Upheld, recommendations

Summary

C operates a restaurant who contracted with Clear Business Water (CBW) for their water supply. C complained that prices charged by CBW increased which was in contrast to what had been agreed. C also complained that CBW unreasonably charged a termination fee when they changed supplier for a better deal.

CBW said that they agreed a contract with C for the supply for a fixed term of 3 years at a discounted rate. They told C that the price being charged increased because of a number of factors but that the discount applied to the account always remained the same. As C left CBW for another supplier, CBW were satisfied that a termination fee was correctly applied in line with the terms and conditions of the contract. C was dissatisfied with the response and brought their complaint to our office.

We reviewed the relevant call recording together with supporting materials CBW said were issued to C following the call. We also considered CBW’s own processes and procedures with respect to the handling of such calls. We found that the communications with C were unreasonable as it was clear during the call that there was a barrier to C and the CBW adviser’s ability to understand each other. The information provided to C after the call did not provide confirmation of certain key aspects of the contract, nor was there confirmation that prices may be subject to variation. Therefore, we upheld the complaint that CBW failed to communicate with C in a reasonable manner. We also found failings with respect to CBW’s handling of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not communicating in a clear manner and failing to appreciate there was the potential for misunderstanding during the call. The apology should also acknowledge that the complaints investigation should have identified issues with respect to the quality of communication with C. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Clear failings should be identified by complaints investigations, with appropriate actions being taken to remedy these.
• Relevant managers and advisers should have a clear understanding on the difference between ‘price’ and ‘discounts’ and the importance of clear communication in this regard. Staff should receive appropriate training on communication with customers and be provided with supporting materials, including call scripts, which provide sufficient clarity and guidance during a call.
• Relevant staff should have an awareness of potential barriers to communication and be able to identify what these are and how these may be addressed and overcome.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C runs a small business and was unhappy with the way Business Stream managed their account. In particular, C was unhappy with what they believe were unreasonable changes to their contract and changes to the amount they were expected to pay for water.

We found multiple failings by Business Stream in their dealings with C; including not taking reasonable steps to address the issue of the removal of the water meter for C’s premises, having no evidence that C agreed to a change of contract or agreeing to online billing only. In relation to moving C to unmetered charging, Business Stream have acknowledged that their failures led to an unacceptable delay and offered the maximum allowable payment and credit available under their Redress and Compensation Policy. However, there is no evidence that the causes of the failings have been investigated or identified. We considered that this was essential given the impact on small businesses of large and unexpected bills, particularly in the aftermath of the COVID-19 pandemic. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Contact C to provide a clear explanation of their options for paying for water usage moving forward, including a site visit with C present to discuss water meter installation if requested.

What we said should change to put things right in future:

• A review of C’s case identifying where Business Stream’s procedures failed to work appropriately and assessing whether changes are required to prevent a recurrence.
• A review of the process for agreeing ‘signatureless’ contracts to ensure that the customer’s agreement is obtained and formally recorded in a retrievable format.
• All staff involved in moving customers onto new contracts to be reminded that it is essential evidence is retained showing the customer’s agreement.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of their clients about a decision made by the Scottish Environmental Protection Agency (SEPA) not to renew a ‘Paragraph 19 Exemption’ (the exemption) for a land re-engineering project. Normally, waste management requires a licence, however an exemption can be applied which allows for the use of waste for the construction, maintenance or improvements of a building, road, railway, airport, dock or other transport facility; recreational facilities; drainage; or certain engineering works. C’s clients had been granted an exemption for four consecutive years but their fifth renewal application was declined by SEPA.

We confirmed that we would not be considering the professional judgement of SEPA, but could look at whether they provided a reasonable explanation for their decision not to renew the exemption.

We noted that the original reason SEPA gave for refusing the application was that the proposed infill of the upcoming phase was of a depth exceeding the dimension of the final cross sections shown on the plans. Additionally, SEPA said that when their officers inspected the site, they observed that waste had been deposited onto waterlogged land. This is not permitted under the terms of an exempt activity.

