Upheld, recommendations

Summary

Ms C complained about the care and treatment her mother (Mrs A) received when Mrs A was admitted to Queen Elizabeth University Hospital. Ms C considered that her mother's death could have been avoided if she had been provided with better care and treatment. Ms C complained that the board:

failed to provide reasonable care and treatment;

failed to advise the family regarding the correct procedure to follow when requesting clinical records;

failed to provide a reasonable response to the complaint; and

failed to respond to the complaint within a reasonable time.

We took independent advice from a clinical adviser. We found that Mrs A should have been seen by a more senior doctor during the four day period she was in hospital. We considered that a more senior doctor may have identified that the use of diclofenac (pain relief) in an elderly patient with renal impairment may affect the kidney function. They may also have identified a need to increase the use of steroids. Therefore, we upheld this aspect of Ms C's complaint. However, we noted that even if Mrs A had seen a more senior doctor this may not have changed the outcome for her.

In relation to procedure information, we found that the board had apologised for giving out incorrect information to the family which meant there was a delay in receiving clinical records.

In relation to complaints handling, we found that the complaint was made beyond the timescale for making complaints set by the board. However, the board decided to accept the complaint for investigation and they were therefore required to follow their complaint handling procedure. When the board responded to the complaint they failed to identify and advise the family that Mrs A had not seen a senior doctor more than once during her stay in hospital. We also found that correspondence on the complaint was ongoing for a period of almost nine months before a meeting was held. We considered that as many issues were being raised and the family were expressing concerns over a course of correspondence, there would have been merit in holding a meeting at an early stage to discuss concerns. Ms C could therefore have been signposted to this office sooner if the board considered they could do nothing further. We upheld these aspects of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to ensure Mrs A was seen by a more senior doctor on more than one occasion when she was in hospital and for failing to identify this during the board's own investigation of the 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:

• The board should review the process they have in place for regular review of patients by senior doctors and confirm the outcomes.
• The board should ensure they have a protocol on pain relief in elderly patients.

In relation to complaints handling, we recommended:

• A response to a complaint should be transparent.

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 his mother (Mrs A) about the care and treatment Mrs A received at the practice. Mrs A attended the practice complaining of flu-like symptoms and was prescribed a particular antibiotic. That evening she became nauseous and started vomiting. Mrs A's condition deteriorated and she was admitted to hospital three days later with dehydration and acute kidney injury. Mr C was concerned that the practice had prescribed a certain type of antibiotic to Mrs A despite her medical history and about the effect this had on her.

We took independent advice from a GP adviser. We found that Mrs A should not have been prescribed the particular antibiotic and that it was almost certain that this aggravated Mrs A's dehydration and acute kidney injury. Mrs A should also have been advised to stop taking other medication until the diarrhoea and vomiting had resolved. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failings around the prescription of the antibiotic. 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:

• All of the relevant healthcare professionals at the practice should reflect on this complaint and its findings in their next appraisal.

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 care and treatment he received at Dumfries and Galloway Royal Infirmary was unreasonable. Mr C has metastatic (cancer that spreads to other parts of the body) prostate cancer and chronic kidney disease. His complaint primarily concerned his nephrostomies (catheters inserted through the skin and into the kidneys to drain urine). He had experienced problems with catheterisations, and had infections and leaking. He complained that the reasons for his treatment had not been explained to him, especially in relation to his elective transurethral resection of the prostate procedure (a surgical procedure that involves cutting away a section of the prostate) and nephrostomies.

We took independent advice from a consultant urological surgeon (a clinician who treats disorders of the urinary tract). We considered that Mr C's initial treatment was reasonable. After catheterisation failed to improve his kidney function, nephrostomies were inserted on both sides. However, we were critical of the follow-up to the nephrostomies, particularly as Mr C was not offered direct access back to the clinical team at the hospital should any problems arise. We considered this especially important in light of subsequent frequent blockages which resulted in an A&E attendance. Taking into account Mr C's particular range of symptoms, we also questioned the decision to operate on Mr C's prostate to relieve obstruction, which carried a low chance of him being able to empty his bladder naturally. Therefore, we upheld this aspect of Mr C's complaint.

