Upheld, recommendations

Summary

C complained that the council did not reasonably assess their application for a Blue Badge (a badge issued to disabled drivers for display on their windscreens, indicating entitlement to specific parking privileges). C applied for a Blue Badge as they suffer from fibromyalgia, amongst other conditions, but noted that due to the variable nature of their condition, it was difficult to answer the questions in the council's application form and considered that they should have received an in-person mobility assessment. C's application for a Blue Badge was refused and the decision to refuse was upheld on review. We found that there was not sufficient evidence for the council to have reasonably assessed C's application in line with The Blue Badge Scheme (Scotland) Code of Practice, and therefore did not adequately demonstrate that a clear and robust decision was made on C's eligibility as the result of the desk-based assessment. We also found they did not explain their decision to refuse C's application in line with the Code of Practice. As a result, we upheld this aspect of C's complaint.

C also complained that they did not received a reasonable response to their complaint from the council. We found that, while the council conducted an appropriate level of investigation into C's complaints, they failed to properly identify, and therefore adequately address, the crux of C's complaints in their responses. We also found that C was not contacted when the complaint response was delayed, which was not in line with the Model Complaints Handling Procedure. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Assess a new application from C in line with the Code of Practice and provide a clear and robust decision.

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

• Assessors should fully demonstrate in desk-based assessment forms that they have made a clear and robust decision on eligibility, and considered the factors relevant to an applicant's ability to walk, in line with the Code of Practice. Applicants applying under the 'unable to walk or virtually unable to walk' eligibility criteria should be referred for an independent mobility assessment if the local authority is unable to make a clear and robust decision on eligibility using cross-checking or desk-assessment, in line with section 4.18.2 of the Code of Practice. Local authorities should clearly state in their letter to unsuccessful applicants why their application has been refused, stating why they did not meet the criteria, in line with section 6.2.7 of the Code of Practice.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the Model 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, an advocacy and support worker, complained on behalf of their client (A) about Self Directed Support (SDS) decisions made by the partnership. A's family had arranged for carers from an agency, which provides carers on a self-employed basis, to provide care to their family member (B). A asked for an SDS assessment to be carried out in order for contributions to the cost of carers to be made by the partnership. Several months later, the partnership told A that the request for SDS payments had been declined on the basis that the local policy advises employing personal assistants, rather than self-employed workers.

During their complaints investigation, the partnership acknowledged and apologised that there had been a delay in communicating their position. They also confirmed to us that they had updated their guidance to make their position on engaging self-employed carers more clear; and that staff training had been carried out on this matter.

We considered that the failure to notify the family of the issues regarding self-employed carers at an earlier stage was unreasonable. We also considered that the explanation provided to the family could have been clearer. On this basis, we upheld this aspect of the complaint.

In terms of actions taken by the partnership, we found that the updates made to the guidance were appropriate, but made a recommendation to ensure that all associated guidance such as practitioner's guides fully reflect the position. We also recommended that the partnership provide a further apology to the family and that they provide evidence of the staff training carried out.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to communicate reasonably with them regarding SDS options and payments. 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:

• Families should be informed at the earliest opportunity of any issues or concerns which may impact on their ability to receive SDS payments.
• The guidance should be clear about the partnership's position on using SDS payments for self-employed carers.

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 child (A) that the board had failed to provide A with reasonable care and treatment for a Phyllodes tumour (a tumour of the breast). C complained that A was told that they had a benign (non-cancerous) Phyllodes tumour when this was not the case. A later found out that the tumour had been malignant (cancerous). C also said that A was not offered radiotherapy (a treatment using high-energy radiation) or chemotherapy (a treatment where medicine is used to kill cancerous cells) following the Phyllodes tumour diagnosis, and that A was not appropriately monitored following the diagnosis.

We took independent advice from a consultant breast surgeon. We found that A was appropriately monitored following the diagnosis and it was reasonable that A was not offered radiotherapy or chemotherapy in the circumstances.

However, we also found that the clinic letters following A's surgery did not describe the Phyllodes tumour as malignant, and the size of the malignant Phyllodes tumour had not been documented in the multidisciplinary team notes. We upheld C's complaint on this basis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to communicate reasonably with them regarding the Phyllodes tumour being malignant and for failing to record the size of the malignant Phyllodes tumour in the multidisciplinary team notes. 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 be informed about the type of Phyllodes tumour identified and such discussions should be clearly documented.
• The size of malignant Phyllodes tumours should be clearly documented in multidisciplinary team notes.

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 clinical care provided to their child (A) by the board, specifically, that a Chiari malformation (where the lower part of the brain pushes down into the spinal cord) was visible on a magnetic resonance imaging (MRI) scan performed by the board and that the abnormality was not noted until they insisted on a further MRI scan.

