Upheld, recommendations

Summary
After an incident involving Mrs C and her teenage daughter, Mrs C and her husband (Mr C) complained to the council about the way that social work services handled matters stemming from the incident. In response to the complaint, the council held a complaints review committee (CRC). Amongst other things, the CRC partly upheld the complaint that the council had not shared all documents with Mr and Mrs C. They recommended that the council's head of children's services and resources should meet with Mr and Mrs C to identify the documents said to be missing and to provide them if appropriate. Mr and Mrs C complained to us that their case was unreasonably progressed to the CRC before the council had provided Mr and Mrs C with all the documents they should have had. They also told us that they still disputed that they had now received all the documents.
 

To investigate this, we obtained all the complaints correspondence and the CRC documentation and made further enquiries of the council. We upheld the complaint as the council did not dispute that they failed to give all the relevant documentation to Mr and Mrs C before the CRC. However, although the council have since provided all the information available, Mr and Mrs C remain adamant that information is still outstanding. We checked the records for the documents they felt were missing, but could not find them. The council said that the documents did not exist, explaining that specific meetings that Mr and Mrs C said took place under the chairmanship of named individuals had not in fact happened. We noted that there were no records of such meetings, but took the view that the council's explanation was reasonable and that it would be disproportionate to pursue this further.

Recommendation
We recommended that the council:

• apologise for their acknowledged failure to provide relevant documentation in advance of the CRC.

Summary

Mr C planned to build an extension to his property. A water main runs through his garden, close to the area into which he intended to extend. Scottish Water require mains pipes to be located at least five metres away from properties. As this was not possible in Mr C's case, they required him to divert the pipe and replace it with one made of ductile iron. Mr C had originally been quoted a total of £500 by his builder to move the pipe, but with reconnection charges and the requirement for different materials, the total cost escalated to the point that Mr C decided not to proceed with his extension.

Mr C complained that, when corresponding with Scottish Water, he learned that ductile iron pipes are not normally used in his area. He noted that the existing water main was located within five metres of his property and was made of plastic. Furthermore, Scottish Water had commented that they 'cannot stress enough that there is no reason to suggest that this main would be in danger from bursting'. Mr C complained that Scottish Water treated him unfairly by asking him to bear the cost of relocating and upgrading the water main when there was no apparent need to do so.

We considered it appropriate for Scottish Water to require that the water main was diverted from its current location and for Mr C to meet the associated charges, as the diversion was required because of his proposed extension. The initial amount quoted by Mr C's builder did not include Scottish Water's standard charges so we did not hold Scottish Water responsible for this. We found that alternative, potentially cheaper, materials could have been used rather than ductile iron. Whilst this material was initially proposed by Mr C's architect, we found that correspondence from Scottish Water also gave the impression that ductile iron was the only acceptable material.

We found clear evidence that Mr C's decision to stop the extension works resulted from news of a further £1,000 charge from Scottish Water, intended to cover operational costs. Once this charge was identified, Scottish Water's staff correctly asked for authorisation from their Customer Connections team who quickly decided not to pass the charge on to Mr C. However, contrary to their written procedures, Scottish Water's staff advised Mr C of the charge before the Customer Connections team had made their decision. This led to Mr C cancelling his extension works.

Recommendations

We recommended that Scottish Water:

• apologise to Mr C for the issues highlighted in this decision letter; and
• waive all reconnection and operational charges should Mr C decide to proceed with his extension in the future.

Summary

Mr C was owed a significant sum of money by a builder who had been declared bankrupt. In June 2005, the builder moved assets into his mother's name. The Office of the Accountant in Bankruptcy (AiB) successfully challenged this in court and raised an action against the builder. Mr C complained about the length of time that it took for the AiB to recover money from the builder and to pay creditors.

We found that the sequestration of the builder's estate was complex and was always going to take time. Ultimately it took more than seven years to pay creditors, and we did not consider this reasonable. Whilst there is no target timescale for the sequestration process and the relevant legislation allows unlimited extensions, our investigation found that the AiB themselves had caused at least fifteen months' worth of avoidable delays. We considered that the individual actions taken to sequestrate the estate were reasonable, but they were carried out in a very linear way and we felt that some tasks could have been completed concurrently rather than waiting for another task to be completed first. Furthermore, midway through the process the builder questioned the amount that Mr C was claiming. This led to the AiB reinvestigating the claim over several months in anticipation of a possible formal challenge. We considered that challenges should be anticipated as a matter of course and that the additional investigation should have either taken place at the start of the claim process, or upon submission of a formal challenge from the debtor.

