Upheld, recommendations

Summary

Ms C complained that the university failed to follow their procedures correctly when they decided that she should be removed from a course due to her lack of progress.

We found that staff had made reasonable attempts to assist Ms C with determining a project topic and identifying a supervisor. However, the university were unable to provide evidence that their mitigation process had been followed appropriately when Ms C made a mitigation claim. Their records in relation to the decision that she should be removed from the course were also inadequate and there was no evidence of her supervisor's view on whether she had made sufficient progress. Therefore, we upheld this aspect of Ms C's complaint.

Ms C also complained that the university had failed to follow their appeals and complaints procedures in response to her correspondence on the matter.

We found that the university's response to Ms C's appeal contained inaccurate information. They had also failed to respond to her correspondence in line with their complaints handling procedure. Whilst the university had told Ms C that staff had reported that they had many meetings with her to discuss the matters she had raised, there were no records of these meetings. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide information that they followed their mitigation process, including inaccurate information in their appeal response, failing to respond to Ms C's correspondence under their complaints handling procedure and failing to make a record of meetings. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Obtain a written statement from the supervisor in relation to Ms C's progress at that time and then decide if any further action needs to be taken in relation to the matter.

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

• Mitigation claims should be dealt with in line with the university's mitigation process.
• The university should be able to demonstrate administratively through clear records that the decision to remove a student from a course is made appropriately.
• The university should ensure that correspondence in relation to appeals is accurate.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the university's complaints handling procedure.
• Where meetings are held to provide an answer to concerns raised by students, an appropriate record should be made.

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 on behalf of a member of his family (Mr A), who was a student with a visual impairment and an autism spectrum condition. Mr A was enrolled on an undergraduate course at the university and he required adjustments to the reading materials so that he was able to access these during his studies.

Mr C complained that the university failed to put in place adjustments for Mr A's reading materials. The university upheld aspects of Mr C's complaint and made recommendations. Mr C remained dissatisfied and brought his complaint to us.

We took independent advice from an equalities adviser and reviewed the documentation provided by Mr C and the university. We noted that part of the adjustment agreed with Mr A involved digitising reading materials and providing these to Mr A in an accessible format.

We found that the university did not accurately calculate how long this process would take. This resulted in Mr A not receiving the materials in an accessible format within good time and caused disadvantage to Mr A. We also identified issues with the way the university communicated with Mr A about this matter, noting that he was incorrectly informed the texts would be provided on time.

We noted that the university had tried to discuss alternative IT systems to support Mr A. However, we found that the university did not adequately consider Mr A's views and his previous difficult IT experiences. In addition, one adjustment made by the university was to provide further detail to Mr A about targeted reading along with a guidance note. We did not consider that the adjustment appropriately took into account Mr A's reading requirements.

In view of the issues identified, we upheld Mr C's complaint and we made a number of recommendations, taking into account the action the university had already agreed to undertake.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to provide him with the reading material requested. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• When providing IT support for students accessing large texts, account should be taken of the individual's needs and preferred IT/reading systems.
• The university should ensure that any adjustment put in place for individuals with a disability constitute a reasonable adjustment in line with equality provisions.

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 Scottish Prison Service (SPS) failed to appropriately investigate his complaint. Mr C said that a prison officer had displayed inappropriate behaviour towards him and asked the SPS that CCTV footage be retained. The SPS concluded that no inappropriate behaviour was displayed towards Mr C and did not uphold his complaint. Mr C was unhappy with this response and brought his complaint to us.

Mr C said that there were at least six officers present at the time when the officer he complained about was allegedly displaying inappropriate behaviour, but said none of those officers present were interviewed. Mr C also questioned whether the CCTV had been viewed. We asked the SPS for notes or statements taken from the staff members spoken to as part of the investigation of Mr C's complaint. We also asked whether CCTV footage had been retained. The SPS confirmed they accepted that the original investigation of Mr C's complaint failed to acknowledge and report on the staff present at the time in question. They advised no statements were taken when officers were interviewed about the alleged incidents. The SPS also confirmed the CCTV footage was not retained and explained that CCTV footage was only retained for matters of security and good order, prisoner disciplinary proceedings or police matters. They told us that CCTV footage was not ordinarily retained for matters of daily activities in the prison including the investigation of complaints. Following our enquiry to the SPS, they also re-investigated Mr C's original complaint and shared the findings with us.

