Upheld, recommendations

Summary

C complained to us that the board had unreasonably given their child (A) an overdose of morphine. We took independent advice from a consultant paediatrician (a doctor who specialises in child medicine). We found that A had received an overdose of morphine as a result of a doctor failing to discard excess morphine from a syringe and giving them the full syringe. We upheld this aspect of the complaint.

C also complained that the board then failed to carry out observations on A appropriately after the error was identified. We found that staff had recognised the need for close observation, but the observations were not clearly documented in A's clinical records and we were unable to say definitively whether or not the observations were carried out appropriately. Therefore, we upheld this aspect of the complaint.

Finally, C complained that the board had failed to provide a reasonable response to their complaint. We found that there had been an unreasonable delay in responding to the complaint. Also, there was no evidence that the board had kept C updated during this time. We upheld this aspect of the complaint.

We noted that the board had already apologised for these failings but we made further recommendations for learning and improvement.

Recommendations

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

• The board should review their guidelines for administration of intravenous medication in light of the findings of this investigation and ensure there are explicit instructions on how to deal with situations where only part of the prepared dose is to be administered.
• Patient monitoring and observations should be appropriately recorded in the medical records.

In relation to complaints handling, we recommended:

• Where an investigation takes longer than 20 working days, the board should inform the complainant, agree revised time limits, and keep them updated on progress.

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 received waste and water services from Clear Business Water (CBW). C was charged for waste and water services for two supply point identification (SPID) pairs for their rented property. C complained because they did not consider that this was reasonable, as they considered they only had one SPID pair associated with their property.

While there were elements of this complaint which stemmed from third party information provided to CBW, we found that CBW failed to bill C reasonably for their water charges. There were failings to identify the duplicate SPID pair earlier in C's contact with CBW, and when C was invoiced for the duplicate SPID, insufficient information was provided to explain the significant bill. We upheld this aspect of the complaint.

We found that CBW failed to reasonably communicate with C. C was charged a significant amount of money with no explanation as to why this was being raised and what SPID or period of time this was in reference to. In addition, CBW continued to pursue C via Universal Debt Collection for payment of the account, despite the account being put on hold. This was unreasonable. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings as identified in this complaint. The apology should meet thestandards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.
• Calculate and credit C's account based on the pseudo meter rate (as applicable) and going forward (omitting the period given) until such time as a meter is installed at the premises/a further reassessment is undertaken.
• Consider whether to offer C a goodwill gesture payment for the length of time take to resolve the issue.
• Reimburse C for any overdue payment charges levied on the account.

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

• When CBW issues bills for SPIDs not previously charged to customers they should explain why they are charging them, the SPID reference and the period for which they are charging.
• When it is possible there are multiple (incorrect) Scottish Assessors Association entries for one premises CBW should take appropriate action to investigate the matter and inform the customer.
• Where a duplicate SPID is identified customers should not be disadvantaged if the SPID with the pseudo meter is de-registered and a clear explanation provided with the options available moving forward.

In relation to complaints handling, we recommended:

• CBW should have a clear understanding of why a complainant is complaining before responding to a 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

Mr C complained that the council failed to take appropriate planning enforcement action within a reasonable timescale in relation to work undertaken near his home.

We took independent advice from a planning adviser. We found that there were failings in the enforcement process, including unreasonable delays and unexplained inaction at certain points. Therefore, we upheld this aspect of Mr C's complaint.

Mr C also complained that the council failed to respond reasonably or appropriately to the concerns he raised about the work carried out. We found that the content of the council's responses to Mr C's enquiries were broadly reasonable and factual. However, we identified several examples of Mr C's correspondence not being responded to in a timely manner, or at all. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the 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.

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

• Correspondence relating to planning enforcement matters should be responded to within a reasonable timescale.
• Enforcement action should be carried out in an efficient and timely manner, allowing for individual circumstances on a case-by-case basis.

