Upheld, recommendations

Summary

Mr C complained that the care and treatment given to his late wife (Mrs A) by her GP practice were unreasonable.

Mrs A had a history of rheumatoid arthritis (an inflammatory disorder that mainly affects the flexible joints). Her health began to deteriorate further, but Mr C said that it took time to establish that Mrs A had heart problems for which she needed an operation. After surgery Mrs A was discharged home, but months later she required to be admitted to hospital again. Mrs A had developed a serious infection in her heart and died shortly afterwards. Mr C complained that it took too long to diagnose his wife's infection.

We took independent advice from a GP. We found that in the early stages of her illness, Mrs A had been investigated and treated appropriately and it had been very unusual for a patient to have developed such severe heart disease in a short space of time. After her operation and return home, Mrs A became increasingly unwell and was regularly seen by members of the GP practice who treated her for a urinary tract infection. However, we found that the severe heart infection (endocarditis) had not been considered as a possible diagnosis, as it should have been, particularly as it was known that Mrs A had an artificial heart valve and persistent signs of infection. Her pre-existing heart condition could have predisposed Mrs A to developing endocarditis, and it was unreasonable not to consider this. This led to a delay in diagnosis and a delay in admitting Mrs A to hospital. Therefore, we upheld the complaint.

During the course of our investigation, we also found the complaint handling to be unreasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to properly consider Mrs A's presenting symptoms and for failing to consider and discount the possibility that she had endocarditis. As a consequence there was a delay in admitting her to hospital.
• Apologise to Mr C for the failure to deal with their complaint as required by NHS Scotland's Model Complaints Handling Procedure.

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

• Patients' symptoms should be considered holistically.
• Clinicians should be aware of National Institute for Health and Care Excellence (NICE) guidance (s64) in relation to the symptoms that may indicate infective endocarditis.

In relation to complaints handling, we recommended:

• Complaints should be addressed and responded to in terms of the NHS Scotland's 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

Ms C complained about the care and treatment she received from Victoria Hospital. She said that there were delays in receiving appointments and treatment; that she was not properly consented for surgery; that a stent was removed without anaesthetic; and that after surgery she was left with a bulge/hernia that did not receive timely treatment. In responding to the complaint, the board acknowledged that Ms C had incorrectly been sent a letter saying that she was no longer on the waiting list for surgery and incorrectly advising that she would require another GP referral. The board also found that the bulge she was concerned about had not been examined as it should have been; that there were some communication failures; and that an appointment had to be rescheduled twice. The board apologised for these errors.

We took independent advice from a consultant urological surgeon (a specialist in diseases of the urinary organs in females and the urinary tract and sex organs in males). We found a number of failings in terms of it being unclear about; what treatment options had been discussed with Ms C; the implications and risks of the change in surgery; poor record-keeping; the removal of the stent was not clearly explained; and no written advice leaflet provided. Therefore, we concluded that Ms C's care and treatment was of an unreasonable standard and upheld her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms 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

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

• The consent process (and evidence of it) should start earlier than the day of surgery and General Medical Council guidance should be followed.
• Clinicians should keep clear, accurate, and legible records which report the relevant clinical findings, the decisions made, the information given to patients, any drugs or other treatment prescribed and who is making the record and when.
• When available, explanatory leaflets should be used to assist patients in their understanding and decision-making.

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 solicitor, complained on behalf of his client (Mr B) about the care and treatment Mr B's mother (Mrs A) received at Stratheden Hospital after she broke her hip. Mr C complained that Mrs A did not get appropriate treatment for her physical health issues; in particular, that her condition was not appropriately monitored, which led to her becoming dehydrated. Mr C also complained about the nursing care, particularly that Mrs A did not receive appropriate nutritional care and that there was a lack of action in response to her weight loss. Additionally, Mr C raised concerns about the board's complaints handling.

We took independent advice from a consultant psychiatrist and from a mental health nurse. We found that Mrs A's treatment plan was reasonable and that she received appropriate treatment for her physical health issues, which led to an improvement in her condition. However, we found that her fluid balance was not recorded appropriately during that time, as the board had acknowledged. We found that after Mrs A's condition improved, the board decided to take a more limited approach to her treatment. We considered that the reasons for that decision were not properly recorded, and Mrs A's condition was not monitored appropriately afterwards. Therefore, we upheld this aspect of Mr C's complaint.