We had a number of concerns about the quality of the SPS' investigation of Mr C's complaint. In particular, the SPS' response inaccurately reflected that Mr C had asked that CCTV footage be reviewed when he had in fact asked several times that it be retained. The response also failed to confirm when the officer in question had been asked about the matter or given the opportunity to put forward their account. This was concerning given the CCTV footage seemed to support some of what Mr C had described. The SPS said they did not take statements from the officers present and they also failed to maintain a proper record of the evidence gathered as part of their investigation of Mr C's complaint. In light of our findings, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to appropriately investigate his complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance

In relation to complaints handling, we recommended:

• Consider whether CCTV footage should be retained in future when a complaint alleges inappropriate behaviours of staff members.
• Feedback our finding's to the staff involved in the handling and investigation of Mr C's 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 about the delay by the Scottish Prison Service (SPS) to provide him with a Psychological Risk Assessment (PRA). Mr C had been assessed by the prison Risk Management Team (RMT) to require a PRA but had not yet received this years later. He complained that there was an undue delay in him receiving his PRA and he noted that this impacted on his progression and chance of parole.

We found that as a result of several factors, there was a significant delay in providing Mr C with his PRA. The SPS advised that the psychologist involved in the RMT meeting would normally set and communicate the timescale to start and complete the PRA but this was not done in Mr C's case and there was no explanation for this. The SPS also noted that as part of his PRA, Mr C needed a particular assessment which only certain members of the psychology department were trained to undertake and, as a result of staffing issues, there was not an available psychologist to complete this assessment. The SPS further noted that due to having to prioritise work on statutory obligations relating to management of other prisoners, outstanding work such as Mr C's PRA, were put on a waiting list. While staff issues as the result of vacancies and sick leave would be hard to predict, there was also a shortage in staff trained in the tool needed to complete part of Mr C's PRA and we were also critical of the failure to set and communicate the timescale for the PRA to be completed in line with normal practice. Therefore, we found that there was an unreasonable delay by SPS to provide Mr C with a PRA and upheld his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unreasonable delay in providing his PRA. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Review PRA process and give consideration to whether formal guidance is required for staff and whether there are enough appropriately trained staff to deliver the process.

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 Scottish Prison Service's (SPS) handling of his sentence management was unreasonable and that this had impacted upon the timing of his progression to open prison (a prison with the minimum of restrictions on prisoners' movements and activities). He said that the SPS had failed to adhere to their management plan, referred to by the Parole Board, and that statements puts forward by them explaining why his progression had been delayed, were untrue.

We looked at the fact that SPS did not adhere to the timing of the agreed management plan and whether doing so was unreasonable. We also reflected on the SPS' communication with Mr C in relation to his concerns that his progression was being unreasonably delayed and that he was left feeling confused about what was happening. In setting out their sentence management plan for Mr C with proposed timings, we acknowledged that this will have led to a reasonable expectation from Mr C for that plan to be followed and adhered to. However, the relevant policies and guidance in place make it clear that extenuating factors can affect the timing of agreed sentence management plans. In Mr C's case, the SPS had indicated his risk assessments, the need for an updated home background report and the suitability of his home leave address impacted upon the timing of his progression to open prison. We accepted that agreed management plans could change, however, we also considered the SPS had a responsibility communicate clearly and accurately with Mr C and to deal effectively and promptly with any concerns and queries he had about his progression and any perceived delays. In addition, we considered the SPS had a responsibility to ensure that proper, full records were kept of important decisions.

In light of the evidence we saw in Mr C's case, we were concerned about aspects of the SPS's handling of his case, particularly in relation to their communication with him. We found that there was failure to provide clarification at an early stage despite Mr C's repeated requests and obvious concern. We noted that Mr C had to raise numerous complaints in an effort to seek clarification and get further information on what was happening in his case. In addition, we believe that the SPS failed to consider whether their own actions were causing Mr C anxiety, confusion and stress which may have been perceived as negative behaviours. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings identified.
• Apologise for the inconsistent and confusing communications and failure to clarify the position clearly and appropriately.

