Upheld, recommendations

Summary

C adopted a young child, however the placement ended after a short period of time and the child was removed from C's care. C complained to the council about the lack of support provided during the adoption placement, that the placement ended abruptly and that the council did not follow all of the recommendations in the disruption report completed after the ending of the placement.

The council advised that support was offered to C, however they recognised that an additional meeting to review the situation and offer practical support may have been helpful. The council also acknowledged the placement ended abruptly but considered it was managed well. The council said they implemented the recommendations detailed in the disruption report.

We took independent advice from a social worker. We found that the council failed to recognise the need to formally review the child's plan and respond to C's requests for support. We found that the council failed to ensure the placement ended in a more planned way or to recognise that more weight should have been given to a child's experience of significant trauma. We also found that the council unreasonably delayed in responding to C's complaint. We upheld C's complaints.

Recommendations

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

• The council should ensure that a child's plan (or adoption support plan) includes details of difficulties that may emerge within the adoptive placement and strategies for the support of the child and of the adoptive parents should be built in from the outset of the new placement. Where possible, placements should be ended in a planned way unless there is significant unexpected risk to the child.
• The right of the adopter to request an assessment for an adoption support plan/formal review should be recognised.

In relation to complaints handling, we recommended:

• The council should ensure that complaints are dealt with promptly and staff should be familiar with how to respond to a complaint under the appropriate 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 and B complained about the council's communication with them when they were arranging a placement for their child (A) at an independent school. A has additional support needs and the placement was arranged and funded by the council at C and B's request. C and B later became aware that the council had previously raised concerns about the school when they managed to obtain information through a Freedom of Information request.

C and B had raised several concerns about A's placement. They complained that the council were aware there were problems with the school before placing A there. As such, they felt the council should have shared these concerns with them so they could have made an informed choice about whether A should have been placed at the school. C and B were also dissatisfied with the council's response to their complaint and how the complaint was handled.

We found that it was not clear that the concerns raised by the council directly contributed, or were replicated in, the difficulties described by C and B in their complaint. However, in our view, it was reasonable to conclude that the concerns raised could have impacted A or the placement. We took into account the nature of the concerns the council raised about the school, the previous difficulties in sustaining an appropriate placement for A, and the challenging nature of the placement. After considering these factors, we concluded that it would have been reasonable for the council to share their concerns about the school in some form with C and B at the outset of the process. Therefore, we upheld this complaint.

In relation to complaint handling, we found failings in respect of timescales, communication and how the council addressed information provided by C and B. We concluded that the complaint handling aspect of the stage 2 investigation was not of a reasonable standard. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and B for unreasonably failing to appropriately share concerns they held about the school with them and for failing to handle their complaint 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:

• When there are concerns about an independent school that could reasonably be anticipated to impact a child's placement, then appropriate information about these concerns should be shared with relevant parties, including the child's parents.

In relation to complaints handling, we recommended:

• Staff dealing with complaints should be familiar with the council's Complaint Handling Procedure, understanding the importance of communication and the need to demonstrate thorough investigation of the points raised.

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

Mr C complained about the council's communication with him. Mr C owns a flat in a building in which the council owns another flat. Mr C arranged repairs due to rising damp in the property, and he complained that the council's communication with regard to their contribution to repairs was unreasonable. He felt the council did not make it clear what they would contribute to and how much; failed to ask for details at the beginning of the process that they later requested; and generally made the process complicated.

We found that much of the council's communication had been reasonable, however, we also found that there had been a delay in acknowledging one of Mr C's emails and that the council had failed to respond to Mr C within the timescale they had agreed to. We also found that at one stage, the council continually referred to requiring invoices when estimates had already been agreed as being sufficient, and that the council's position on betterment and the evidence needed from Mr C could have been clearer from the outset.

For these reasons, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in acknowledging his communication and that the response did not adhere to the timescales the council set themselves; the repeated references to requiring invoices when estimates had already been agreed as being sufficient; and the failure to make the council's position on betterment and the evidence required from Mr C clear from the outset. The apology should meet the standards set out in the SPSO guidelines on apology available at: www.spso.org.uk/leaflets-and-guidance.