Recommendations

We recommended that the AiB:

• apologise to Mr C for the delays to the completion of his claim;
• review Mr C's claim and their procedures with a view to identifying tasks that can be completed concurrently, or other opportunities to minimise delays to the completion of claims; and
• consider conducting a review of how and when they investigate creditors' claims in anticipation of challenges from debtors.

Summary

Ms C inherited a property from her mother, who had died unexpectedly. Unable to sell it, Ms C decided to rent the property out. She complained that the council had unreasonably held her liable for council tax during periods for which exemptions should have been granted. She said the council had pursued her relentlessly and had taken recovery action unreasonably when she had already provided all the information they had asked for.

We upheld all Ms C's complaints, as we agreed that the council took too long to resolve this. They missed the opportunity to reply to letters from Ms C in which they could have clarified that information, which Ms C clearly believed had been sent, had not in fact been received. We concluded that the council were also responsible for creating unreasonable confusion. Not only had they failed to clearly explain that information had not been received when Ms C repeatedly said it had been sent, they requested information which had already been provided, and did not send the correct exemption form. We concluded that the council should not have pursued debt recovery action when they had missed an opportunity to explain clearly to Ms C what information they still needed from her.

Recommendations

We recommended that the council:

• apologise for the distress caused by their administrative shortcomings;
• review arrangements in the council tax and revenues team for reviewing and responding to correspondence to ensure that customers receive a high quality and responsive service; and
• review any costs to Ms C arising from the recovery action taken by the council for the period in question and consider whether any reimbursement is warranted.

Summary

Mrs C attended the board's dental service, as her dentures were loose and uncomfortable. She had a new lower denture fitted and her top denture relined. However, she found the new dentures uncomfortable from the outset and returned to the service. The dentist made her a new lower denture based on her original dentures. Mrs C was unable to eat with these dentures and they caused her pain. She went back to the dental service again and was referred to the dental hospital. She was told to wear her old dentures in the meantime, as they fitted better.

Mrs C saw a consultant at the hospital. He suggested replicating her old dentures, and adding a permanent soft lining material. He placed her on the waiting list for treatment by postgraduates at the hospital. However, at that time, they were reaching the end of their placements and were unable to offer treatment to new patients. Mrs C told us that due to the delay, she decided to get private treatment. She said that the dentist she saw privately was able to make her dentures without any difficulty.

Our investigation found that the board had failed to let Mrs C know that there would be a delay in her treatment because the postgraduates were unable to offer treatment to new patients at that time. Due to the delay that occurred as a result of this, the board failed to meet the 18 weeks referral to treatment target. Although the board's view was that the dentures made by the dental service were not defective, we found that they had accepted that the dentures were not fit for purpose by agreeing to make new ones.

Recommendations

We recommended that the board:

• consider how they can prevent delays for patients referred to postgraduates at the dental hospital for treatment; and
• refund the money Mrs C paid for dentures that she was unable to wear.

Summary

Mrs C complained that she experienced an unreasonable delay in receiving appointment notification letters from the board. After she was referred to a respiratory clinic by her GP, the board wrote inviting her to an appointment at the clinic. Mrs C did not receive this letter until after the time of the appointment on the day it was due to be held. The letter was dated seven days earlier. It had been sent via a private delivery firm and had not been stamped with the date it had been posted. Mrs C went to her medical practice and a receptionist phoned the hospital to rearrange the appointment.

The board wrote to Mrs C the next day to confirm the rearranged appointment time and date. Mrs C received the letter two days later. The envelope was marked first class and had two Royal Mail first class stamps on it. She attended the appointment four days later, but returned home to find another letter inviting her to the appointment. The letter had been dated six days earlier. It had been sent via the private firm and had not been stamped with the date it had been posted. The letter said that if she failed to keep the appointment without notifying them in advance, she would not necessarily be given another one.

Mrs C did not receive the two appointment letters posted via the private firm until after the appointments were due to be held. In view of this, we upheld the complaint. In addition, we found that Mrs C had told the board that she was deaf. However, in their response to her complaint, they said that she should phone them if she had any questions.