Mr C also complained that the board's communication was unreasonable. We found that there were shortcomings in record-keeping and could not find evidence that the board had provided Mr C with clear information regarding the prostate surgery and nephrostomies, or the impact that this would have on Mr C long-term. We noted that Mr C did not appear to have been given written information about who to contact in case of difficulties or concerns. 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 in treatment, with a recognition of the impact on Mr C's quality of life and apologise for the failings in communication. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The board should provide Mr C with a point of contact, to ensure he is seen promptly by a clinician with understanding of his condition in the event he experiences further problems with his nephrostomy.

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

• If possible, the terms of this decision letter should be shared with those clinicians who were involved in Mr C's care, in a supportive manner, with evidence they have reflected on this. An anonymised version of this letter should also be shared with urology clinicians employed by the board to carry out treatment of this nature, with a reminder of the importance of good record-keeping. The board should consider the presence of urology nurses during consultations, which may be of value.
• Clinicians providing this treatment should ensure that appropriate information is supplied at the time of discharge. They should plan ahead for exchange of nephrostomies and ensure patients have a forward plan.

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 tennis club that they were unreasonably billed for water it did not use. Mr C said that Clear Business Water (CBW) had failed to read the meter as required. This meant that a leak had not been identified and an excessive amount of water had been lost. Mr C also complained about CBW's handling of his complaint. Mr C received correspondence which appeared to be from a debt collection agency. Mr C said that he had discovered this was in fact part of the same organisation as CBW, although this was not communicated clearly. Mr C felt that this was deliberate and designed to intimidate.

We found that CBW had acquired the account from another licensed provider, who had failed to read the meter as required of them. Consequently, CBW were responsible for this failure and should have identified and addressed it in their complaint investigation.

We also found that the approach taken by CBW to debt recovery was inappropriate, as the correspondence sent to Mr C had failed to explain the reason why a different organisation was pursuing payment. It also referred inaccurately to the English court system. We found that CBW had refused to suspend recovery while the sum was in dispute and had been unable, or unwilling, to allow the club to continue paying for their ongoing water usage, insisting that all payments should be put towards the disputed amount. This meant that Mr C's club was continually hit by late payment charges. Therefore, we upheld Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for their failure to provide an appropriate and reasonable level of service. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Calculate the average usage of the club and reimburse the difference between this and the recorded usage for the period that meter readings were not taken in line with the requirements of the operational code. 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:

• Any correspondence from Universal Debt Collections must make it clear that they are not a licensed debt collector, they must make it clear that they are an internal department of CBW's parent organisation and they must provide accurate information about CBW's debt recovery process.
• CBW should review their processes, so that automated requests for payment can be stopped if a complaint is received.

Summary

Mrs C complained on behalf of her daughter (Miss A) about the support the university provided to Miss A. Miss A had lost two grandparents, following an extended period of illness. This affected her time at university and she did not pass one of the modules necessary to progress to fourth year. After having an academic appeal turned down, Miss A returned to university to retake the module. The module was due to take place in the first semester but was cancelled due to an unexpected staff absence and rescheduled to take place in the second semester. This meant that Miss A did not have any tutorials or classes during the first semester but still had financial outlays relating to her rented flat and living away from home.

Mrs C complained that, throughout this time, Miss A did not receive sufficient support from the university. She highlighted concerns about Miss A's experience of the university's personal academic tutor provision. She also complained that the university failed to provide appropriate support or guidance following the cancellation of the module.

The university had partially upheld Mrs C's original complaint and had acknowledged that they had not provided sufficient support and guidance following the cancellation of the module. In respect of the personal academic tutor provision, the university initially did not identify any failings; however, in a subsequent response, they outlined a number of improvements relating to the department's personal academic tutor provision.

We found that the personal academic tutor provision Miss A had received had not been delivered in line with the university's internal policies and guidance. In particular, we identified a lack of sufficient record-keeping and structure. We concluded that there was insufficient evidence that the delivery of the personal academic tutor provision was adequate or in line with the university's own policies and procedures.

Overall, we concluded that the university did not provide Miss A with an appropriate and reasonable level of support. The university had acknowledged some failings in response to Mrs C's complaint but had not identified failings in other areas. Furthermore, where the university had identified failings, it was not clear that a reasonable level of reflection, learning or service improvement had taken place as a result. For these reasons, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss A for failing to provide a sufficient personal academic tutor service and for failing to provide an appropriate level of support and guidance to her following the cancellation of the module. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Address Mrs C's point about the accommodation/living costs incurred while Miss A did not have any classes to attend or academic work to undertake. This response should go directly to Mrs C.

