Upheld, recommendations

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took before Mr C saw the dentist was unreasonable and not in accordance with the guidance in place at the time, or the draft guidance due to be published.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.

Summary

Miss C complained that she and her elderly mother (Mrs A) were unreasonably removed from the practice's list of patients without any discussion. She had received no prior warning from the practice, nor had she been invited to the practice to discuss this. The practice believed that they had followed procedures by informing the health board and that they were only responsible for Miss C and Mrs A's care and treatment for a period of ten days after notifying them of the removal.

We upheld the complaint, as our investigation found that the practice had not followed the guidance from various organisations and the NHS General Medical Services Contract that where deregistration was a possibility it should only be as a last resort. Although a practice is entitled to remove a patient from their list, action should only be taken after giving the patient prior warning that their behaviour is giving cause for concern, and advising that should matters not improve then there is a risk of deregistration. The only exception to this is where a patient has demonstrated violence, which would result in immediate deregistration - this was not the case here.

Recommendations

We recommended that the practice:

• remind staff to act in accordance with the various pieces of guidance regarding the removal of patients from a practice list; and
• apologise to Miss C for their failure to follow the guidance on the removal of patients from the practice list.

Summary

Mr C had a a temporary dental bridge put in place while he was abroad. He complained that the board delayed in providing appointments after his dentist referred him to the dental institute for a treatment plan to replace it. Mr C said that the delays resulted in additional damage to his teeth, which meant that his preferred treatment plan was no longer possible. In response to the complaint the board said that Mr C had been seen twice within the guaranteed waiting time of 12 weeks for an out-patient appointment.

We confirmed that Mr C's first appointment was within the national waiting time target for new out-patient referrals. Although the institute agreed the treatment plan at this appointment, one of Mr C's teeth then fractured, so his dentist had to refer him there again because it affected the new bridge design. We did not consider that it was reasonable for Mr C to wait a further 13 weeks to have his original treatment plan reviewed, and we upheld his complaint. However, after taking independent advice from our dental adviser, we noted that his tooth could have fractured at any time, even if the new bridge had been in place.

Recommendations

We recommended that the board:

• apologise to Mr C for the delay in his treatment plan being re-assessed; and
• consider reviewing the referral process so that patients who require their original treatment plans to be reviewed are seen in a timely manner.

Summary

Mr C complained on behalf of his late aunt (Mrs A) who was admitted to hospital from her nursing home with sudden pain in her legs. She had been previously diagnosed with dementia (her solicitor held welfare power of attorney) and chronic peripheral vascular disease (a long-term condition where the blood supply to the leg muscles is restricted). Mrs A was prescribed medication for pain and agitation and discharged back to the nursing home the next day. The hospital wrote to her GP and the nursing home detailing her care and said that the vascular surgical team felt that this represented an acute episode of her long term vascular disease, but had decided that surgery was not in her best interests and she should be treated with simple pain relief. They said Mrs A had complained of some pain before discharge and it was decided that this would be better controlled in her normal environment at the nursing home. The nursing home, meanwhile, had identified that Mrs A needed morphine on the day of her discharge and three days later, for the first time, there was an entry in her medical records about palliative care (care purely to prevent or relieve suffering). She was prescribed additional medication for palliative care on the following day, and the nursing home requested more morphine for her. Mrs A died six days after being discharged from hospital.

Mr C said that Mrs A's GP, nursing home and solicitor all knew that she was terminally ill when she was discharged from hospital and that this diagnosis was made while she was a patient there. Mr C said that within a few days of Mrs A being discharged, the GP told Mrs A's solicitor that she had a major inoperable blood clot in one of her main arteries and was being kept comfortable at the nursing home, but that otherwise nothing beneficial could be done and that the 'time-frame' could be days. Mr C also complained that the board failed to provide him with a proper answer about why Mrs A was not immediately referred for palliative care.

After taking independent advice from a medical adviser, who specialises in care of the elderly, we upheld Mr C's complaints. The adviser said that the care and treatment in relation to diagnosis, discharge, communication and record-keeping was below a reasonable standard and impacted adversely on the board's decision-making about palliative care. Mrs A was a vulnerable adult, and we found that the clinicians underestimated her symptoms and their severity and significance, leading to an inaccurate diagnosis and a failure to meet her palliative care needs. We also found that the board failed to provide a detailed explanation of the clinical thinking at the time of Mrs A's discharge to justify their position, which would have added to the distress of Mrs A's family.

Recommendations

We recommended that the board:

• ensure that the failures identified are raised as part of the annual appraisal process of relevant staff;
• review the admission of older adults to assess whether staff have sufficient expertise (such as consultant geriatricians) to assess such patients;
• bring the failures in record-keeping to the attention of relevant staff;
• bring the failures identified in this investigation to the attention of the board's complaints team; and
• apologise for the failures identified this investigation.