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

• Acknowledgements and responses to communication should be timely; where there is an unavoidable delay in providing a full response this should be explained to the service user.
• In similar circumstances, wherever possible, the obligations of the service user and the position of the council should be made clear from the outset.
• Where a position has previously been agreed, ongoing reference to the previous position should be avoided as this can be confusing.

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 applied for a community care grant from the Scottish Welfare Fund (SWF) at the council. C's application was refused and they submitted a first tier review request. The council partially changed their decision and awarded C some household goods. C complained that their application for a community care grant was not assessed reasonably in line with the SWF statutory guidance. C said that they had incurred rent arrears because their application was refused incorrectly at initial decision and they were unable to move into their new tenancy without the award of goods from the SWF.

We found that C's application was refused at initial decision as the council assessed that C had not signed for their tenancy. We found that the council had not followed the SWF guidance as they failed to give the applicant an opportunity to resolve any conflicts in evidence regarding whether they had signed for their tenancy or not. We further found that the council had a policy not to make awards in principle which was not in line with the statutory guidance, and we considered an award in principle should have been made in C's case. As a result, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably asses C's SWF application. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Calculate and reimburse C for rent arrears accrued from the earliest date they could have reasonably moved into the tenancy had an award in principle been made in line with the guidance, to the actual date of delivery of the full SWF award. The payment should be made by the date indicated: if payment is not made by that date, interest should be paid at the standard interest rate applied by the courts from that date to the date of payment.

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

• Applicants should be treated fairly and openly and understand what evidence they need to provide to support their application. It should be clear when they make their application if there is further information they need to provide. Applicants should be contacted when gathering information to have an opportunity to make their case. Where evidence is counting against their application, applicants should be told what it is and have an opportunity to explain further. Applications to the SWF should be assessed and decisions issued within the timescales set out in the regulations and the guidance. Decisions on first tier reviews where new information or a change of circumstances would cause the decision-maker to make an award should be made as soon as possible in line with sections 9.13 and 9.14 of the guidance.
• Guidance for decision-makers on SWF applications on making awards in principle should have regard to the statutory 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 has two children, one of whom attends nursery and the other attends primary school. C complained that the school failed to communicate with them appropriately about their children's poor attendance and that they failed to correctly implement and follow their attendance policy. The council provided details of the supports they put in place to manage the children's attendance.

We found that the school did not appear to have an up-to-date attendance policy in place as per the council's instructions. While the school took some appropriate action to address the children's poor attendance, some of these actions were delayed and were not documented. We also found that the school failed to respond to all of C's concerns in a timely manner, their communication with C overall was insufficient, and the council's response to C's complaint was inadequate as they failed to demonstrate that the attendance policy was followed, despite saying that it was. We upheld all of C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to correctly implement and comply with their attendance policy; to communicate reasonably with C regarding their children's attendance; and to fully investigate and respond to their 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:

• A communications policy should be developed which sets out reasonable timescales for responding to correspondence from parents. The council may wish to consider introducing an automated response acknowledging receipt of information.
• Relevant staff should reflect on this case and review their communication with C and identify where communication could have been improved.
• The council should review their attendance policy and ensure the school has its own individual policy; it should be made available on the school's website; parents should be notified of the policy; and school staff should be trained in the policy.
• The council should seek clarification, if this has not been done already, on the information that can be shared with parents.

In relation to complaints handling, we recommended:

• School staff should receive training on the council's complaint handling procedure, with a particular focus on identifying complaints and ensuring that evidence is provided to support their position.

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 school's handling of concerns they raised about the impact on their child of ongoing safety incidents within the classroom. C said they were not given clear information about the safety incidents, the applicable policy or the action being taken to address these, and the school did not put in place a risk assessment until after they complained. C also raised concerns about the school and the council's handling of their complaint.

The head teacher met with C to discuss the matter and upheld C's complaint. The school offered to put in place a number of measures aimed at supporting C's child, but did not share information on other action that had been, or was being, taken in response to their concerns, due to concerns about the confidentiality of other pupils. When C escalated the complaint to the second stage of the complaints procedure, the council investigated the school's handling of the complaint, and did not uphold C's concerns about this. The council also told C that no information would be shared about action taken in response to the safety concerns they had raised earlier, as this was confidential.

