Upheld, recommendations

Summary

C complained that the council unreasonably assessed that a property was in a safe and lettable condition when they handed the tenancy over, that the council failed to make, or communicate, reasonable arrangements for carrying out repairs, and that the council failed to provide a reasonable response.

In respect to the aspect of the complaint that the council had unreasonably assessed that their property was in a lettable condition when the tenancy was allocated, we found that the capacity of the council’s systems to record safety and quality checks led to the council being unable to evidence that the property met the lettable standard at the time the tenancy was allocated. We therefore upheld this complaint.

C also complained that the council failed to make, or communicate, reasonable arrangements for carrying out repairs. We found that C was put to having to arrange repairs that could have been carried out before the property was let. We also found that the council did not communicate effectively with C when appointments were cancelled or had to be rearranged. We therefore upheld this aspect of the complaint.

C also complained that the council did not provide a reasonable response to their complaints. We found that the responses to the complaints did not address all of the concerns raised and failed to recognise the impact the issues had on C. We therefore also upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to ensure that repairs were carried out to the required standard prior to letting the property, for failing to check that the heating and smoke alarm systems were in full working order, for failing to make or communicate reasonable arrangements for appointments and for failing to provide a reasonable response to their complaints. 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:

• Where the council have informed a tenant that they will carry out repair work, officers should keep the tenant updated about any delays.
• The council should have effective systems in place to ensure the Lettable Standard is met and that records are well maintained and easily accessible. Tenants must have a satisfactory provision for heating their property.

In relation to complaints handling, we recommended:

• Complaint responses should comply with the Model Complaints Handling Procedure and council staff should be familiar with the Complaints Handling Procedure. Responses should address each point of the complaint, providing a clear explanation of what occured and describing action that will be taken where something has gone wrong. The information in responses should be supported by the evidence in the relevant records.
• Complaint responses should recognise the complainant’s experience and demonstrate empathy for their situation.

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 reported concerns to the council’s environmental services department about smoke pollution over a number of years as a result of their neighbour burning bonfires and a wood-burning stove. C was dissatisfied with the lack of action taken by the council and submitted a complaint. C considered that the council’s investigation of their concerns was insufficiently detailed, failed to take account of available evidence, and dismissed factors which C considered important. C also complained that the council’s response contained a number of inaccuracies.

We found that the council did not meet the timescales set out in their complaints procedure. However, the complaint was raised and investigated during the COVID-19 pandemic and C was advised from the outset that timescales were being affected. The council also apologised for this delay. We considered the overall time taken to have been understandable in the circumstances. However, we did note that the council failed to communicate to C that their complaint was being considered at stage 2 of the complaints procedure, despite initially advising that it would be reviewed at stage 1 and that C was not provided with updates when they asked.

It is also clear that there was ongoing communication between C and environmental services throughout the investigation period, correspondence sent and received via a councillor on C's behalf and Freedom of Information requests made. This all contributed to an overall confused chain of correspondence.

Generally, we were satisfied that C’s complaints were taken seriously and an investigation was carried out before the council’s response was issued. However, we found that the investigation sought mainly to respond to the complaint, rather than get to the root cause and attempt to resolve C’s dissatisfaction. The council’s response to C’s complaint reiterated their previously-stated position on whether they considered statutory nuisance had been witnessed. However, C’s complaint referred to the way that the officers had reached their decision, and the lack of objective measurement of the problem or use of official monitoring tools and the apparent disagreement as to which legislation was relevant. We considered that the council’s response should have explained matters such as why the smoke was not considered to be a statutory nuisance, what would be considered a statutory nuisance, why no equipment was deemed necessary to establish that no nuisance existed, and how the officers assess such situations.

We found no evidence that the council’s response to C’s complaint was inaccurate, or that a more detailed investigation would have altered the outcome in terms of the environmental services' assessment of C’s reports.

C also appears to have been given conflicting explanations as to why video evidence was not considered. However, this was clarified in response to our enquiries. We considered that this highlights the importance of collating a single clear explanation before responding to an individual’s enquiry.

Taking all the evidence into account, we found that the council did not reasonably respond to C's complaint. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to address some of the issues C raised, that their communication with C regarding the complaints procedure was poor and their general communication was confusing. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Write to C to provide a more comprehensive response to the outstanding issues we have identified in this decision.

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

• The council should consider how they could have better managed correspondence from C to ensure that, where individuals communicate through multiple channels or across multiple departments on the same issue, all points are responded to fully and consistently.

