable response to Mr C's enquiries; and
• review their practice to ensure that correspondence querying the relevance of their complaint responses is properly considered without the need for SPSO involvement.

Summary

Mr and Mrs C complained about a proposal by the developer of an adjacent site to vary a planning consent. Planning officers had regarded the proposal to vary the consent previously issued (to convert a former school to a care home and construct an extension) as a non-material variation (a material variation is a genuine planning consideration related to the purpose of planning legislation, which is to regulate the development and use of land in the public interest). The officers approved it as a delegated decision without reference to the relevant council committee.

In dealing with the complaint, the council accepted that although the request to vary did not raise new planning issues, and more windows in the new extension would overlook Mr and Mrs C’s rear garden, a corner of the extension had been brought forward 70 centimetres closer to the boundary than the council’s published guidance. In that regard, the request to vary should not have been dealt with as a non-material variation. In light of the council’s acceptance of their error, we upheld the complaint and made two recommendations.

Recommendations

We recommended that the council:

• review the criteria for non-material variation in their procedure note to include the previous history of objections to the assessment of any neighbour interest; and
• confirm that in respect of condition 9 of planning application A that the approved landscaping scheme has been fully implemented and that the additional screening alluded to, if not surviving, is replaced by suitable replacements at the council’s expense.

Summary

Mr C's partner submitted a claim to the council for damage to their car. After a number of messages from Mr C about delay in dealing with this, the council refused the claim, saying that there was no fault or negligence attributable to them. Mr C disputed this on a number of occasions and asked for the decision to be reviewed. He then complained about the way the council were handling matters. The council upheld part of his complaint but said that the complaints procedure did not allow for a review of the decision on his claim and that he should seek legal advice if he remained unhappy. Mr C wrote to the council again saying that their response had been unreasonable, in particular with relation to his claim, but the council repeated their decision.

Mr C continued to write to the council, and they wrote again, saying that while their decision on the insurance claim was one for the courts, they recognised that they had not been as helpful as they could have been and that their explanations could have been clearer. As a consequence, they said, the claims process was being reviewed.

Mr C complained to us that the council failed to operate and comply with reasonable procedures concerning his claim and because of this they did not deal properly with his complaint. We upheld Mr C's complaint as our investigation confirmed that there were defects in the council's internal claims process and that the council failed to follow their own stated procedures when dealing with his complaint.

Recommendations

We recommended that the council:

• apologise for their failing in this matter; and
• ensure that staff in the claims department are fully aware of the policies with regard to complaints handling and to requests for liability reviews.

Summary

Mr C complained about the care and treatment that his father (Mr A) received during his stay in hospital, and particularly during the final three days of his life. Mr A was diagnosed with myasthenia gravis (a medical condition where muscles become easily tired and weak) while he was on a neurology ward (for disorders of nerves and the nervous system) and was then transferred to a cardiology ward (for heart disorders) due to the deterioration of a long standing heart condition. While he was in the cardiology ward, the consultant neurologist remained in contact and reviewed him regularly. When Mr A was about to be discharged, he contracted a norovirus (winter vomiting) infection, and was not well enough to leave. His family asked for assurances that the consultant neurologist was consulted about the delayed discharge, but medical notes indicate that he was not told about the delay until late on the third day after. He then reviewed Mr A promptly.

That night Mr A's heart condition deteriorated, and he became weak and tired. He had difficulty swallowing his pills the next morning, and his family said that he choked on his food at lunchtime, although the board did not provide any information about that incident. After lunch, Mr A's condition deteriorated rapidly. A chest x-ray indicated that he had an infection, with possible signs of aspiration (when material from the stomach or throat is taken into the lungs), and although staff tried to stabilise his condition, Mr A died.

We obtained independent advice on this complaint from a medical adviser. They said that the neurologist should have been told earlier about Mr A's delayed discharge. They also said that Mr A should have been given a swallowing assessment to ensure he would not choke on food. They concluded that there was evidence that aspiration had led to an infection (pneumonia), which contributed to Mr A's deterioration, although this evidence was not completely conclusive. We upheld Mr C's complaint about his father's care and treatment, on the basis that communication between specialist teams was inadequate and that a swallowing assessment should have been conducted.

Mr C also complained about the board's handling of his complaint. Our investigation found that the board had given Mr C conflicting information. We also found evidence that their initial investigation was not sufficiently robust. We upheld this complaint, and highlighted that it took a full eight months for Mr C to get a final response to all the issues he raised, which was far too long.

Recommendations

We recommended that the board:

• ensure that, where a review is requested from another specialist, adequate notes are taken in enough detail for staff to carry out appropriate tests and monitoring;
• raise staff awareness to ensure that all complaints are handled in line with their complaints procedure, and in particular, that investigations are thorough and responses adequately address all the issues raised; and
• apologise to the family of Mr A for the failures identified.