A suffered from a number of symptoms including headaches, tinnitus (ringing or buzzing in the ears), vertigo (a sensation of loss of balance or that objects around you are spinning) and drop attacks (sudden falls to the ground) for a number of years.

In relation to the reporting of the MRI scan, the board considered it was a miss of an incidental finding and apologised for the matter in retrospect.

We took independent advice from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). Whilst we found that it was reasonable to ask only about a possible tumour, we considered that it was unreasonable that the radiology report did not report on the cerebellar tonsillar protrusion (a type of brain herniation) or indicate the presence of Chiari malformation. We also noted that the type of Chiari malformation A had (Chiari I) does not necessarily produce symptoms, but good practice would have been to record this finding and suggest review by a neurosurgeon, which did not happen in this case. We upheld this aspect of C's complaint.

C also complained about the communication that occurred with an ear, nose and throat (ENT) consultant. We took independent advice from an ENT consultant. We found that it would not be reasonable to expect an ENT clinician to recognise the Chiari malformation when the radiologist did not. However, we found that it was unreasonable that there was no record of discussions with A or C about the third scan being arranged, or discussions about medications. The board accepted that there had been failings in communication with the family and they took steps to address the matter. We upheld this aspect of the complaint, but made no further recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for not having referred in the radiology report to the cerebellar tonsillar protrusion, or indicate the presence of a Chiari malformation. 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:

• Radiological reports should be accurate and reasonable.

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 sibling (A) after A was admitted to hospital with a history of progressive vomiting and nausea. The dietetics team (specialists in the scientific study of the food that people eat and its effects on health) asked for A to be prescribed thiamine (vitamin B1) for malnutrition as A had recently lost ten percent of their body weight. The prescription was not made and A did not receive the thiamine supplements. A was discharged several days later as their symptoms had improved and investigations had been generally reassuring. Several weeks later, A suffered a collapse and was readmitted to hospital with confusion and reduced mobility. After extensive investigations, A was diagnosed with Wernicke's encephalopathy (a condition which affects the brain, caused by lack of thiamine). C complained that the board had failed to provide reasonable care and treatment to A in relation to the failure to prescribe thiamine, and that discharging A had been unreasonable.

We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines). We noted that the board had previously acknowledged that there was a failure to give A thiamine when originally recommended by the dietetic team, and they had apologised for this. They had also implemented a ward round checklist to prevent similar failings recurring. However, based on the advice we received, we were concerned that the board had not fully considered or accepted the potential impact of this failure, as we considered that thiamine supplements may have at the very least lessened the severity of the Wernicke's that subsequently developed. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide A with thiamine, and for failing to acknowledge the potential impact of this. 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 be aware of the potential impact of thiamine deficiency and the manner in which Wernicke's encephalopathy develops.

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 admitted to hospital for an elective hernia repair. The procedure was said to have gone well and it was agreed that C could be discharged home. Before leaving hospital, C took a stroke (a serious medical condition that happens when the blood supply to part of the brain is cut off. Strokes are a medical emergency and urgent treatment is essential). In C's case, it was thought they had experienced a reaction to the medications they had been prescribed and it was deemed that they could be discharged from hospital. Once at home, C was reviewed by their GP, who arranged for them to return to hospital for further tests. Those tests confirmed that C had had a stroke prior to being discharged from hospital.

We took independent advice from an appropriately qualified clinical adviser. We found that the board failed to document the assessment of C that was undertaken prior to them being allowed to return home. Without that evidence, we were unable to determine whether the assessment of C's symptoms was of a reasonable quality. We reached the view that the board unreasonably failed to diagnose that C had suffered a stroke and upheld the complaint.

In addition, we found that the board's response to C's complaint was too brief, and lacked sufficient detail. There was little recognition that a significant diagnostic error had occurred, or the effect this may have had on C. The board's investigation and response did not note or disclose to C that there was no documentation in relation to this aspect of their care. The response also lacked appropriate detail in relation to the relevant discussions held as a result of C raising their complaint. We made recommendations to the board concerning these points.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to diagnose that they had suffered a stroke prior to being discharged home; assess them in sufficient detail; and record details of the assessment in their notes, and discharge letter. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The board should write to C clarifying what action was taken once the educational supervisor was informed of the matter. The response should also provide further feedback in relation to the discussion held at the general surgery meeting, and what actions may have been agreed.

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 family member (A) about the way A was treated by the university. C’s complaint was regarding a support meeting which they attended with A. C said that the meeting was unreasonably cut short by university staff after a disagreement about recording the meeting; A was required to make a recording as he is blind, but university staff refused to allow this. C also held concerns regarding the handling of the complaint they subsequently made about this matter.

We found that the university had unreasonably refused to allow A to record the meeting, despite this being an established practice. When C attempted to raise this with the staff, they abruptly ended the meeting, stating they considered that C’s behaviour had become unreasonable. In doing this, we found that they had not followed the university’s policies for managing unacceptable behaviour. We upheld this aspect of the complaint.

