Upheld, recommendations

Summary
Mr and Mrs C complained about the games area in a new community campus beside their home. They were unhappy about light spillage from the floodlighting for the games area into their garden. In particular, they complained about the council's failure to take enforcement action on a planning condition about light spillage from the community campus. The planning condition for the campus said that there should be no light spillage beyond the boundaries of the site to the satisfaction of the planning authority.

We were satisfied from the evidence we saw that light spillage from the games area had occurred. Planning authorities have a general discretion to take enforcement action against any breach of planning control if they consider such action appropriate. We did not consider that the council had taken satisfactory steps to mitigate the effects of the floodlighting and to address Mr and Mrs C’s complaints about this matter. Although the light levels in Mr and Mrs C’s garden had been measured, this was done by staff from the facilities management group contracted by the council to manage and run the facility, and not by council staff.

Our planning adviser commented that the use of terms such as ‘to the satisfaction of the planning authority’ had been discouraged in the Scottish Government Planning Circular 4/1998 – ‘The Use of Conditions in Planning Permissions’.

Mr and Mrs C were also unhappy that the council had failed to take action in response to their complaints about antisocial behaviour by users of the games area. The Centre Manager confirmed that Mr C had contacted him about this eight to ten times during two months in 2010. We found that the council had taken action to try to prevent balls going into their garden and had put up signs asking customers to mind their language.

However, the Centre Manager also stated that he did not have a record of each time Mr and Mrs C made a complaint. It was clear that management staff at the campus did not adequately record their complaints about noise/swearing and the balls coming into the garden. There was no evidence that the council established the facts and determined whether the behaviour complained of constituted antisocial behaviour. There was also no evidence that consideration was given to referring the matter to the council’s Antisocial Investigations Team.

When Mr and Mrs C made a written complaint to the council about this, they were told that they needed to notify the council of incidents at the time so that management staff at the campus could investigate and deal with the matter. The council also delayed in responding to their written complaints about the matter. In view of all of these failings, we upheld the complaints.

Recommendations
We recommended that the council:
• remind staff that, in line with Scottish Government planning circular 4/1998, they should not use phrases such as ‘to the satisfaction of the planning authority’ in planning conditions for matters such as floodlighting. in such cases, specific and detailed plans should be sought from developers, and subsequent planning conditions should be worded to ensure compliance with these plans;
• take all reasonable action to enforce the planning condition;
• review their guidance on obtaining statistical evidence relating to a condition of planning consent from staff employed by the operators of the site to which the condition applies;
• remind the relevant staff involved in the case that complaints of this nature should be clearly recorded and investigated where appropriate;
• give consideration to taking further action to try to resolve the matter and/or referring the matter to the council’s antisocial investigations team; and
• apologise to Mr and Mrs C for the failings identified.
 

Summary
In August 2009 Mrs C attended her GP complaining of a lump in her left breast. She was examined and asked to return for a follow up appointment a week later. She was seen by a different GP at the review appointment and was advised that the lump was most likely a cyst. She was told to monitor the lump over the course of a few menstrual cycles. No follow-up appointment was made. Mrs C said that the lump increased in size and she returned to her GP practice in August 2010. She was seen by a third GP, who was concerned by the lump and referred her to a breast clinic for further investigation. The lump was found to be cancerous. Each of the three GPs described the lump as being in a different location and the Practice concluded that different lumps had been examined.

Mrs C maintained that she had had the same lump since August 2009 and that it had increased in size. She complained that the first GP incorrectly noted the lump as being in her right breast, and that she should have been referred to the breast clinic by the second GP. Although it was not possible for us to confirm whether there had been three different lumps, or if the same lump had been described differently, we upheld both of Mrs C's complaints, as we found the first GP's record-keeping to be poor and possibly inaccurate. We found that the treatment plan proposed by the second GP was not in line with good practice guidance and that Mrs C could have been referred to the breast clinic significantly earlier, or had it confirmed whether her lump was just a cyst.

Recommendations
We recommend that the practice:
• add a note to Mrs C's records clarifying that she attended her examination on 14 August 2009 complaining of a lump in her left breast;
• draw their staff's attention to the guidance in SIGN 84 and the Scottish Primary Care Cancer Group's publication: Scottish referral guidelines for suspected cancer; and
• apologise to Mrs C for the failings identified by our investigation.

 When this report was first published on 21 September 2011, it was incorrectly categorised as being about Greater and Glasgow and Clyde NHS Board. This was due to an administrative error which we discovered on 22 September 2011, and for which we apologise.

Summary
Mr C owns a flat in a tenement block in central Edinburgh which he lets out. In March and September 2008 the council served two statutory repairs notices on owners of the block under section 24(1) of The City of Edinburgh District Council Confirmation Order Act 1991. Mr C was unaware of the notices until about a week before the works were due to start. He complained that the council failed to serve notice on him of the repairs. Our investigation established that this was the case and that in drawing down the list of owners to be served, Mr C's flat was wrongly numbered.

Summary
Mr C complained that the council had effectively recommended a tradesperson by giving him a trader's contact details. He was also concerned about the way the council handled his subsequent complaint. When we investigated this, the council said that they did not have a written policy on recommendations, as their standard practice was that they did not make these. We decided that this position was in fact undermined when they provided Mr C with contact details for a particular trader. Whether the council chose to refer to this as a 'recommendation' or not, we took the view that members of the public are likely to consider a trader suggested by an authoritative body such as the council as, effectively, having been recommended. On the complaint handling, we found that the council suitably investigated Mr C's concerns about his consumer complaint. However, they did not look at his concerns about the 'recommendation'. Instead they took the view that a complaint would only be accepted where 'there is evidence of service failure or maladministration on the part of the council'. We found that this was not supported by their complaints process. The council should have been able to investigate and respond to his concerns that their consumer adviser provided him with the trader's contact details.

