Upheld, recommendations

Summary

Miss C was dissatisfied with the council's handling of her and her partner's housing complaints.

We upheld her complaint. We found that that the council had not responded reasonably to the complaints and that they did not provide responses or updates in line with their complaints procedure. We found that they unreasonably considered the complaints twice at the first two stages of the complaints procedure, and repeated incorrect statements about Miss C after they had apologised for this. We made recommendations for improvement.

Recommendations

We recommended that the council:

• apologise for failing to handle the complaints in line with their procedures; and
• take steps to ensure that they keep complainants updated when they are unable to respond to complaints within the published timescales.

Summary

Mr C is a solicitor acting on behalf of his client (Mr A). Mr C complained about the way the council handled Mr A's request for a travel allowance for his son to attend school by car.

The journey to Mr A's son's school took an hour and fifteen minutes. The council explained that their policy stated that when the journey to school exceeded an hour, lodgings would be made available. However, they added that there had not been demand for this for a number of years and that the list of approved accommodation was probably no longer in operation. This advice led Mr A to apply for a mileage allowance. His request was refused by the council. The council were also unable to provide accommodation, and said that Mr A's request for mileage was contrary to the council's policy. The situation continued like this for almost two years, when Mr A was offered a mileage allowance.

Mr C complained that the council failed to provide lodgings for Mr A's son and delayed in dealing with his applications for lodgings and mileage allowance. He further complained about the council's complaints handling.

Our investigation found that although the council had a policy to provide accommodation in these circumstances, they did not do so. They also failed to provide a viable alternative solution until much later. It was also apparent from the available documentation that the council did not deal with the complaint in accordance with their policy as there were delays in responding. We upheld both Mr C's complaints and made recommendations.

Recommendations

We recommended that the council:

• apologise for their failure to provide lodgings;
• backdate the mileage payment;
• apologise for their delay in dealing with applications for lodgings and mileage allowance;
• apologise for their delay in responding to the complaint; and
• emphasise to those staff concerned the importance of adhering to the stated complaints policy.

Summary

Ms C (an advice worker) complained about the care and treatment provided to her client (Mrs A) by her medical practice.

Mrs A has a history of early osteoporosis (abnormal loss of bone tissue causing fragile bones), and a family history of osteoporosis. In 2010, her GP prescribed her with a long-term course of steroids for another condition. The GP planned a scan to measure her bone density in May 2010, but the hospital did not receive a request form. For the next five months, Mrs A attended the practice complaining of severe back pain. She said that she raised the possibility of osteoporosis with her doctors. She also went to her local accident and emergency department three times because the pain was so bad. The practice treated her symptoms as mechanical back pain. They referred her to a physiotherapist, ordered x-rays and blood tests, and prescribed painkillers. In November 2010, another doctor referred Mrs A for a scan. This showed that she had severe osteoporosis and fractures to four vertebrae.

Ms C complained that her client was not told about the potential side effects of the steroids and was not given medication to counteract the side effects. She said that the scan should have been carried out earlier and that the practice did not reasonably monitor Mrs A. She also raised concerns about the level of steroids prescribed. Mrs A now has severe osteoporosis and daily pain, curvature of the spine and has lost three inches in height. She said that the failures by the practice had a significant adverse impact on her quality of life.

Our investigation found that Mrs A was at high risk of developing osteoporosis and we identified failures in treatment, monitoring, communication and record-keeping. Mrs A should have been given treatment to counteract the effects of the steroids and the practice should have ensured a scan was performed earlier. However, we found that the dose, duration and adjustment of the steroids was reasonable in relation to the symptoms she was displaying. It was not certain whether earlier treatment would have made a difference to the outcome, but it was clear that specialist intervention was delayed which caused Mrs A distress.

Recommendations

We recommended that the practice:

• review its record-keeping, particularly relating to advice on medication with significant side effects; and
• confirm they have implemented the recommendations in their significant event analysis and report back to us on progress.

Summary

Mrs C complained that a doctor in a hospital's accident and emergency department did not order an x-ray despite her prior history of osteopenia (a condition affecting bone density). Mrs C said that the doctor had examined her and advised that nothing was broken but that there was some bruising to her ribs that was likely to last two months or so. She also said that the doctor had told her to take 500 milligrams of paracetamol four times a day for pain relief. Mrs C said that the doctor planned to do a rectal examination but she left before it was carried out. This was because of the time it was taking to arrange a chaperone, and because she was unable to get into the required position due to the level of pain she experienced.