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

• Relevant staff should review the case with a view to acknowledging the failures identified and giving an explanation of the learning/action that will be taken to prevent the same thing happening again.

In relation to complaints handling, we recommended:

• Ensure relevant staff undertake SPSO complaint handling e-learning course focusing particularly on the module on bias.

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 had handled a planning application inappropriately under the wrong section of planning legislation and failed to properly screen it to see if it required an environmental impact assessment (EIA).

We found that the council had acknowledged that it had failed to handle the application properly, or to screen it for an EIA as required. We upheld both aspects of Mr C's complaint. However, we were not satisfied that the actions proposed by the council were sufficiently robust to prevent a reoccurrence, and so we made further recommendations in order to ensure the relevant learning was embedded within the council's planning procedures.

Recommendations

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

• The council should ensure they have adequate checks in place to prevent planning applications being processed inappropriately.
• The council should ensure they have adequate checks in place to ensure planning applications are screened appropriately for EIAs.

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 council's response to the child protection concerns raised in respect of her child (Child A). The council led a child protection investigation and Mrs C complained about the handling of the investigation, highlighting a number of concerns about the quality of the initial assessment undertaken, the actions taken in response to Child A's disclosure and the level of initial support and follow-up provided to Mrs C and her family.

The council acknowledged that there were some failings in their handling of the child protection investigation and they confirmed that, since the complaint was raised by Mrs C, an external review was conducted and child protection training was delivered to all social work staff. We investigated the complaint further to ensure that all failings were identified and that appropriate learning and improvement was put in place. In doing so, we examined the case records and sought independent advice from an experienced social worker.

We found that the council's case records were of a poor standard and as a result, there was a lack of evidence of the actions taken and the rationale for the decisions made. We also identified that communication with Mrs C and her family was unreasonable. We concluded that the council failed to adhere to the child protection procedures and relevant guidance by failing to ensure that there were two social workers present when Child A was interviewed; to consider the gender appropriateness of the interviewing social worker; to undertake a welfare home visit to Mrs C and Child A; and to consult with health or education prior to undertaking the investigation. We upheld the complaints and made some additional recommendations, including a request for evidence of the actions already taken by the council.

Recommendations

What we asked the organisation to do in this case:

• The council should share the outcome of the review in an appropriate manner that protects any confidential information.

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

• The council should ensure that all staff are aware of the importance of maintaining accurate case records which detail notes of the decisions made and the rationale for them.

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 care and treatment he received at Ninewells Hospital after he ruptured his Achilles tendon. After he was reviewed by a consultant, conservative (non-operative) treatment of his injury was initiated. After a number of reviews, Mr C was discharged. He requested a further review as he was concerned about the progress of his recovery but no further action was taken following this review.

Months after his initial injury, Mr C re-ruptured his Achilles tendon. He was reviewed the following day and it was decided that surgery was necessary. There was a delay in surgery taking place, partly due to the surgeon being on annual leave. When Mr C attended the hospital to receive surgery, he remained on the ward all day before being told in the evening that surgery would not be required. He then underwent surgery two days later.

Mr C complained to us about the care and treatment he received for his initial injury, including the fact that he did not receive physiotherapy after his cast was removed. He also complained about what he considered to be unreasonable delays and communication after he re-ruptured his Achilles tendon.

We took independent advice from an adviser with a background as a trauma and orthopaedic consultant (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the board had failed to provide reasonable or appropriate care and treatment to Mr C following his initial injury. Although conservative treatment was appropriate for this kind of injury, we did not consider that other treatment options were fully discussed with Mr C. In addition to this, we concluded that it was unreasonable for an appropriate form of physiotherapy not to be suggested or discussed with Mr C. We highlighted that there was no evidence to suggest that this contributed to Mr C re-rupturing his Achilles tendon. However, we concluded that there were failings in Mr C's care and treatment that had had a negative impact on his patient journey. Therefore, we upheld this aspect of the complaint.