Summary
Mr C complained that the council failed to respond to his written complaint about a road layout. Our investigation found that the council had contacted Mr C to discuss his concerns. The officer who spoke to him said the matter would be dealt with the following week. Mr C said he was happy with this and the council closed their complaint file. When we looked at the correspondence, however, it became clear that as a result of the discussion the officer thought that Mr C was complaining about problems in a different place. The officer, therefore, arranged for work to be carried out in an area that was not mentioned in Mr C's original letter. As Mr C had said during the discussion that he was happy the work was going to be done, the complaint was closed without replying to the original point. We, therefore, found that the council had not answered Mr C's complaint. We also noted that it would have, in any case, been appropriate to respond in writing to complete matters. Had this been done it is possible that the misunderstanding could have been resolved then. As a result of this we upheld the complaint and recommended that the council respond to the points raised in his letter. The council have now done so.

Summary
Mr C was a new patient at the practice and his medical records had not yet arrived. While the practice was waiting for them, Mr C asked for additional medication. When he did not receive this, he complained about how the practice had dealt with his request. We found that they had not in fact properly actioned it. We recommended that the practice apologise to Mr C and carry out a significant event analysis to identify the problem and prevent a recurrence.

Recommendations
We recommend that the medical practice:
• apologise to Mr C for the way they dealt with his request; and
• conduct an Significant Event Analysis of this incident.

Summary
Mr C raised concerns about a telephone consultation that he had with his GP. He was suffering from severe lower back pain. He told us that he believed that he should have had a home visit as he was admitted to hospital later that evening with Cauda Equina Syndrome (a disabling condition caused by compression of the nerves of the spine). Although our investigation found that the GP's management plan was reasonable, we found that her notes of the consultation were limited. Our medical adviser told us that in the circumstances a physical examination of Mr C was required. As this should have been carried out at his home, we upheld Mr C's complaint that the GP's telephone assessment of his condition was inadequate. We did, however, recognise that it was possible that the outcome would have been the same, even had the physical examination taken place.

Summary
Mrs C complained that the board failed to inform her of a meeting which took place to discuss her and her children. The evidence showed that the meeting was arranged to discuss suspected child protection matters. It also involved people outside the children's core care team. The Scottish Government's guidance on child protection makes it clear that all service providers have a responsibility to act to make sure that a child whose safety or welfare may be at risk is protected from harm. If a child is considered to be at risk of harm, relevant information must always be shared which may prevent problems from escalating. However, the guidance also says that when involved in child protection work, authorities should ensure that, wherever possible, parents are given full information about the nature of the concerns, and the child and family are consulted on and given explanations for any actions/decisions taken. The board's own child protection guidelines are clear that if children are suspected to be at risk, these concerns should be raised without delay. When such concerns are formally raised, the parents should be informed. Only in situations where there are clear and present reasons that make informing the parents inadvisable or unsafe can it be justified not to do so. We found that the board should have told Mrs C about the meeting, and about the support services that exist to help families in these situations.

Summary
Mrs C complained about the service that she received when attending her local out-of-hours medical service. She felt that the information that she was given delayed her treatment. She had been unwell for a number of days and called NHS 24 for an appointment at the out-of-hours centre. Before the appointment was arranged, she took a turn for the worse and made her way to the centre. She was met by an unidentified individual (understood to be the doctor's driver). She was told that she could wait for the doctor but that this could take several hours. Alrternatively she could return home and call NHS 24. Mrs C returned home. When NHS 24 called with her appointment, she cancelled it as she was too unwell to return to the out-of-hours centre. Mrs C saw her GP the following morning and was immediately referred to hospital. We found that the service provided was poor as a result of the Board's policy for out-of-hours walk-in patients, which required a medical assessment to be made by non-medical staff. Information provided to patients in the absence of a doctor was also found to be poor.

Recommendations
We recommend that Highland NHS Board:
• review their policy with specific attention given to which members of staff should assess patients' medical records;
• apologise to Mrs C; and
• review the information provided to patients when the reception is unmanned.

Summary
Mr C said that the university did not follow their complaints policy when considering his complaint. He said they delayed and, because he was not allowed to proceed to the final stages of their complaints procedure, he was denied assistance from the ASK service (a student support service). Mr C made eight complaints to the university. Because of their overlapping nature and the voluminous correspondence associated with them, the university decided to deal with them together in terms of the Student Complaints Procedure. They gave Mr C their decision just over four months later, telling him that their involvement in the matter was at an end and that he should complain to the Ombudsman if he was unhappy with their decision. Our investigation determined that, although the university had at all times been courteous and objective in the face of a huge flow of correspondence from Mr C, they failed to follow their stated complaints procedure by allowing him to appeal their decision to them. Similarly, we agreed that there had been delay in dealing with the matter and that, as a consequence of the university's refusal to proceed to an appeal, the ASK service had withdrawn their involvement. Our recommendations were aimed at ensuring that the university follow their own policies correctly in future.

Recommendations
We recommend that University of Strathclyde:
• remind staff of the importance of following their stated complaints procedure;
• apologise to the complainant for failing to inform him of his right to appeal at stage 3 of their complaints procedure;
• in the event that Mr C wishes to appeal any decision made on his stage 2 complaints to the university, we recommend that his appeals are considered in terms of stage 3 of their stated complaints procedures; and
• apologise to Mr C for their delay in dealing with his complaint made in July 2010.