In the correspondence with C that followed, we found that SEPA gave a number of differing reasons for their decision not to renew the exemption. When C advised SEPA they had referred to the wrong plans in reaching their decision, rather than provide an explanation or apology, SEPA gave a different reason for declining the renewal application. We found that SEPA did not adequately address a number of matters raised by C in relation to their decision. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide a reasonable explanation for the decision not to renew C’s clients’ Paragraph 19 Exemption. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Consider what we have said in our decision and assess whether it is appropriate to reassess the Paragraph 19 Exemption on the basis of our findings. If SEPA do not consider that reassessment is warranted, or if they reassess and decline the application, they should write out to the applicant providing clear and justifiable reasons for their decision.

What we said should change to put things right in future:

• Appropriate and clear reasons should be provided for decisions in relation to waste management exemptions.

In relation to complaints handling, we recommended:

• Complaints should be accurately identified as such and dealt with through the correct procedure.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the Crown Office and Procurator Fiscal Service (COPFS), regarding interactions they had before, during and after a homicide prosecution following the death of their adult child (A). C did not consider that COPFS had adopted a reasonable approach to victim support in their case. They expressed a number of concerns about the support that they had initially been provided. They told us that this led them to request no further contact with the officer initially allocated to provide support, but when they changed their mind and asked for contact to resume, COPFS had refused to allocate another officer to support their family. They also raised concerns about COPFS communication with them and their family, both in terms of the tone, and failures to respond to specific points raised by them. In addition, they told us they did not consider COPFS had reasonably handled their resulting complaints about these matters.

On investigation, we found that COPFS had failed to provide C and their family with appropriate support in a number of ways. We found that COPFS had internally recorded a number of concerns about C’s attitude and behaviour, suggesting that they were acting in a way that was difficult or unreasonable, without recording what behaviours they considered were unreasonable or why, or raising these concerns with C to allow them the opportunity to amend any behaviours COPFS considered unreasonable. This was despite the difficult circumstances C’s family were facing, and nothing within the records evidenced that COPFS had considered the additional pressures facing C and their family.

We considered that COPFS had effectively refused to provide normal victim support to C and their family, by failing to honour clear requests by C for support to resume. We also found that COPFS had failed to follow their normal protocols when the case had been handed over from the Police, which negatively impacted C’s family’s experience of that process. Overall, we considered that COPFS had failed to meet the standards they had committed to provide in the Victim’s Code for Scotland by failing to treat C’s family with sensitivity and tailor their approach to support based on C and their family’s needs.

Regarding C’s communication concerns, we found a number of examples of unreasonable failures in communication. We found that there were a number of delays and/or failures to respond to contacts from C. We also found that a number of COPFS communications failed to treat C with appropriate sensitivity, including failures to offer appropriate condolences to C’s family on their loss. We also found a number of entries in COPFS internal records which used a concerning tone when referring to C. We did not consider that this could be said to meet the standards that COPFS committed to providing to victim’s families under the Victim’s Code.

Regarding C’s complaints handling failures, we found that COPFS had failed to respond appropriately to all of C’s complaints. A number of their responses failed to respond to specific points C had raised or failed to respond in sufficient detail.

Given all of these points, we upheld all of C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for failing to provide them with appropriate support, failing to communicate with them reasonably, and failing to handle their subsequent complaints reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• All of COPFS interactions with victims and their families should meet the standards of the Victims’ Code. Communication should be sensitive and tailored to victims’ individual needs. Records made about individuals should also be sensitive and appropriate in tone.
• The Managing Family Liaison Protocol should be followed whenever making initial contact with a victim or their family.
• When concerns are held about someone’s behaviour, COPFS should make a clear record of the reasons for this and follow their Unacceptable Actions Policy if they wish to take action to address those concerns.

In relation to complaints handling, we recommended:

• COPFS should fully investigate all complaints and provide detailed explanations of their findings. Where failings are evident, these should be highlighted and appropriate steps taken to avoid similar mistakes in future.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment their parent (A) received from the partnership. A was referred to the partnership’s Rapid Early Assessment Care Team (REACT) for Hospital at Home care due to shortness of breath upon exertion. A’s condition did not improve with treatment and they subsequently developed sepsis (a life-threatening reaction to an infection) and died. C considered that A should have been admitted to hospital for treatment, rather than being expected to continue with oral antibiotics which were making no improvements to their condition.

We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that the initial care provided by the REACT team was of a reasonable standard. However, we could not find clear evidence to support the decision to continue antibiotic treatment, which did not appear to be improving A’s condition, without trying other options. We were critical of the decision to discharge A from the Hospital at Home service without a full medical review and treatment of their ongoing treatable symptoms. It was not clear whether these failings contributed to the deterioration in A’s condition, but we found that clearer decision making and closer attention to A’s treatable symptoms may have provided their family with some reassurance as to the standard of care they were receiving. Taking all of this into account, we upheld this part of C’s complaint.