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 actions of the council. Her grandchild (Child A) had been placed in a kinship care arrangement with their maternal aunt (Mrs C's daughter) and uncle. Child A's father requested that he be allowed full-time care of the child.

A number of assessment were undertaken by the council which resulted in a Safeguarder (someone appointed by a children's hearing to help them make the best decisions for a child or young person) being appointed to gather more information. The Safeguarder issued their report and recommended that Child A be returned to the full-time care of their father. As part of the Safeguarder's investigation, they interviewed a social worker involved in the case. In response to the Safeguarder's questions, the social worker highlighted some concerns about the kinship care placement and the involvement of Child A's maternal family. Mrs C states that she and her family were unaware of these concerns until the Safeguarder's report was issued. Mrs C complained that the council should have raised these concerns directly with the family to allow them to act on them.

We took independent advice from a social worker. We concluded that, regardless of the council's general impression that the kinship carers and maternal family were providing good care, any concerns or issues should be discussed openly and transparently. We also raised concern about the council cancelling and then failing to rearrange appropriate reviews.

We did not consider that the areas the social worker highlighted to the Safeguarder to be minor or insignificant. Therefore, regardless of where Child A's future place of residence would be, it would have been beneficial to discuss these matters openly with the kinship carers and maternal family at the time. This would have meant they could take steps to address any concerns and, if necessary, work with the council to ensure appropriate support was in place. We also recognised that the council's failure to schedule reviews within an appropriate timescale could have contributed to relevant information or concerns not being shared in a timely manner. In light of this, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and the kinship carers for failing to act on or share concerns that were later discussed with a Safeguarder. 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 involved in kinship care placements should be provided with relevant information regarding any concerns the council has about the placement.
• If there are difficulties in the relationship between the social work department and a service user, appropriate steps should be taken to resolve these difficulties where possible. This includes ensuring appropriate reviews are held within reasonable time.

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 to the council for a disabled parking badge. After waiting a period of time for the badge to arrive, they contacted the council to advise they had not yet received it. The council agreed to send C a replacement badge. C received a badge in the post and proceeded to use it, understanding this was the replacement badge.

C received two penalty charge notices from another council while they were parked and displaying their badge in that council area. The badge had a valid date. The penalty charge notices stated the reason for issue as 'parking in a restricted street where restrictions are in force'. C's car was impounded a few days later and they were advised by the other council that this was because they had been displaying a cancelled badge. The badge C understood to be the replacement badge was in fact the original badge which the council had cancelled after C reported that they had not received it.

C complained that they had no way of knowing they had been using a cancelled badge. C believed they should be reimbursed for the sums they had been fined, and for additional costs they had incurred as a consequence of using the badge, including taxis to and from work while waiting for a new badge to arrive.

We found that this situation could have been avoided if the council had been explicit about the number of the badge they were cancelling and the number of the replacement badge they were sending. There was no evidence that C was made aware or could have had any awareness that the badge they were using was cancelled. We considered that the administration of the badge was unreasonable and we therefore upheld this complaint.

C also complained that the council's handling of their complaint was unreasonable. We found that the council had failed to follow the Model Complaints Handling Procedure. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in complaints handling, including delays and failure to follow stages one and two of the process. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the failings we have identified, with a recognition of the impact on them. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Revisit C's claim for compensation and consider offering some financial redress in light of the failings identified by this investigation.

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

• The council's processes are improved so that in the event of a badge being cancelled the applicant is made aware of the number of the badge that has been cancelled and the number of the replacement badge.

In relation to complaints handling, we recommended:

• Staff in the Blue Badge Team are familiar with the Model Complaints Handling Procedure and follow the two-stage process 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, an advice worker, complained about the council on behalf of their client (A). A's relative (B) was placed with them after difficulties in their parents' circumstances. It was initially agreed that a parenting assessment be carried out, which led to a joint care arrangement being agreed. However, an incident later in the year highlighted that it would not be suitable for this arrangement to continue. It was agreed at a Looked After Child Review that a kinship care assessment in respect of A assuming full time care of B should be progressed.