As the pain had not improved, Mrs C visited her GP some two weeks later. An x-ray was arranged and showed a fracture to her spine. In their response to the complaint, the board advised Mrs C that it was not possible to make a judgement on whether it would have been appropriate for the doctor to have requested an x-ray, as she had left the department before the clinical assessment could be completed.

Following advice from our medical adviser, we concluded that, although Mrs C had left the department before the rectal examination was done, the doctor should have considered an x-ray based on the risk factors Mrs C presented with and her previous medical history. We also noted that most protocols suggest that, in women over fifty years of age, back pain caused by trauma requires

x-ray investigation.

We also identified that the doctor had not documented the partial examination he had carried out on Mrs C, nor had he noted the plan to carry out a rectal examination. The doctor has said that he will learn from the incident and ensure that relevant information is recorded if a similar situation were to arise in future.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failures identified; and
• review their accident and emergency guidelines for the management of patients presenting with thoracic back pain caused by trauma and non-trauma, to ensure appropriate x-ray investigation and pain management where relevant.

Summary

Mr C complained that the university had not fairly and fully considered his appeal in relation to his first year assessment. Mr C failed three of four modules and was required to leave the course as a result. He went through the appeal process, and then through the complaints process as he was unhappy with the handling of his appeal. We found that the university did not acknowledge or consider some of the issues raised in his initial appeal, and we were critical of this. Mr C also provided further information in relation to an issue which was not acknowledged by the university. We were critical of this too.

When Mr C complained about the way his appeal was handled, we found the university's response more thorough. It addressed all the issues raised, but we noted that one issue (which Mr C had not pursued via the complaints process) remained outstanding in relation to the original appeal. We found that generally the other points raised about Mr C's claims of extenuating circumstances were reasonably dealt with. On balance we upheld Mr C's complaint.

We also noted the university appeared to have no guidelines in realtion to the use of proof readers and whether this would be acknowledged or taken into account in relation to the written presentation criteria for assessments, and made a recommendation about this.

Recommendations

We recommended that the university:

• revise the assessment criteria to recognise if a disabled student has had their written work checked by a proof reader provided by the university; and
• provide a full apology to Mr C for the failings identified.
•  

Summary
Mr C, who is a prisoner, complained because he said he was denied the opportunity to question the witness at his disciplinary hearing. A disciplinary hearing is held to determine whether a prisoner has broken prison rules and to impose an appropriate punishment if proven.

The Scottish Prison Service (SPS) acknowledged that Mr C's hearing was delayed for seven days to allow him to seek legal advice and to enable the reporting officer (who was the witness in Mr C's case) to attend. The SPS told us that the adjudicator who oversees the hearing confirmed that Mr C was given the opportunity to question the reporting officer. SPS guidance on disciplinary hearings states that prisoners must be allowed to ask questions of the reporting officer and witnesses.

In Mr C's case, the evidence confirmed that the hearing was adjourned to enable the reporting officer to attend. The adjudicator said Mr C was given the opportunity to question the reporting officer but there is no record of this in the adjudication paperwork. Mr C disputes that he was given this opportunity. We upheld Mr C's complaint as we considered it reasonable to expect the adjudicator to record whether Mr C was given the opportunity to question the reporting officer. In the face of this dispute, the absence of such evidence means that the SPS cannot demonstrate compliance with SPS guidance. Mr C had also raised other complaints with us, but we could not look at them as at the time he had not taken them through the SPS complaints procedure.

Recommendation
We recommended that the SPS:
• take steps to ensure adjudication paperwork reflects whether the prisoner was given the opportunity to ask questions of the reporting officer or witnesses in line with section 6.13 of the SPS Guidance on Orderly Room Procedures.

Summary
Mr C, who is a prisoner, injured his hand and was advised by a prison doctor that he would need to attend hospital. He was unhappy that he was not taken to hospital until the next day and he complained about this to the prison. The prison told him that the doctor said that they could wait until the following day to take Mr C to hospital, and so their actions were appropriate. Mr C then complained to us that the prison had failed to properly and fairly investigate his complaint.