C also complained about the communication between the REACT team and A’s GP practice. We did not consider there to be a systemic issue. However, as accepted by the partnership, there had been a clear delay in issuing the discharge letter after A’s discharge from the Hospital at Home service. We found that if A had lived, there could have been significant implications for their ongoing care due to the request for monitoring and bloods not reaching the GP within the requested timescale. With this delay in mind, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the failings highlighted in this decision notice. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Ensure that the partnership raise this case for discussion at a mortality and morbidity meeting (or other such team forum) with a view to discussing: the delay in communicating with A’s GP, the lack of medical input before their discharge, and the lack of evidence for continuing the same antibiotic for so long.
• (It is noted from the partnership’s comments on our provisional decision that this case was discussed at a mortality and morbidity meeting last year, but the partnership have agreed to discuss the case with the team again in view of our findings).

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C and their partner (B) complained about the actions of the partnership’s social work department. B’s sibling (A) had been removed from their parents’ care. B and C wished to be considered as carers for A, and also requested contact with A. However, they did not have contact with A for several months. C complained that the partnership failed to take appropriate action to facilitate and support contact between A and B during this period. Following contact being initiated, kinship care assessments were carried out and A was placed to reside with B and C.

We took independent social work advice. We noted the partnership’s explanation regarding the challenges contact with B potentially posed and the need for A to settle into their placement with foster carers. However, we found that it would have been reasonable to support some contact between A and B during this period. We found that the partnership had not provided a reasonable explanation as to why contact did not take place. We also noted that contact should not have been contingent solely on B’s capacity to provide kinship care of A, and we found it unreasonable that contact was only pursued when it was required to progress the kinship assessment. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the failure to facilitate and support contact between B and A. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Contact between care-experienced children and their siblings should be promoted where possible, even if this is not straightforward. If there are concerns about potential emotional distress, there should be a focus on how to help children manage this rather than seeking to avoid the contact in the first place.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about various aspects of the care and treatment their spouse (A) received from the partnership.

A was an in-patient at a community hospital. Over the course of a few days, A was repeatedly admitted to a larger, specialist hospital for treatment before being transferred back to the community hospital.

C complained to the partnership about the care and treatment A received in both hospitals. The partnership apologised for any distress caused to A or C but did not identify any failings in A’s care. C remained unhappy and brought their complaint to us. C complained that there had been a failure to adequately monitor, manage, and treat A in both hospitals, which had led to a serious deterioration in their condition.

We took independent advice from a consultant in care of the elderly and general medicine. We found that there had been a failure to medically review A. We also found that there had been a failure to obtain a urine sample during A’s first admission to the specialist hospital and that this had resulted in a failure to detect a serious infection. Therefore, we upheld C’s complaint.

We also found that the partnership’s response to the complaint failed to fully reflect the information they obtained during the investigation and failed to adequately detail the learning taken from A’s experience.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• When there is an acute deterioration in the condition of a patient at the community hospital, a prompt medical review of the patient should be carried out. Nursing staff at the hospital should be appropriately trained to ensure they are empowered to request a prompt medical review of a patient from the out-of-hours teams when there is no medical cover on site. At the second hospital, appropriate systems should be in place to ensure that when a urine sample is requested, it is actioned and the result fed back to the appropriate clinical staff.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their parent (A) by the board. A was admitted to the hospital due to a catheter blockage. On examination, it was determined that A required specialist treatment and an ambulance transfer to another hospital within the board was arranged. It took approximately six hours for the ambulance to arrive by which time A was showing signs of sepsis (a life-threatening reaction to an infection).

Antibiotics treatment was initiated on A’s arrival and they had regular washouts of their catheter and continuous irrigation due to blockages and bleeding. A had ongoing uro-sepsis and required blood transfusions. A suffered a heart attack during their admission and blood-thinning medication was prescribed. However, this made the bleeding at the catheter site increase. A died in hospital several days later.