In relation to the nursing care provided to Mrs A, we found that insufficient action was taken in relation to her nutrition and weight loss. The board identified these failings and apologised to Mr B. We upheld this aspect of Mr C's complaint.

Finally, we found that the board did not clearly respond to all aspects of Mr B's complaint. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B for the failures to appropriately monitor Mrs A's condition, to record relevant information about her care and treatment, and for not providing a clear response to aspects of 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.

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

• In similar cases, fluid balance sheets should be completed appropriately and in accordance with the board's procedure.
• If a decision is made to change the treatment plan for a complex patient, the clinical reasons should be clearly recorded, along with the parameters of what that means for managing their condition.
• Nutritional screening should be carried out promptly and patients should receive effective nutritional care, which is in line with the relevant national nutritional guidance.

In relation to complaints handling, we recommended:

• Complaint responses should be clear to avoid any misunderstandings and the issues should be thoroughly investigated.

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 there was an unreasonable delay in diagnosing her with a breast abscess. Following the birth of her child, Mrs C's GP referred her to Borders General Hospital with a suspected breast abscess after she had been suffering from mastitis (when a woman's breast tissue becomes painful and inflamed). On admission, a surgeon said that there was no evidence of an abscess and Mrs C was discharged. Mrs C was due to return for an ultrasound scan the following day, however, the hospital changed her appointment to a later date. In the interim period, Mrs C experienced a deterioration in her condition and was referred back to the hospital. An ultrasound scan was carried out which confirmed that she had a breast abscess, requiring surgery. Mrs C said the length of time that it took for a scan to be arranged meant that there was an unreasonable delay in diagnosing her with a breast abscess and, as a result, she endured significant distress and her baby did not gain weight appropriately due to difficulties with breastfeeding.

We took independent advice from a medical adviser who specialises in breast surgery. We found that an ultrasound scan should have been carried out to investigate the possibility of a breast abscess during Mrs C's first admission, and that the subsequent delay in arranging the scan was unreasonable. We determined that these failings meant that there was an unreasonable delay in diagnosing Mrs C with a breast abscess. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to arrange an ultrasound scan within a reasonable time and the associated delay in receiving treatment. 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:

• Ensure that ultrasound scans are carried out within a reasonable timeframe in line with the relevant guidance.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C, an MSP, complained on behalf of her constituent (Mr A) that Business Stream had unreasonably failed to provide Mr A with an accurate bill for his water usage. Mrs C also complained that the handling of her complaint by Business Stream was unreasonable.

Mr A owns a farm which shares the same water supply with five other properties and historically the meter readings for the usage of all the properties were taken from the main meter sited at a neighbouring farm. Scottish Water installed a new meter at the farmhouse, however, they subsequently stated that the new meter was installed in error and could no longer be used. Billing reverted to the original meter and sub-meters were installed in the five properties.

Mr A complained to Business Stream as his licensed provider. They liaised with Scottish Water who confirmed that the initial instruction to install a new meter outside the farm was the wrong action. Business Stream outlined that Mr A had two options presented, and proceeded to set up the billing based on the option to deduct the usage on the five domestic sub-meters from the readings on Mr A's meter. There were further billing issues which exacerbated Mr A's concerns and he took practical action to remove his meter from the non-domestic water market. Mr A remained unhappy that his bills had been inaccurately calculated and Mrs C brought his complaint to us.

We found that Business Stream's shared supply policy set out only three options when a shared supply has been identified. These were that the pipework is altered to remove the domestic property from the supply at the cost to the customer, to remove the meter and charge unmeasured services, or that the customer is billed fully and can then recoup the charges from the domestic customers as a private arrangement under water re-sale rules. We noted the option progressed by Business Stream was not in their policy. Business Stream explained they were following a briefing note from Scottish Water issued years before which included a wider range of options for customers in shared supply scenarios. They said that they were following this briefing note as it was in the best interests of the customer.

We found that Business Stream had not clearly explained to Mr A all the appropriate options available to him in order to resolve the shared supply situation. We found their communication had been unclear and, while well intentioned, the briefing note they referred to was not a policy document but described the process Scottish Water hoped to move to. We also did not see evidence that all options set out in the briefing note were fully explained to Mr A. We therefore upheld Mrs C's complaint. However, we noted that wider changes regarding shared supply meters are anticipated to be implemented across the non-domestic water industry in Scotland in 2020 and therefore, did not make any recommendations in this respect.