The initial kinship care assessment was not completed and there were delays before the assessment was re-started. This meant it took many months for A to be approved as a kinship carer. After C complained, the council agreed that kinship care assessments should be completed within twelve weeks and three days of the placement. However, in their view, the twelve weeks and three days should begin from the date it was agreed a kinship care assessment should be carried out. C complained to us as they did not agree with this position and felt the twelve weeks and three days should be taken from the date B was placed with them.

We independent advice from a social worker. We found that the council's decision to commence the kinship care assessment from the date it was agreed a kinship care assessment should be carried out was not supported by the relevant guidance and evidence. We considered it reasonable for the council to pursue a joint care arrangement with a view of eventually returning B to their parents' care. However, in our view, the council unreasonably failed to commit to a position in respect of A's kinship care status until the joint care arrangement became untenable. Based on the circumstances detailed in C's complaint, we concluded that A should have been assessed as a kinship carer from the date B was placed with A. Therefore, we upheld this complaint.

C also complained that A was not aware B received Disability Living Allowance (DLA), which was being paid to the parents. The council explained that social work staff were not aware DLA was in payment. However, in C's view, the council should have been aware that B may be eligible for DLA and provided advice about this.

We found that social work staff would not receive automatic notification of what benefits someone is in receipt of. However, we concluded that an assessment of financial circumstances or potential eligibility for disability benefits did not appear to be built into the council's standard processes. Nor did these factors appear to be considered in light of the B's circumstances in this case. We concluded that this was not reasonable and opportunities to gather information about the family's financial circumstances and potential entitlement to disability were missed. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the 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.
• Calculate the amount of kinship allowance that would have been payable to A had a kinship care assessment commenced on the day B was placed with A. Make payment of this amount to A. 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. It is reasonable for the council to take into account payments already made under Section 22 of the Children (Scotland) Act 1995.

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

• Kinship care assessments should commence from the appropriate date, in line with relevant guidance and legislation.
• Relevant social work staff should be aware of when service users may be eligible for disability benefits and how to provide appropriate advice/signposting.
• The council should have clear guidance on the interaction between joint care arrangements and kinship care placements. Relevant staff should be aware of this guidance.
• Where appropriate, social work assessments should include consideration of the service user's financial circumstances and any potential eligibility to disability benefits.

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 that the council had failed to take reasonable enforcement action over breaches of planning control by the operator of a café. Mrs C said that the council had been aware of these breaches for an extended period of time and that the breaches included a failure to comply with the conditions of the café's planning permission. Mrs C said this was unreasonable, and that the council had failed to respond adequately to her complaints.

We received independent advice from a planning adviser. We found that the council had been aware of the breach of planning control for an extended period. The council had correctly stated they had a broad discretion to determine whether it was in the public interest to take enforcement action. However, we noted that there was no evidence of the enforcement investigations undertaken by the council, nor was there any evidence that they had assessed the progress being made by the café to regularise the planning situation. The council had, therefore, failed to comply with its own planning enforcement charter.

We found that the council had acted unreasonably by failing to record its planning enforcement activity. It had also failed to respond appropriately to Mrs C's complaint. We upheld Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to take reasonable steps to investigate breaches of planning control and for the failure to handle Mrs C's 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:

• Ensure accurate recordings of the actions taken by the council during planning enforcement investigations are taken, including the outcome of any informal negotiations.
• Staff should be reminded of the importance of accurate record-keeping.

In relation to complaints handling, we recommended:

• Council staff should be able to identify accurately the substantive issues contained within a complaint, and the appropriate application of time constraints.