In respect of the complaint about delays and communication, we found that the timescale for Mr C receiving surgery was reasonable. However, we considered that the internal communication and communication with Mr C on the day he was initially due to receive surgery was unreasonable. The records show that he remained on the ward, while fasting, from early in the morning until the evening. However, at some point during the day, his surgery was cancelled due to there being more urgent emergency cases. This information was not relayed to staff on the ward, despite them making enquiries. We did not consider the fact that the surgery was cancelled to be unreasonable, as it is understandable that emergency cases may have to take priority at short notice. However, when it was known that the surgery was cancelled, this should have been relayed to the ward as soon as possible. The fact that this did not happen resulted in further frustration and anxiety for Mr C. As a result of this, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for unreasonably failing to fully discuss treatment options with him, discharging him without discussing physiotherapy or a home exercise programme and for keeping him in hospital despite the fact that the surgery had been cancelled earlier that day. The apology should meet the standards setout in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

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

• Where appropriate, a range of treatment options should be openly discussed with the patient and a shared decision-making approach taken.
• The board should reflect on what happened and ensure that appropriate follow-up actions are considered when a patient is discharged following an Achilles tendon rupture. This includes discussing relevant physiotherapy and home exercise options with the patient.
• Reflect on how this situation happened and consider whether there are any improvements that can be put in place to help prevent a similar situation from occurring again.

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 complained about the way in which the board handled her complaint and what she considered to be inaccurate information in their response. Ms C highlighted a section of the response where the board detailed two tests they claimed were previously carried out. Ms C stated that these tests did not, in fact, take place. We reviewed the relevant medical records and were satisfied it was reasonable for the board to state that one of the tests took place. However, there was no evidence of the other test taking place and we concluded that the evidence provided by Ms C supported her account of cancelling the appointment for this test before it took place. It was not clear to us why this inaccurate information was included in the board's response, along with a statement that the results were normal. Therefore, we upheld this aspect of the complaint.

Ms C also complained that the board's response contained inaccurate information about whether she had been diagnosed with a type of anaemia (a condition in which there is a deficiency of red cells in the blood). We found that Ms C had previously received the diagnosis. The diagnosis was subsequently questioned by other medical professionals. However, there was no evidence to confirm that this had ever been fully clarified to Ms C. Furthermore, the medical records show that the initial diagnosis, whether correct or not, continued to inform subsequent consultations. In light of this, we upheld this aspect of the complaint.

Finally, Ms C complained about the board's failure to respond to her correspondence within an appropriate timescale. We considered her complaint itself to have been handled appropriately. However, we considered the board's handling of her post-complaint correspondence to be unreasonable. Although we considered that the board's complaint and feedback team were not the most appropriate place for Ms C to direct some of her enquiries, it still would have been reasonable to expect the board to respond in a clear and timely fashion. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for providing inaccurate information in their stage two response about a test being carried out; providing an inaccurate or incomplete account of Ms C's diagnosis history in relation to pernicious anaemia in their stage two response; and for failing to respond to Ms C's correspondence within an appropriate timescale after they issued their stage two response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Provide clarification, as far as is possible, about whether or not Ms C's symptoms and test results support a diagnosis of pernicious anaemia. If necessary, carry out appropriate tests to allow such clarification to be provided.

In relation to complaints handling, we recommended:

• Stage two complaint responses should contain accurate information and establish all the facts relevant to the points made in the complaint. The board should explore how and why the stage two response contained inaccurate information.

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 treatment which her late husband (Mr A) received at the Queen Elizabeth University Hospital following a fall, in which he sustained a fractured leg. Mr A was admitted for conservative treatment rather than surgery, however, a few days after admission, Mr A's condition deteriorated; he suffered a cardiac arrest and was taken to intensive care.

We took independent advice from an medical adviser. We found that initially Mr A received appropriate medical care in view of his presenting symptoms, but when Mr A's condition began to deteriorate, there was an avoidable delay by junior medical staff in seeking a more senior medical review for Mr A. While this may not have prevented the cardiac arrest or affected the final outcome, it would have allowed for the appropriate medical investigations to be instigated at an earlier time. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to refer Mr A for a senior medical review at an earlier stage. 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 need to refer patients for a more senior medical review when their medical condition deteriorates.

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.