In relation to complaint handling, we found that Business Stream failed to properly acknowledge and investigate the complaints and that there was an unreasonable delay in responding to correspondence. Therefore, we upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise Mrs C and Mr A for the failures identified that they did not set out options available nor did they clarify the basis of Scottish Water's actions to resolve the metering/billing issue. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to Mrs C and Mr A for failing to properly action and process Mrs C's complaint in line with their complaint handling procedures and for the resulting unreasonable delay. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C submitted an application for escorted day absence from prison to allow him to visit his father who was ill and unable to travel. Mr C understood that the application had been refused on the basis of adverse intelligence so he complained. The prison's internal complaints committee (ICC) said that the application had been rejected because there were no exceptional circumstances. The ICC told Mr C that they did not uphold his complaint because his application for escorted day absence had been denied after fair consideration.

Mr C complained that the Scottish Prison Service (SPS) failed to properly consider his application for escorted day absence. He said that there was no evidence to show that his application was ever properly considered by the prison according to published rules, criteria and procedure. SPS said that Mr C had disengaged from the application process because he was frustrated by the length of time that the paperwork was taking to be completed. The SPS said that they had spoken with Mr C on several occasions to encourage him to resubmit his application but he had repeatedly refused to do so.

In light of the information received from the SPS, we sought further clarification on what happened with Mr C's application for escorted day absence given the ICC indicated in their response to the complaint that the application was rejected because there was no exceptional circumstances and that it was denied after fair consideration. There was no evidence to suggest that the application process was stopped because Mr C refused to engage. The SPS told us there had been some confusion when responding to Mr C's complaint because his application paperwork had been misplaced. SPS acknowledged the ICC's response to Mr C's complaint was inaccurate. In addition, they explained that when Mr C's application form was found, it was incomplete. It was also discovered to contain an internal email exchange between staff discussing intelligence about Mr C. SPS said Mr C had disengaged from the process when he saw that email.

The SPS previously issued a notice to all staff stating that the escorted day absence application form must be used for all requests and must be fully completed to ensure responses were properly recorded. This did not happen in Mr C's case and in our view, it should have. At the very least, once Mr C's paperwork was found, steps should have been taken to complete it even if Mr C was refusing to engage with the process.

In addition, Mr C complained that the SPS failed to appropriately handle his complaint. We were concerned that the ICC had reached a decision on Mr C's complaint without having regarded the relevant information and despite that, they took the decision to conclude that the application had been denied after fair consideration. We felt that was a significant failing given the nature of Mr C's complaint.

Therefore, we upheld Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Take steps to confirm with Mr C whether he can have his application for escorted day absence reconsidered.
• Apologise to Mr C for failing to properly consider his application for escorted day absence. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to Mr C for failing to handle his complaint 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:

• Remind staff that the application form for escorted day absence must be completed in all cases to properly and accurately record the outcome of a request, including instances where an individual may withdraw from the process.

In relation to complaints handling, we recommended:

• Review how the complaint handling failures identified in Mr C's case occurred and identify measures that will be taken to prevent this from happening again.
• Share details of the complaint handling failures identified in Mr C's case with staff involved in complaint handling to encourage learning and to prevent the same thing from happening 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 that the council failed to appropriately investigate an incident that caused injury to her child at school. Ms C also said that they failed to handle her complaint reasonably.

We found a number of failures by the council in following their internal health and safety policy. They had failed to take witness statements at the time of the incident, sections of the forms in question had not been completed and there was a delay of a number of weeks in completing the form. There was also insufficient contemporaneous evidence to support what was recorded on the forms and on further investigations that the council told us were carried out; this meant that they were unable to demonstrate they had drawn fully formed conclusions.

We also found that the council had made errors in escalating Ms C's complaints, and failed to consistently acknowledge the seriousness of the injury. Therefore, we upheld Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to carry out an adequate investigation in line with relevant guidance. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise to Ms C for failing to provide a reasonable response to her complaint.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:

• Investigations of any future incidents should be carried out in line with relevant guidelines.
• Documentary evidence should be kept.
• An incident report form, and relevant guidance, appropriate to schools should be developed.

In relation to complaints handling, we recommended:

• Complaint responses should respond to all relevant concerns 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 to the council that flooding in his back garden was caused by drainage problems in the school grounds located to the rear of his back garden. The council's position was that the flooding was not their responsibility and may be caused by landscaping in Mr C's garden.