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

• Department staff members who act as personal academic tutors should be aware of their duties and responsibilities, in line with the university's policy and guidance.
• The university should learn from Miss A's experience. When a module is cancelled, the university should make every attempt to meet the terms and conditions contained in 'essential information for students'. This includes taking steps to “mitigate any disruption arising from the change and to identify appropriate alternative arrangements.”

Summary

Ms C complained about the responses she had received from Revenue Scotland during a tax enquiry. Ms C said Revenue Scotland had unreasonably tried to impose additional tax following a property transaction. Ms C said that although her position had remained the same throughout the enquiry, Revenue Scotland had refused to accept she was correct, introducing a series of 'tests' which had no basis in law, and did not address the points she had made. Ms C had first engaged a solicitor, but Revenue Scotland had refused to alter their view. Ms C had then engaged a Queen's Counsel (QC – a lawyer appointment by the monarch), and following submission of their opinion, Revenue Scotland had agreed that she did not owe any additional tax. Ms C said it was unreasonable for Revenue Scotland to have accepted the QC's view, when it did not differ from the points she had originally put to them. Ms C said she had been forced to accrue unnecessary and substantial expenses because of the failure by Revenue Scotland to communicate reasonably with her.

We found that Revenue Scotland had failed to act in line with their Code of Customer Service. They had not provided Ms C with accurate advice and they had not communicated with her in a way which ensured she paid the right amount of tax and did not incur unnecessary expense. Revenue Scotland had refused to accept the points Ms C had consistently made, introducing a series of different reasons and failing to engage directly with the points made by Ms C until put forward by a QC. We also found there was no evidence that proper consideration had been given to a recommendation by senior Revenue Scotland staff that Ms C should be offered either some form of goodwill payment, or a contribution towards her legal fees. Additionally, we found internal correspondence suggested that Revenue Scotland staff were not identifying complaints timeously, due to a lack of awareness of the complaints process. Therefore, we upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the 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/leafletsand-guidance.
• Reimburse Ms C for the cost of obtaining legal advice, on receipt of proof of the cost, e.g. an invoice. 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:

• Review the factsheet to ensure it sets out clearly when the taxpayer can apply to the first tier tribunal and the role of Revenue Scotland.

In relation to complaints handling, we recommended:

• Ensure staff are trained in the complaints procedure.

Summary

Mr C was admitted to hospital following a stroke. In order to prepare for his discharge, the council arranged for a homecare service to be put in place. Due to his level of personal savings, Mr C was advised that he would be required to pay the full amount of his care. Mr C complained to the council that he was given the incorrect information in relation to his care costs and that the council unreasonably invoiced him for a larger amount of care costs than he was previously advised.

The council acknowledged they provided Mr C with the wrong information about the cost of his care package on a number of occasions, and they apologised for this. However, as Mr C signed a document to indicate he understood he would be required to pay the full cost of his care, the council considered he should still be liable to pay the full cost of his care.

We took independent social work advice. It is not disputed that Mr C was required to pay the full cost of his care; however, we considered whether it was reasonable that the council insisted Mr C should pay the full charge. Our investigation found that the council failed to provide Mr C with clear written information about what his care costs would be from the outset. Mr C was wrongly informed that his weekly care charge was his monthly care charge. We also considered it was unreasonable that the council took almost eight months to resolve the issue and inform Mr C of his correct weekly charge. We upheld Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• The council should reconsider their decision not to reduce care home costs in light of the failings identified in this investigation.

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

• The council should take steps to improve their processes by ensuring that more accurate information is provided at the outset and that the invoice is issued more promptly after the financial assessment is signed.

Summary

Mr C complained about the manner in which the social work department communicated with him and his wife regarding the removal of their children from the family home. Mr C also complained the child protection investigation was inappropriate, the investigation was not thorough, and social work were over critical of how the parents disciplined their children. The council were of the view that they were working with the parents and that the placement of the children was on a voluntary basis. They said delays in holding a child protection case conference was due to a criminal investigation which was on-going into the matter. They advised that the children were placed appropriately following assessments of the children's grandparents and they had no concerns about the placement.