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

Ms C, a support and advocacy worker, raised a complaint on behalf of her client (Mr A) about the support he had received from the community mental health team and in particular about access to services and communication. We took independent advice from a mental health nursing adviser. We found that a number of aspects of the support Mr A received was reasonable. However, we also found that there was a delay in offering support over one weekend. We noted that this delay had not placed Mr A at risk and he had been contacted by phone. We found that Mr A expressed reservations about seeing clinicians of a particular gender but these were not properly acknowledged and explored by the clinical team caring for him.

We also found that there were failings in relation to the notice given to Mr A about staff sickness/absence. We noted that this failing had been accepted by the partnership. The partnership had also accepted that there was evidence of an incident where a service was not made available due to a family connection between staff and patient.

Finally, we also found failings in relation to the management/allocation of out-patient appointments.

Given the failings identified, we upheld the complaint and made recommendations. However, we noted that the partnership had already taken some action to remedy these failings and asked for evidence of this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the failings identified in this case. 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:

• Phone messages from patients should be recorded and passed on. Also patients should be timeously notified when scheduled appointments require to be rearranged for unforeseen organisational reasons and decisions taken by clinical teams to arrange or reschedule appointments should be actioned in an appropriate and timely manner.

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, a support and advocacy worker, complained on behalf of their client (A). A received psychiatric and social work support for a number of years. A obtained copies of letters written by their psychiatrist to other clinicians. C complained to the partnership about the actions of the psychiatrist and social workers. There were issues with the investigation of the complaint and a response was ultimately provided a number of months later. The response included the partnership's views on the actions of the psychiatrist but not of the social workers. The response also included acknowledgement that there had been delays in the handling of A's complaints. A was dissatisfied with the response and C brought their complaint to us.

During our investigation of these complaints it became clear that A was not a client of the partnership in respect of social work matters. We found that the delays had been caused by confusion over which of the bodies within the partnership were responsible for the matters complained of, the partnership's inability to quickly and accurately determine the whereabouts of a complaints co-ordinator, the failure to alter voicemail messages or monitor voicemails received and confusion over management responsibility. We found that the partnership had opportunities to pro-actively advise C of these delays but had not done so. We also found that the partnership had unreasonably failed to advise C that A had not been a client of theirs in respect of social work. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the unreasonable handling of A's complaints. The apology should make clear mention of each of the failings identified and meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the complaints process, including that any barriers to meeting the timescales of the complaints process are identified at an early stage or as quickly as possible when they arise.
• Complaints should be dealt with in accordance with the complaints process, including that complainants should be pro-actively contacted to advise of likely delays.
• When the partnership receive complaints about the actions of bodies that are not involved with the partnership, they should advise complainants of this as soon as possible and give any advice they can about how to raise complaints about the organisations complained of.

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, a lawyer, complained on behalf of his clients (Mr and Mrs A), parents of an adult with additional needs. Their child lives independently in their own home, which is partly funded by the partnership and supplemented by Mr and Mrs A in order to provide 24/7 hour support. Mr and Mrs A requested an increase in funding from the partnership, as they are no longer able to provide the same level of support due to their own health needs. While the partnership had assessed the client as requiring 24/7 support, they advised that they cannot provide the level of support that would allow the client to live in his own home within their finite resources. As an alternative, they offered to place the client in foster care or shared accommodation. Mr C complained that the partnership unreasonably failed to provide the appropriate support to meet the client's needs.

We took independent social work advice. We found that while the partnership are working within their statutory framework by considering their overall resources, we did not consider that the partnership had fully taken account of the reasonable evidence, based on previous experience, that the client would not cope in a shared accommodation setting. The Ombudsman is clear that she cannot instruct the partnership on how to spend their resources, however, we recommended that they should assess the fragility of the care package. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• The partnership should assess the fragility of the care package taking into account the historical evidence which strongly suggests a strong likelihood of challenging behaviour occurring and the implications and further examine the resource implications and futures costs with a view to finding an acceptable solution that maintains the client's mental wellbeing and future independence.

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.