The council said that the school contract requires the school area to be free of standing water after a number of hours following rainfall and that additional gully drainage was installed many years ago to assist with localised ponding. They said their investigation showed there was a gradual slope to the playground which water would run down away from Mr C's property.

The council instructed an engineer to attend Mr C's home and visit the school site. A few weeks later a council officer and a contractor visited Mr C at home, and advised Mr C that their opinion was that the hard landscaping in his back garden was forming a basin which was likely to be the reason the rainfall was pooling in his garden. The council emailed Mr C to confirm that, given his concerns, their facilities management contractor had instructed work to be carried out to jet the drains in the school again. They later confirmed to our office that this work had not been carried out.

Although we considered that the council had carried out reasonable investigations in order to assess Mr C's concerns, we were critical of the council for failing to carry out their commitment to jet the drains. We also noted discrepancies in the records of the facilities management contractor, which showed no evidence or record of ponding. This was at odds with the engineer's reports and confirmation supplied by Mr C, showing evidence of ponding.

On the basis that the council offered to undertake works, which an appropriately qualified person instructed and put in writing to Mr C, but then did not carry out, we upheld this complaint.

Mr C also complained that the council failed to handle his complaint reasonably. We found that the council had failed to set out or explain their investigations in their complaint responses. We found the responses to be brief and that they did not include the level of detail required to evidence that the council had investigated Mr C's complaint. We also upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to adequately address his concerns about flooding on his property and for failing to handle his complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Arrange for the jetting of the drains at the school to be completed. They should contact Mr C, following receipt of a report from the contractor, to discuss the findings.

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

• Council staff should properly inspect and scrutinise maintenance records of external facilities management services, taking into account information received from third parties, its own inspections and complaints, to ensure records are being maintained correctly and contractual obligations are being met.

In relation to complaints handling, we recommended:

• The council should respond to complaints in accordance with their complaints procedure. Stage 2 responses should contain sufficient detail to evidence the investigations undertaken and the conclusions.

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 unfairly imposed restrictions on his contact with them, had not followed their unacceptable actions policy (UAP) and failed to properly consider Mr C's appeal against the restrictions imposed under the UAP. Mr C also complained that the council unreasonably failed to respond to his complaint in line with their obligations.

We found that the council had failed to provide Mr C with a warning about his contact at the time these contacts were received from Mr C. In addition, we considered that the council were unable to evidence that a warning letter, which is required under the UAP, was sent to Mr C. Therefore, when restrictions on Mr C's contact were imposed, these were done immediately and without the UAP having been followed. We also found that the council failed to properly consider Mr C's appeal against the restrictions imposed. We, therefore, upheld these aspects of Mr C's complaint.

In relation to complaint handling, we found that Mr C raised issues in his complaint that the council had not considered as a complaint, and had not responded to. We found that these issues should have been considered as a complaint and that, in accordance with the council's complaints handling procedure, a response should have been provided. 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 not providing him with warnings, as required under their UAP, prior to imposing restrictions on his contact. Also apologise for failing to respond to his complaint in accordance with their complaints handling procedure. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise to Mr C for failing to respond to the appeal within 10 working days, and not appropriately considering the points raised in Mr C's appeal. 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:

• The council must make a note of phone calls and retain evidence of a customer's contact where this is relied upon to justify imposing restrictions on a customer's contact under the UAP.
• The council must ensure that relevant staff are reminded of the requirements of the UAP, particularly the procedures to be followed on receipt of an appeal, including the appropriate staffing and timescales of appeals.
• The council must ensure that consideration of appeals under the UAP are appropriately documented.

In relation to complaints handling, we recommended:

• Complaints should be appropriately identified and responded to in accordance with the complaints handling procedure.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C complained that the council's communication with her regarding the need for planning permission was unreasonable. Mrs C suggested that the council had provided incorrect planning advice and later unreasonably changed their view on whether an application for a change of use was required, causing a delay to when Mrs C's business could commence trading.

We took independent advice from a planning adviser. We found that the council had adequate information at an early point to reasonably conclude that it would be necessary for Mrs C to require a change of use planning permission. The initial advice indicated that planning permission was not required unless the anticipated level of sales and activity increased. The council provided inconsistent information and rationales to support their decisions. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to reasonably communicate with her. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets.

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

• The council should communicate in a clear manner, ensuring a clear, consistent rationale is provided when issuing pre-application advice and appropriately recorded.

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.