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, an adult with autism, was receiving treatment from the Partnership as a new patient after moving into the area and was unhappy with their psychiatrist. C felt that the Partnership did not have appropriate staff who specialised in treating adults with autism.

C complained that the psychiatrist questioned the diagnoses and treatment plan already in place, that the psychiatrist told them that the treatment plan was wrong, that they asked questions in an unstructured way and made unreasonable remarks about C’s personal life. Further, during an online consultation the psychiatrist allowed a second person to be present without having made C aware this would happen and ignored their request for an adjustment to have a doctor of the same gender as them. C also complained that the Partnership accused them of being misogynistic by asking for a same-gender doctor.

The Partnership said that the psychiatrist did agree to provide the prescription C was seeking as C was very fixed on the recommendations made by their previous psychiatrist. The Partnership also said that C was derogatory towards the psychiatrist due to their gender and questioned their ability.

We took independent advice from an adult consultant psychiatrist. We found that the evidence showed that the Partnership provided elements of good care and treatment to C. However, their response to C’s request for a same-gendered doctor was unreasonable, the consultation deviated significantly from recognised good medical practice and it was unreasonable to have an additional person present without C having been told or asked for consent beforehand. In addition, we found that there was no evidence that would support the Partnership’s position that C was derogatory towards the psychiatrist due to their gender, and there was no evidence to suggest C was significantly hostile. Therefore, the Partnership’s assertions about C’s manner were unreasonable. As such, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this complaint. 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:

• Complaints should be investigated in line with the Model NHS Complaints Handling Procedure. Particularly they should identify and clarify all points to be investigated at the outset of the investigation, address all of the points raised and be person-centred and non-confrontational.
• New patients should receive initial appointments with clinicians that are conducted reasonably and in line with good practice. Particularly these should ensure questioning and summarisation of clinical information is structured, appreciate the importance of establishing a therapeutic relationship between the clinician and new patient and establish the patient’s expectations from the outset.
• Observations and opinions on a patient’s manner and motivations should be fair, accurate, and evidenced in so far as possible.
• When student or trainee clinicians sit in on appointments for training, the Partnership should introduce the person and explain why they are there, where possible, the patient should be informed in advance of the appointment and the patient's consent should be sought. When a patient does not consent to a trainee/student being present they should leave the appointment.

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 was sent to hospital by the GP with a diagnosis of severe cellulitis (an infection caused by bacteria getting into the deeper layers of your skin). Prior to being sent to hospital, C received paracetamol, intravenous fluids and intravenous antibiotics. On arrival at hospital, C had a long wait until being treated and C complained that the delay in admission and treatment was unacceptable.

The board apologised that C had to wait in their car and explained that patients were seen on a clinical priority basis. They advised that C's clinical priority was not deemed to be urgent as C had received paracetamol, fluids and antibiotics before arrival.

We took independent advice from an acute and general medicine adviser. We found that at the time, there was no clear system for prioritising patients. However, since then the board have improved their practice. We found that the triage which had been undertaken after admission had not followed guidelines. Additionally, we found that the waiting time to receive antibiotics was longer than the recommended maximum wait between antibiotic doses. As such we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in admission and treatment, specifically that clinical priority was not appropriately assessed, that the triage decision was not in line with the guidance and that there was a delay in administering medication. 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:

• Staff should triage patients in line with the relevant guidance.

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 that they received during their labour and delivery of their baby (A). In particular, C complained that the standard of care and treatment they received had been unsafe, that there had been a lack of communication in relation to their requested position during labour, the use of forceps and the provision of pain relief. C also complained that they had been unable to give their informed consent for the use of forceps.

The board, when responding to C’s complaint, accepted that some aspects of C’s care did not meet the standard that they would expect in terms of communication and C’s requested positioning throughout the labour and delivery of A. As a result of C’s complaint, the board had shared the complaint with the midwifery staff responsible for C’s care. The board asked them to reflect on C’s experience and consider ways of improving care for the purpose of providing person centred care. The board also accepted that they had failed to arrange C's postnatal review clinical appointment. The board said they had taken action to review and amend the process for appointing consultant led postnatal follow-up. The board indicated that, while the event had not been recorded as an adverse incident and a Datix (an incident/risk management reporting system to collect and manage data on adverse events) had not been submitted, a review had been carried out and action had been taken as a result of that review.