We found that the school should have taken action earlier in response to the safety concerns C raised (rather than waiting until C complained). We noted that the school had already apologised for this. We also found that the school should have kept C and other parents better informed about serious incidents affecting their children, in line with the school's policy on promoting positive behaviour. We upheld this complaint.

In relation to complaint handling, we found that the council's response should have set out their position on the original complaint (not just the complaint handling), and the investigation should have involved checking relevant records, such as records of safety incidents and correspondence, and referred to the relevant policy. We upheld this complaint. However, we also noted some aspects of good practice in the council's response, and we fed these back to the council.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not keeping them better informed about matters affecting their child's safety in the classroom, and for the failings in complaint handling. 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:

• The school's Positive Behaviour Policy should include clear guidance for teachers on actions that should be taken to safeguard the safety and wellbeing of other children affected by behavioural incidents, and on communication with parents about this.

In relation to complaints handling, we recommended:

• Stage 2 complaint responses should clearly reference the applicable policies or guidance and set out the organisation's final position on the original complaint (not just comment on the complaint handling).

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 partnership's actions in respect of their parent (A), who they have power of attorney for. Requests for an assessment for A's needs were made to the partnership and it was deemed they did not have capacity. An assessment was completed and a Self-Directed Support (SDS) budget (a package that allows individuals to choose how they receive their social care and support) was calculated. However, before SDS funding was put in place, two further assessments took place. These related to an increase in A's care needs. Based on the final assessment, the partnership concluded that A was not able to care for themselves safely and would require 24-hour care. The partnership sent C documentation relating to SDS payments. C did not return this documentation, as they did not consider it to reflect the recent assessment of A's care needs. As a result, the SDS process was not completed and no payments were made.

C complained as they did not consider the partnership to have assessed A's needs or handled the SDS process appropriately. Furthermore, C did not consider the partnership to have communicated with them in a reasonable and appropriate manner.

We took independent advice from a social worker. We found that the content and substance of the assessments carried out by the partnership appeared reasonable, appropriate and in line with relevant guidance and legislation. We also concluded that the partnership acted appropriately in other respects such as highlighting the potential of detention under the Mental Health (Care and Treatment) (Scotland) Act 2003 and in offering to provide SDS funding equivalent to the cost of a care home if A stayed in their own home. However, we considered it unreasonable that the process to put in place SDS funding for A's personal care needs, which were identified in the first assessment, was not finalised. There was an unreasonable delay of five months between the completion of the initial assessment and SDS payment documentation being issued to C. In light of this failing, we upheld this complaint.

In respect of communication, we concluded there were instances of unreasonable failings in the partnership's communication and missed opportunities to clarify matters in respect of the SDS process. We also concluded that the partnership unreasonably failed to share assessment reports with C. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out the SDS process within a reasonable timescale following the initial completion and assessment of A's needs and for the communication failings identified in this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Recalculate and provide backdated SDS funding in respect of A. The partnership's calculation should give consideration to A's entitlement to free personal care and take into account the initial assessment completed and subsequent assessments. The partnership should provide an explanation and rationale for their decision to both this office and C.

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

• Communication with the family members of service users or those with power of attorney should be clear, consistent and of a reasonable standard. Completed assessment reports should be shared with relevant family members, carers or people with power of attorney.
• Following an adult care assessment, the SDS process should be carried out within a reasonable timescale to ensure SDS or free personal care provision is in 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 that the Scottish Ambulance Service (SAS) failed to respond reasonably to the request for an ambulance from their late relative (A). C also complained about the way their complaint to SAS about the matter was handled.

Through its own investigation, SAS found that the second call from A was not handled appropriately because medical priority despatch system was not utilised to assess A's symptoms and the level of response required. In addition, the first crew to attend A's home did not follow clinical practice guidelines and policy in relation to consent. The crew felt A did not want any help. SAS also found that information on the patient report form was limited and did not meet the expected standards of clinical reporting.