In addition, we agreed that there had been failings in the handling of the complaint, including a failure by the staff involved to provide reasonably accurate statements of what had occurred, and a failure by the university to fully respond to the points of complaint raised. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for failing to take account of their equalities obligations in refusing consent to record the meeting, for ending that meeting unreasonably, and for failing to reasonably handle C’s 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:

• Staff should follow the Code of Practice when addressing unacceptable behaviour.
• Staff should take account of their equalities duties when considering requests for reasonable adjustments made by disabled students.

In relation to complaints handling, we recommended:

• All complaints should provide clear outcomes to all complaints raised, and reasonably consider and interrogate all available evidence to resolve contradictions, where possible.
• Staff should give reasonably accurate statements in complaint investigations, being clear about any factors which may impact their recollection or the accuracy of their statements.

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 way that the Criminal Injuries Compensation Authority (CICA) handled their application for criminal injuries compensation. We were not critical of the length of time taken to progress C’s application. However, we found that C’s expectations were not appropriately managed regarding how often they could expect updates on the progress of their application and regarding when or if they could expect to receive acknowledgements of correspondence. We upheld this aspect of C’s complaint.

C also complained about how the CICA had handled their complaint. We found that the CICA complaints procedure does not comply with the Model Complaints Handling Procedure. In particular:

- the customer-facing complaint handling procedure does not explain the three stage process that they follow or set out the timescales for each stage of the process.

- the Criminal Injuries Compensation Authority did not provide a thorough and robust response to C’s Stage 2 complaint.

- the Criminal Injuries Compensation Authority incorrectly signposted C to complain to the SPSO via an MP (which is not a requirement for bringing a complaint to the SPSO).

We upheld C’s complaint about the way their complaint was handled.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to manage C’s expectations regarding how often they could expect updates on the progress of their application; failing to manage C’s expectations regarding when or if they could expect to receive acknowledgements of their correspondence; failing to handle C's complaints in a way that complied with the Model Complaints Handling Procedure; failing to provide a thorough and robust response to C’s stage 2 complaint; and incorrectly signposting them to complain to the SPSO via an MP. 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:

• Applicants should be informed regarding how often they can expect updates on the progress of their application.
• Applicants should be informed regarding when or if they can expect to receive acknowledgements of their correspondence.

In relation to complaints handling, we recommended:

• The organisation’s complaints procedures should comply with the Model Complaints Handling Procedure https://www.spso.org.uk/the-model-complaints-handling-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 that they were unreasonably banned from Live Borders museum premises, services and events. We found that while Live Borders were entitled to impose the ban as a discretionary decision, we considered that there were failings in their handing of the ban. We found that while Live Borders’ Health and Safety Policy outlines a zero tolerance approach to unacceptable behaviour, we considered that a clearer procedure should have been in place in line with the Model Complaints Handling Procedure (MCHP). Additionally, we found that the record-keeping and communication around the decision to ban C could have been clearer. We found that there was no record of the initial decision to impose a ban or the communication of this to C. We also found that more consideration could have been given to including specific examples of C’s offending behaviour in the complaint response letter, given the decision to impose an immediate ban. C should have been advised of their right to appeal the decision at the time it was imposed; instead, the earliest documentation of the reasons for the ban was the complaint response letter (which also served as the response to C’s request for an appeal). As a result, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in handling the decision to ban them from Live Borders’ services. 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:

• In line with the MCHP, Live Borders should ensure they have an appropriately detailed procedure for dealing with problem behaviour, and staff are supported in using this. The revised MCHP (found at https://www.spso.org.uk/the-model-complaints-handling-procedures) published on 31 January 2020 provides additional information under the section 'Expected behaviour'.

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 enrolled on a lifeguard course delivered at a leisure centre run by Glasgow Life. The course was delivered over six days, with an assessment on the final day. C sustained an injury on the final day and did not pass the assessment. C raised a number of concerns about the course and requested a refund. Glasgow Life partly upheld C’s complaint and offered C a place on another lifeguard course as a goodwill gesture. C remained dissatisfied and brought the complaint to SPSO.

C said that Glasgow Life provided insufficient information about the assessment criteria and did not obtain a completed medical questionnaire before the course started. C also felt that Glasgow Life should have assessed their condition after they reported an injury in writing.

We found that, although C had undertaken a pool test to confirm swimming ability, Glasgow Life did not obtain a completed medical questionnaire from C. We concluded that they did not take sufficient steps to verify that C met all the entry requirements for the lifeguard course. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to ensure that they completed a medical questionnaire before enrolling on the course. 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:

• Steps should be taken to establish that an applicant meets all the entry requirements before they are accepted on a lifeguard course.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the Model 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.