Recommendations

We recommended that the board:

• carry out a further audit of the time taken for letters posted via the private delivery firm to arrive and take appropriate action on the results of this audit;
• provide clarification to staff on when first class Royal Mail/private delivery postage should be used; and
• issue a written apology for stating that Mrs C should contact the complaints team on the phone number provided if she had any questions, despite the fact she had told them she was deaf.

Summary

Mr C complained on behalf of his father (Mr A) about the care and treatment he received when he was admitted to hospital three times over a period of about eleven days. Mr A had a history of high blood pressure and arthritis, as well as a history of heavy drinking, for which he was being treated by his GP with Antabuse (a drug that causes an unpleasant reaction when taken with alcohol). Mr A was taken to hospital after suffering a seizure. He was complaining of shaking in his right arm and leg, speech disturbance and confusion, and had a three-day history of headache. He was admitted overnight for observation and investigation and was discharged the next day. Mr A's wife (Mrs A) and daughter went to collect him and felt that the attitude of the staff on the ward changed towards him when Mrs A mentioned that he was taking Antabuse. Despite Mrs A and her daughter telling staff that they thought Mr A was still confused and unwell, he was discharged.

Mr A was re-admitted to hospital later that night suffering from confusion and hallucinations. He was again kept in overnight and discharged the next day. Mrs A was told that his condition had been brought on by his previous lifestyle. The family said that Mr A remained confused and disorientated over the next week. He then suffered four or five fits at home and was taken by ambulance to the hospital, where he was again admitted. Mrs A phoned the hospital the next morning to ask if she could bring in some personal items for her husband at lunchtime, and was told that she could do so. However, when she phoned again at 11:45 she was told that Mr A had been discharged some ten or 15 minutes previously.

Mrs A and a friend went to the hospital and also reported to the police that Mr A was missing. He was later found sitting at the main entrance to the hospital dressed only in a vest, cardigan, jogging bottoms and slippers. He had a supply of medication with him that he had been given on discharge from the ward. He had no money with which to phone home or pay for a taxi. His family say he was generally confused and did not know what the supply of medicines he had were or when he had last had his regular medication. It was only after Mr C made a verbal complaint to the hospital that someone phoned and spoke to Mr A's daughter and explained the medication. The caller did not phone Mr C or respond to his verbal complaint as he had been expecting them to do. Mr C, therefore, made a written complaint but was dissatisfied with the response he received.

We upheld Mr C's complaints. Our investigation, which included taking independent advice from two of our medical advisers, found that while in general the investigations of Mr A's condition were reasonable, there were some deficiencies in the care and treatment provided. In particular, the discharge planning and documentation were inadequate. There were also insufficient arrangements made for Mr A to be followed up in the community after his discharge from hospital.

Recommendations

We recommended that the board:

• apologise to Mr A and his family for the failings identified;
• consider the introduction of structured pathways for patients presenting with complications of alcohol consumption to standardise appropriate treatment, discharge and follow-up; and
• ensure that all relevant staff are aware of and properly trained to apply the board's admissions and discharge planning guidelines.

Summary

Mr C said that when he consulted his dentist for the first time, she carried out an initial examination and told him he required six fillings. Three of these were carried out nine days later, but when Mr C returned to to have the remainder of the work done, he said that the fillings she had completed earlier were sensitive. The dentist replaced the filling in the tooth that she decided was the problem, and arranged a date for the rest of the work to be done. However, before returning, Mr C obtained a second opinion. He said he was told, after examination, that the teeth remaining to be filled did not require work. Mr C complained that dental work was carried out unreasonably when none had been required.

As part of our investigation we took independent advice from a dental adviser, who reviewed Mr C's dental records and relevant x-rays. We also looked carefully at the complaints correspondence. We upheld Mr C's complaint, as the adviser agreed that there was no evidence to suggest that Mr C required the number of fillings that had been suggested.

Recommendations

We recommended that the dentist:

• apologise to Mr C; and
• provide the Ombudsman with an undertaking that she will address the concerns raised in this complaint through her continuing professional development.