We took independent advice from a consultant obstetrician (a doctor who specialises in care during pregnancy, labour and after birth). We found that during C’s labour there were significant periods of loss of contact (LOC) during the recording of the foetal heart rate. However, we also found that, while labour would have been complicated by the LOC there was no evidence that C or A were put at risk. We also found that the actions of staff during this period were reasonable and proportionate to the needs of C and the clinical circumstances which occurred at the time. We found that safe care and delivery had been provided to C. However, we also found that there had been a material change in C’s birth plan and that there had been a failure to communicate these changes with C.

The board accepted that there was no documentation in the medical records of a discussion with C in line with Royal College of Obstetricians and Gynaecologists guidance on obtaining verbal consent on assisted vaginal births. We found that obtaining consent is an important aspect when providing care and treatment to a patient, and completing the appropriate documentation is a professional standard. The event should have been recorded as an adverse incident and a Datix should have been submitted. We upheld the complaint and provided feedback to the board in relation to the use of the adverse event process and the submission of a Datix.

Recommendations

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

• Patients should receive clear explanations and appropriate information where there are changes to their birth plan. Where discussions have taken place with a patient, this should be documented.
• Staff should be aware of the relevant Royal College of Obstetricians and Gynaecologists (RCOG) guidance on documenting consent.

In relation to complaints handling, we recommended:

• Complaint responses should be informed and accurate and address all aspects of the complaint.

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 council had unreasonably failed to carry out an adequate assessment of their parent (A)'s personal care needs and made an unreasonable decision that A did not meet the criteria for free personal care funding.

We found that the council's records did not evidence that thorough assessments of A's needs were carried out. There was no evidence that A's needs had changed, or that they no longer met the criteria for free personal care funding when the funding stopped. Although there was some evidence that A's needs were considered when the decision to stop funding was challenged, there was no evidence of an adequate assessment. Therefore we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to complete an adequate assessment of A's needs, for failing to work in partnership with A and their family and for stopping free personal care funding. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Provide financial redress for an amount equal to the payment of free personal care funding that A should have received between the dates specified in our decision notice.

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

• Assessments and reviews should be fully and accurately recorded within a reasonable timeframe.
• Funding decisions should be based on robust assessments that are completed and recorded in accordance with council procedures.

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 council's handling of reports they made about their neighbours' antisocial behaviour. They reported a number of incidents to the Police and to the council's Antisocial Behaviour and Private Sector Services teams. Although C's reports were investigated, they were dissatisfied with the action that was taken by the council. C complained that the council failed on multiple occasions to respond to their contacts or took an unreasonable length of time to respond. C submitted a formal complaint to the council. Again, they considered that the council took an unreasonable length of time to respond to their concerns and inappropriately assigned an individual who was involved in the matters they complained about to conduct the investigation.

We found that although the council communicated clearly and regularly with C regarding their ongoing reports of antisocial behaviour, more could have been done to explain their assessment of the situation and the reasons why no formal action was being taken. We found that the council failed to follow their complaints handling procedure. There were delays in responding to C's complaint and it would have been better practice for the complaint to be investigated by someone with no involvement. On balance, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted in this decision. 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:

• Staff should handle complaints in line with the Model Complaints Handling Procedure, ensuring that wherever possible the complaint is investigated by someone not involved in the complaint.
• The council should ensure that when customer contact is escalated to a formal complaint, it is dealt with under the complaints handling 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 that the council failed to respond appropriately to concerns they raised about their child (A) who had cancer. C was separated from A's other parent (B) and, at the time A became ill, both C and B shared A's care on an equal basis and had Parental Responsibilities and Rights in relation to A. C was concerned about aspects of A's care and quality of life during their illness. C raised concerns that B repeatedly acted against medical advice, and acted aggressively and was abusive to C and C's partner while A was present. C complained about the way social workers and A's Named Person (a central point of contact if a child, young person or their parent(s) want information or advice) dealt with their concerns. C complained that during A's illness council staff acted unprofessionally and did not take their repeated requests for help seriously.

We took independent advice from a social worker. We found that the council should have more fully investigated the concerns C raised about A's welfare. In particular, they should have made contact with a relevant health professional involved in A's care to clarify whether they shared C's concerns. The council had a statutory duty to make enquiries in connection with A's welfare, to satisfy themselves that A was not at risk. We found that the council failed to meet their statutory obligations in this regard. Therefore, we upheld this part of C's complaint.