C complained to the board about A’s care and treatment but the board did not identify any failings. The board did identify and apologise for failure in communication with C. C remained unhappy and asked us to investigate. C complained that the staff in the first hospital had unreasonably delayed in treating A with antibiotics. C complained that staff in the second hospital subjected A to unnecessary pain while irrigating their catheter. C also complained that staff failed to identify that A’s catheter had been incorrectly placed. C complained about a decision to prescribe A with the anti-coagulant. C also complained about the palliative care given to A.

We took independent advice from a consultant in emergency medicine and a consultant urological surgeon (specialist in the male and female urinary tract, and the male reproductive organs). We found that staff in the first hospital had unreasonably delayed in treating A with antibiotics and we upheld this aspect of C’s complaint. We found that the care and treatment given to A in the second hospital was reasonable. However, we considered that staff had failed to recognise that A’s catheter was in the incorrect position within a reasonable timescale and therefore upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in treating A with antibiotics until they had been transferred to the specialist; and in recognising that A’s catheter was in the incorrect position. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients diagnosed with sepsis should have antibiotics administered promptly and without delay.
• Patients undergoing catheter insertion should be closely monitored so that any complications such as incorrect placement are recognised and treated without delay.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the medical practice failed to provide reasonable care and treatment to their spouse (A) after they presented with a lump in their right breast.

We took independent advice from a GP. We found that the time taken to refer A to hospital when they first consulted the medical practice with the lump in their right breast was unreasonable. It was also unreasonable that the referral was not marked as urgent.

The medical practice had carried out a detailed review of A’s care and had accepted that there was a complete systems failure in the care and treatment provided to A. They had made a number of changes which we welcomed and considered were appropriate. Nevertheless, we found that they had not fully acknowledged their specific role and responsibility in relation to the failings which had occurred given their responsibilities for the supervision, training and actions of their employed staff.

We also identified additional issues not addressed by the medical practice in their consideration and response to the complaint. In particular, that the medical practice should have a system in place to ensure any outstanding referrals were identified when a colleague is unexpectedly absent due to sickness or ill-health and that it was unreasonable that A was not contacted by the medical practice after the cancer diagnosis given the significance of the diagnosis and their delay in sending the referral and marking it as urgent. We also found that the medical practice did not appear to have considered their duty of candour responsibilities in this case. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients should receive appropriate assessment and referral in line with relevant guidelines. Patient referrals should be reviewed and actioned when the responsible member of staff is absent unexpectedly. Where appropriate, patients should be contacted after receiving a significant diagnosis. This should include when the practice become aware that harm has occurred as a result of an unintended incident in healthcare to take into account duty of candour responsibilities, individual roles and their role responsibilities in making sure this happens.

In relation to complaints handling, we recommended:

• The practice should ensure that, where failings have been identified during a complaint investigation, the investigation and response fully acknowledges and take responsibility for the failings and ensures there is appropriate learning across the practice.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board took too long to offer them steroid/local anaesthetic injections for vulvodynia (chronic pain or discomfort in the vulva). C felt this was dismissive and unsatisfactory. The board said that C did not receive the treatment initially as it was not clinically appropriate at that time. They said in order for the treatment to be effective, there should be a locally tender area to inject which C did not have. The board added that it was important to note that the treatment is unlicensed and so is only to be considered for use when definitely clinically indicated.

We sought independent clinical advice from a consultant. We found that it is right for the board to have a cautious approach to the use of unlicensed treatment. We noted that the treatment C received for many years was reasonable. However, it was later indicated that C had developed a localised area of pain and it would have been reasonable to discuss the treatment with C at that point.

We considered that whilst the care and treatment provided to C was generally reasonable, the board should have discussed the treatment option of steroid/local anaesthetic injections earlier than they did. For this reason, on balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not discussing the pros and cons of steroid/local anaesthetic injections as a treatment option or offering C the chance to decide whether or not they wanted to try this treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients attending vulval pain clinics should be fully informed about their condition as well as the pros and cons of available treatments. Staff caring for patients attending vulval pain clinics should be aware of the full range of treatment options so that they are able to provide holistic care and advice to patients.

In relation to complaints handling, we recommended:

• Complaints should be responded to in line with the Model Complaints Handling Procedure (MCHP) and issued within the expected timescale of 20 working days. If the board are unable to meet the 20-working day deadline, updates and a new deadline should be issued to C in line with the MCHP.
• Letters of complaint received by the board should be logged and forwarded as appropriate to the complaints and feedback team.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.