Summary

Mrs C's daughter (Miss A) has a rare disorder affecting her joints. Since 2010, Miss A has had the support of iCare (a subsidiary of the health board) a respite service for children and young people with complex needs. The care is delivered at home and, to qualify, clients need to meet six health indicators. Mrs C complained that, despite her daughter's condition being unchanged, she was told that Miss A would no longer qualify as her points score had reduced to five from six.

In investigating this complaint, we looked at all the available information, including the complaints correspondence and Miss A's relevant medical records. We also asked the board to provide more information about what had happened. The board in their comments said that they no longer provided Miss C with any health intervention and that she was continent. They added that she could move independently in her electric wheelchair. The board said that Miss C's points had reduced to reflect the change in her mobility.

Our investigation confirmed that Miss C's condition was unchanged and that it would not improve. We found that she was not continent although her incontinence was managed with the use of pads. The level of support from other agencies had been the same since 2010. We found that it was not clear what health intervention had ever been provided to Miss C. Furthermore, Miss C had had the use of an electric wheelchair for many years which she had been able to operate herself.

Although we agreed that it was for the board to set qualifying criteria in the face of competition for finite resources, the assessment of individuals under these should be transparent and ensure visible fairness to all. No guidelines had been provided to show how the staff concerned assessed Miss C's health needs. We upheld the complaint and made a recommendation to address this.

Recommendations

We recommended that the board:

• create appropriate guidelines for the assistance of staff when assessing care requirements and reassess Miss C accordingly.

Summary

Mrs C complained on behalf of her son (Mr A), who was admitted to hospital on a voluntary basis to try to address his obsessive-compulsive disorder (OCD - an anxiety disorder where a person has obsessive thoughts and displays compulsive behaviour). Among other things, Mr A found it very difficult to share toilet facilities with other people, including his family. He was admitted to a mixed-sex dormitory-style ward, where there were only a few single rooms with private toilets. These rooms were allocated on the basis of clinical necessity. Although at times one or more of these rooms was vacant while Mr A was on the ward he was not allocated one, despite his and his mother's requests. Mr A became dissatisfied with his care and treatment, and discharged himself against medical advice. Mrs C later complained that her son did not receive appropriate care and treatment while he was on the ward. She said that he was not allocated a single room with private facilities, so instead he used bedpans, which were not emptied frequently enough; a doctor did not listen to Mr A during a review; and, when Mr A discharged himself, he was told that he would not get his medication.

When we investigated, the board told us that they decided to place Mr A on the ward on the basis of a clinical assessment that providing him with access to private facilities would not help him address his OCD. Our investigation, which included taking independent advice from one of our medical advisers, found that this was a reasonable decision. However, the adviser considered that allowing Mr A unlimited and unsupervised access to bedpans was in fact counter-productive. We found no evidence that the disposable bedpans used were not regularly disposed of, but noted that the board also said that Mr A sometimes hid used bedpans or would only accept assistance to dispose of them from certain staff and would wait until they were on duty.

Similarly, we found no evidence that the doctor involved in the review talked over, or would not listen to, Mr A. Where versions of events differ, and without truly independent evidence to support either version, we cannot prefer one version over another. We did find evidence that Mr A was very keen to discuss certain issues, mainly to do with dissatisfaction with some staff members, but that the doctor did not pursue these. It is possible that Mr A may have perceived this as not being listened to or being talked over. On the matter of medication, a series of appointments with a psychologist had been made, the first of which was to be on the day after Mr A discharged himself. He was issued with only 24 hours worth of his regular medication, in the hope that this would encourage him to keep the appointment. Unfortunately, he did not. Our adviser considered, however, that it was reasonable to only dispense a limited amount of medication in these circumstances. There was no evidence that Mr A was refused medication or only proved with medication on condition that he signed the discharge form.

Overall, however, as we found little evidence of the type of structured, supportive and focused care plan that we would have expected to address Mr A's complex condition and behaviours, we upheld Mrs C's complaint and made recommendations to address the failings our investigation found.

Recommendations

We recommended that the board:

• provide appropriate training to enable multi-disciplinary team working to be supported by cohesive and structured care plans that are appropriately recorded in a patient's notes;
• monitor the implementation of the 'Ten essential shared capabilities for mental health practice' training to ensure that relevant rights-based and recovery-focused care is being provided; and
• apologise for the failings identifed.