C complained about the council's complaint handling. We recognised this was a difficult and complex complaint for the council to investigate, but we were critical of a number of aspects of the complaint handling. We recognised that the complaint investigation spanned some of the COVID-19-related lockdowns, when services were adversely impacted. However, we found that the council not only failed to meet the relevant timescales in accordance with their complaints handling procedure, they also failed to keep C updated regarding progress. We were critical of the complaint being passed back to the team manager to finalise the response when the senior manager investigating the complaint retired; the team manager was not sufficiently senior to deal with the complaint and they were cited in the complaint themselves. We also found that there was a lack of depth in the investigation. We considered the complaint handling was unreasonable and upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in our investigation. The apology should recognise the impact of these failings on C, C's wider family, and on 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:

• Council staff are clear about their obligations and act within the relevant statutory framework. Parents with parental responsibilities and rights are treated equally by council staff. In particular, where parents present differing accounts of significant events which cannot be reconciled, relevant independent third parties should be contacted for verification, both parents should be involved in planning for meetings such as TATC, the child's views should be sought in relation to matters affecting them.
• The council should consider putting in place a system for auditing records of child protection concerns reported to a school or noted by a school.

In relation to complaints handling, we recommended:

• Complaints are investigated in line with the Model Complaints Handling Procedure. Complainants are kept updated regularly. Complex stage 2 complaints are investigated by a senior manager. Complaints should not be investigated by staff cited within the complaint.

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 provided to their elderly parent (A). A had to remain in bed to allow several pressure sores to be treated. To assist with moving A out of bed and changing A's position, a manual handling assessment was requested. C felt that there was an unreasonable delay in conducting this assessment and that when it was carried out, the equipment was provided too slowly and was not fit for purpose.

The partnership responded to C but denied acting unreasonably, or that there had been an undue delay. C responded to this challenging the accuracy of the partnership's response. The partnership issued a second response which acknowledged the first response had been inaccurate. However, they maintained that staff had acted reasonably, and that A had not been put at risk by the handling equipment used to move them.

We found that there had been a delay in providing a manual handling assessment caused by the referral not being initially received, which was compounded by staff absence on leave. However the partnership were able to demonstrate they had already addressed this through the recruitment of additional staff. We also found that the partnership's procedures required them to review the suitability of manual handling equipment after it was delivered to the patient, as well as ensure care staff were competent at using the equipment properly. This was not done, and we found it was unreasonable for the partnership not to have followed their own procedures. We also found that it was unreasonable for the partnership to have issued a stage 2 complaint response which was inaccurate, as their follow-up response acknowledged that it had not reflected the partnership's electronic records accurately. Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

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

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 they received from the board in relation to an incident of extravasation (the leakage into surrounding tissue of medication administered intravenously) of chemotherapy into their arm. C told us that following the incident, their arm became painful and swollen and that they were left with loss of function in their hand and arm, despite being referred to the board's orthopaedic, plastic surgery and physiotherapy departments for further treatment. C considered that the aftercare they had received had been unreasonable and that there had been a lack of diagnosis in relation to the injury to their arm. C also complained about the attitude of nursing staff after the incident, which they felt lacked compassion.

The board told us that extravasation is a known risk of chemotherapy treatment but that once the extravasation was noticed, chemotherapy treatment was stopped immediately and that attempts were made to aspirate the fluid from C's arm. The board also noted that C was reviewed by an on-call plastic surgeon, all in accordance with their extravasation policy. The board acknowledged that, while C was subsequently seen by specialist in orthopaedics and physiotherapy, their recovery appeared to be slower than would normally be expected and that the long term implications were unclear.

We took independent advice from an oncologist and a nurse. We found that the board's response to the extravasation incident, both immediately and in the months that followed, was in keeping with their extravasation policy and established good practice. However, on review of the available documentation, there was no evidence to show that nursing staff had completed the necessary hourly checks of C's peripheral vascular cannula (through which the chemotherapy was administered) or that the extravasation incident had been discovered as a result of monitoring by nursing staff. This was unreasonable and contrary to professional nursing standards in relation to record-keeping. For this specific reason, we upheld C's complaint. However, there was no evidence within C's clinical records to confirm that the attitude of nursing staff had been poor.

We also found failings in the board's handling of C's complaint and made recommendations under our powers to monitor and promote best practice in relation to complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the complaint handling failings identified in this decision. 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 relevant staff should be trained in and be aware of the relevant guidance in relation to PVC insertion, monitoring, maintenance and removal; and the completion of the relevant PVC monitoring documentation (this should include reference to the NMC Code Section 10). There should be a reliable method of ensuring that a PVC chart/aide memoire/policy/guideline is included in each patient's record as required. Relevant documentation should where appropriate be marked “N/A” if the sections are not required, so it is apparent that they have not just been missed.

In relation to complaints handling, we recommended:

• The board should comply with their complaint handling guidance when investigating and responding to complaints.

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.