Mr C said that he called four witnesses to the complaint hearing: the doctor, an officer, and two senior members of staff. The chair of the complaints committee spoke to the doctor and one of the senior members of staff in advance of the hearing and decided that the presence of the witnesses would not be necessary. We found that the prison rules say that he was entitled to do this, but also that this decision should have been taken in discussion with Mr C and he should have been notified in advance. We were satisfied that the chair spoke with the two most relevant individuals when investigating the complaint. However, in responding, the chair stated that he had also spoken to the other senior member of staff which subsequently proved to be untrue. Finally, he did not address the request to call the officer as a witness. In the circumstances, we upheld Mr C's complaint and made recommendations to address the failings we found.

Recommendations
We recommended that the Scottish Prison Service:
• carry out an investigation of the prison’s handling of Mr C's complaint and report back to the Ombudsman with their findings; and
• remind those staff acting as ICC chairpersons of their duties under Rule 123(7) to discuss with prisoners, and inform them in advance of, any decisions surrounding the refusal to allow them to call witnesses to hearings.

Summary
Mr C complained that the council had not stored his belongings safely while he was in prison. He had been living in temporary accommodation before beginning his prison sentence in December 2010. His belongings were bagged and tagged by a removals contractor and placed in a council owned storage facility.

When Mr C came to collect them in June 2011, he complained that some of his personal items were missing. He provided lists of items to the council. The council’s position was that the belongings bagged and tagged had not been touched or moved during the time in storage. However, at that time the council did not keep inventories of belongings kept in storage. Since October 2011, as a result of Mr C's complaint, they have requested copies of inventories prepared by the removals contractor. However, we found that this does not include a fully itemised inventory.

We upheld Mr C’s complaint as we found the current system meant the council could not provide evidence of what exactly they were storing and for whom.

Recommendations
We recommended that the council:
• provide a full apology to Mr C for the failings identified;
• consider Mr C's complaint as a claim via the council’s insurers; and
• provide evidence to the Ombudsman that the council ensure they take itemised inventories of the belongings which they accept for storage in their facilities.

Summary
Mr C complained to a medical practice about the care and treatment that his mother had received. The practice responded but did not address the matters he had raised. Mr C was dissatisfied with this and his wife raised the matter with us. During our consideration the practice wrote again to Mr C.

We decided that the practice did not reasonably provide him with all the information suggested by their complaints procedure, provided inaccurate information to him, requested unnecessary information from him, and did not advise him of the reasons for their delay in providing a full response. When read together, all the responses from the practice did reasonably address the matters he complained of, but as those responses did not reflect the practice's complaints procedure we upheld the complaint.

Recommendations
We recommended that the practice:
• apologise to Mr C that they did not respond reasonably to his complaint; and
• take steps to ensure that their implementation of their complaints handling procedure and their responses to complaints are in line with that procedure.

Summary
Miss C complained about the care and treatment provided to her late uncle (Mr A) by his medical practice. Her mother (who is Mr A's sister) had initially made the complaint, but Miss C eventually took it forward on her mother's behalf. Mr A had cancer and was undergoing chemotherapy in hospital.

Several days after he was discharged from hospital, he telephoned the practice asking for a prescription for antibiotics and a telephone consultation with his doctor. His doctor returned the call and issued a prescription for antibiotics.

A few days later, Mr A's sister became increasingly concerned about his condition and telephoned the practice requesting a home visit from a doctor. The practice advised her to contact emergency services. She was dissatisfied with the advice and phoned NHS 24, who arranged with the practice to send a doctor to visit him at home. The doctor arranged for an emergency ambulance to admit Mr A to hospital. Mr A died several weeks later.

Miss C complained that Mr A should have been seen by a doctor after her mother called the practice, and that the practice's response to the request for a home visit was unreasonable.

We upheld Miss C's complaints. We found that, given the seriousness of Mr A's illness, he should have had a face-to-face assessment rather than a telephone consultation. We could not establish what was said between Mr A's sister and the practice during the telephone call. However, we found that the problems of communication were compounded by a lack of specific instructions about the advice from the practice to contact emergency services. As a result, there was a delay in admitting Mr A to hospital and, while this may not have affected the outcome, it was clearly distressing to him and his family. We made recommendations in respect of both the doctor concerned and the practice.

Recommendations
We recommended that the practice:
• reflect on its management of this case particularly in light of the complications of chemotherapy;
• review its record-keeping for telephone consultations;
• apologise to Miss C for the failures identified; and
• review its procedures for house calls in light of this case.