We took independent advice from a paramedic. We found that SAS took reasonable corrective action in response to failings highlighted through its investigation. However, we noted that there was a missed opportunity for interaction between the ambulance control centre (ACC) clinical advisor, who had spoken with A, and the clinician who attended A's home. This may have afforded the attending clinician the necessary information to prompt a more comprehensive clinical assessment of A. There was also an opportunity for the attending clinician to seek clarifying information and question the ACC on the requirement to send a frontline ambulance to A. This would have stimulated discussion and provided an opportunity to share both information and the decision-making responsibility prior to ending the engagement with A. Finally, having listened to the recordings available, a call made from the ACC to A was not ended properly. We upheld this complaint.

In relation to complaints handling, we found that C was not kept reasonably informed about what was happening with the complaint and the investigation itself took a long time. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to handle their complaint reasonably and for for the failure to handle contact with A appropriately. 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:

• SAS should take steps to ensure the process for ending calls is improved; review/implement a process for passing complex background information to the attending clinician to assist clinical judgement and decision-making; and introduce procedures as preventative measures to ensure that a paramedic would seek clarification from the ACC when a patient denies calling for an ambulance or the patient cannot be located.

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 failed to provide them with reasonable care and treatment regarding their Lyme disease (LD – a disease caused by bacteria).

We took independent advice from a consultant in general internal medicine.

C raised concerns that they were refused intravenous antibiotics when they understood this was an available treatment option. The evidence in C's medical records suggested a treatment approach was discussed and agreed about this. We took account of the advice we received that it did not appear from the evidence that any of the relevant medical complications of LD, which applied for starting a patient on intravenous antibiotics, had been established in C's case. We, therefore, did not find evidence that the clinical judgement of C's doctor was exercised in an unreasonable manner. Furthermore, the board's actions were consistent with the relevant guidelines when applicable.

C also raised concerns about the manner and approach of a doctor. Our investigation did not identify the supporting evidence needed to conclude that unreasonable communication had occurred.

However, we found that the time C waited for diagnosis of LD was unreasonable. We also found that there was an unreasonable delay before a referral for a second clinical opinion was actioned and a significant delay before nerve conduction studies were carried out, in particular, given that in C's case, the test results may have altered their clinical management.

C also reported difficulties contacting the medical team to obtain the results of their investigations. We noted that the board had acknowledged this and apologised to C. For the reasons outlined above, we found there were elements of C's care and treatment that were unreasonable and we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonably delay in diagnosing them with Lyme disease, the delay in the referral for a second clinical opinion, and the time taken to receive a nerve conductivity appointment. 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:

• Tests and investigations should be carried out in an appropriately timely manner. Patients should be provided with clear information in relation to waiting times for testing and referrals.

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

Mrs C complained about the care she received at St John's Hospital. In particular, Mrs C was unhappy with delays in the identification, monitoring and diagnosis of an abnormality in her pancreas. Mrs C had a number of hospital admissions and underwent four scans. The scans showed that the abnormality had increased in size. By the time of the final scan, it was identified that the abnormality was likely to be cancer. Mrs C was subsequently diagnosed with cancer and had surgery to have part of her pancreas removed as well as chemotherapy.

We took independent advice from a radiologist (a specialist in the analysis of images of the body) and a general surgeon. We found that the management of the abnormality was reasonable until the point of the third scan. The report of this scan identified a definite increase in size of the abnormality, although inconsistently referred to it as unchanged. We considered that a referral should have been made to the surgical team to follow up the abnormality and concluded that the failure to do this was unreasonable. We upheld the complaint. However, we concluded that if follow-up had been appropriately planned, it was unlikely that the course of events would have been different in this case. This is because Mrs C received a scan to investigate abdominal pain around the same time that a scan would have been planned in line with the recommended timescales for follow-up of abnormalities.

Mrs C also had concerns about the way the board handled her complaint. We noted that the board had acknowledged and apologised to Mrs C that there had been a significant delay in responding to the complaint. We were critical that the board did not seem to have identified the cause of the delay. We also found that the board had failed to provide updates to Mrs C about the delay. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to make a pancreatic surgical referral after a CT scan identified a definite change in the size of a pancreatic lesion. 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:

• A definite increase in size of a pancreatic lesion should prompt a pancreatic surgical referral.

In relation to complaints handling, we recommended:

• Where there has been a significant failure follow the Complaints Handling Procedure, the board should consider whether they need to take any actions as a result of learning from this case.

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.