We took independent advice from a social work adviser. We found that the council unreasonably failed to follow their procedures in relation to child protection concerns. We found that there was no evidence that a careful assessment was carried out in respect of the family friend that the children were initially placed with (and removed from shortly after) and therefore it was unclear how much confidence social work could have had that the parents would have cooperated with the measures. We found there was no evidence that appropriate paperwork had been completed. We did note that there was an appropriate assessment of the grandparents despite the fact that the children had not seen them in a number of years. However, we noted that the placement with the grandparents was treated as an emergency placement which would suggest that kinship care procedures should have been implemented but this was not done. In any case, there was no evidence of any looked after and accommodated child reviews being carried out, even if it had been. We considered that the reasons given for the delay in the child protection case conference were unreasonable as this could have been progressed regardless of any criminal case. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C, and his wife, for not sharing enough detail about their concerns so that he could make an informed decision regarding voluntary measures, and failing to carry out a careful assessment of the initial placement. The council should apologise for the misjudged use of section 25 and for the failure to follow appropriate procedures and timescales with respect to the investigation of concerns, and the requirements to have appropriate plans in place for the children. 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:

• That social work act in accordance with the Looked After And Accommodated (Scotland) Regulations 2009 and hold LAAC reviews within 72 hours of a child being moved to an emergency placement and reviews before the expiry of six weeks from the date a child is moved to an emergency placement.
• That kindship care assessments are commenced within three days of a child's placement, in accordance with the council's Social Work Child Protection Procedures (paragraph 2.8.1).
• Child protection case conferences should be convened with 21 days in accordance with the council's Social Work Child Protection Procedures paragraph 5.9.1.
• The council should ensure that it complies with paragraph 2.11 of their Social Work Child Protection Procedures.

Summary

Ms C's home is accessed along a single-track lane. Ms C complained that contractors' vehicles, involved in works on behalf of the council, obstructed the lane on a number of occasions. She complained that this was a contravention of the masterplan, in terms of which the lane must not be used by contractor vehicles.

The council said that where access had been required via the lane, contractors had been advised to take due consideration of the residential surroundings, and to notify residents in advance where construction vehicle access was planned. They provided copies of email correspondence regarding the use of the lane, which evidenced that some efforts were being made to minimise disruption to residents.

We found that although the council had made some efforts to address Ms C's concerns, there were still ongoing issues regarding the use of the lane. Therefore, we upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to address her concerns about obstruction of the lane by contractors' vehicles. 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:

• Contractors must be aware that they cannot obstruct access to the lane.

In relation to complaints handling, we recommended:

• Council staff should clearly record reports of obstruction and also note the action taken to address each incident.

Summary

Ms C, an MSP, complained on behalf of her constituent (Ms A) that the council unreasonably failed to follow their Unacceptable Actions Policy (UAP - a policy that outlines how an organisation will approach situations where the behaviour of individuals using their service becomes unacceptable, including any actions the organisation will take to restrict contact from the individuals concerned).

The council are entitled to apply their UAP in appropriate circumstances and we are not an appeal route for that decision, rather, our role was to consider their administrative handling of the matter. We considered the council's UAP and the actions they took in Ms A's case.

We found that the council's letter to Ms A, restricting her contact with them, failed to include details of the appeals process, failed to make it clear what behaviour they considered unacceptable that led to them apply the UAP, and failed to explain the extent of the UAP restriction. The council also failed to respond to Ms A's appeal against the UAP restriction.

There was no contemporaneous record or audit trail to explain the rationale for not issuing a warning letter to Ms A prior to invoking the UAP restriction, and not reviewing Ms A's restriction at a bi-annual meeting as per the council's UAP. We therefore upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for failing to include the details of the appeals process, failing to respond to Ms A's appeal and the failure to review Ms A's unacceptable actions restriction at a bi-annual meeting. 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:

• Letters restricting a person's contact with the council should include details of the appeals process, details of the behaviour that is considered to be unacceptable and explain the extent of the restriction.
• Appeals against an unacceptable actions restriction should be responded to in accordance with s7.2 of the Unacceptable Actions by Customers Policy.
• Clear records should be kept to explain the rationale for not issuing a warning letter and for not reviewing a restriction at a bi-annual meeting as detailed in the Unacceptable Actions by Customers Policy.