Upheld, recommendations

Summary

This summary is linked to case 201608499 in relation to Clear Business Water.

Mr C complained to Clear Business Water about roads drainage charges applied to his business. Mr C argued that these charges should not apply as he does not have a physical connection to the water supply. Clear Business Water said they could not deregister this aspect of the charges however, they referred the matter to Scottish Water who carried out a site inspection. Scottish Water advised Clear Business Water that the charges should still apply as Mr C's business has the benefits of facilities which drained to the public sewerage systems, implying that Mr C's employees could use the facilities of a business next door.

While SPSO's investigation was ongoing, Scottish Water identified that Mr C should never have had roads drainage charges applied to his business. Mr C was refunded appropriately. Under our powers of the SPSO Act 2002, the Ombudsman decided that we should review the actions of both Scottish Water as a listed authority and Clear Business Water. We found that Clear Business Water failed to take responsibility for reaching their own determination of Mr C's liability and to pursue any disagreement with Scottish Water through the dispute resolution process detailed in the Operational Code.

With regards to Scottish Water, we were critical that they took the view that Mr C's business should be liable for roads drainage charges but did not provide adequate evidence to justify their position. We were also critical of the length of time it took both Clear Business Water and Scottish Water to resolve this matter. We upheld the complaint and made recommendations to both Clear Business Water (see case 201608499) and Scottish Water (see below).

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to identify that the roads drainage charges were inappropriately applied to his business within a reasonable timescale. 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:

• Scottish Water should understand the reasons for their failure to identify these premises as being exempt from roads drainage charges by carrying out a significant event review and ensure that steps are taken to review and amend their processes in light of their subsequent findings.
• Scottish Water should provide assurances that similar errors have not occurred in the last 12 months in cases where Scottish Water has been approached by licenced providers on behalf of end-customers, contending that charges should not be applied, in circumstances where the end customer does not have a direct connection to the public water system or public sewerage system and the customer does not have a legal right to access communal facilities which are so connected.

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

This summary is linked to case 201810639 in relation to Scottish Water.

Mr C complained to Clear Business Water about roads drainage charges applied to his business. Mr C argued that these charges should not apply as he does not have a physical connection to the water supply. Clear Business Water said they could not deregister this aspect of the charges however, they referred the matter to Scottish Water who carried out a site inspection. Scottish Water advised Clear Business Water that the charges should still apply as Mr C's business has the benefits of facilities which drained to the public sewerage systems, implying that Mr C's employees could use the facilities of a business next door.

While SPSO's investigation was ongoing, Scottish Water identified that Mr C should never have had roads drainage charges applied to his business. Mr C was refunded appropriately. Under our powers of the SPSO Act 2002, the Ombudsman decided that we should review the actions of both Scottish Water as a listed authority and Clear Business Water. We found that Clear Business Water failed to take responsibility for reaching their own determination of Mr C's liability and to pursue any disagreement with Scottish Water through the dispute resolution process detailed in the Operational Code.

With regards to Scottish Water, we were critical that they took the view that Mr C's business should be liable for roads drainage charges but did not provide adequate evidence to justify their position. We were also critical of the length of time it took both Clear Business Water and Scottish Water to resolve this matter. We upheld the complaint and made recommendations to both Clear Business Water (see below) and Scottish Water (see case 201810639).

Recommendations

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

• Clear Business Water should reach their own view on whether or not a customer is liable for charges and if this is contradicted by Scottish Water, they should pursue this as a dispute through the dispute resolution process detailed in the Operational Code.

Summary

Mr C complained about works carried out by the council to lower the footway at his property to allow for access to his driveway. The council carried out works to drop the kerb, but did not lower the heel kerb. Mr C complained that, as a result of the council not lowering the heel kerb, his car grounded on the footpath. Mr C believed that the council should have dropped the heel kerb as part of the works. The council said that they had carried out works to specification and that they considered the issue was the level of the Mr C's driveway which was not their responsibility. Mr C was unhappy with this response and brought his complaint to us.

We requested the council's documentation with respect to their inspection and agreed specification for the works. The council were not able to provide documentation relating to their inspection, even though they had visited the site on a number of occasions. We concluded that the council had failed to appropriately document their inspection and the specified works. The council confirmed during our investigation that they no longer offered to carry out such works and that, in an effort to conclude matters and in acknowledgement of the inconvenience, they agreed to waive their fee for the works carried out. We considered that the council should re-inspect Mr C's driveway, document their findings with respect to the works that should have been carried out at the time and, if further works were required, they should liaise with Mr C to arrange for these to be completed. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for their failure to document their assessment of whether the heel kerb should have been lowered. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• The council should carry out a further inspection of the footway and driveway to determine whether, at the time the works were completed (prior to the installation of the gravel grid system on the driveway), the heel kerb should have been dropped to provide level access. If they determine the kerb should be dropped, the council should arrange, in consultation with Mr C, to drop the kerb and pavement to the original driveway levels.

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 to the council about her child (Child A)'s school. Ms C complained about the school's communication with her and about decisions made about Child A's education. Ms C said she felt excluded from decision-making and communication about Child A and that there was a lack of engagement by the school with the Children's Hearing arranged for them. Ms C also complained that the council failed to thoroughly investigate and respond to her complaints.

In response to our investigation the council explained they found no evidence that the school informed Ms C of decisions about Child A's education, nor was there any information recorded about the reasons why these decisions were made. The council advised they recognised that the issue of invitations to hearings and meetings was an issue and explained that they had developed a system whereby there would be a single point of contact and invitations would be acknowledged once received.

We found that the council failed to demonstrate that they carried out a thorough investigation of Ms C's original complaints and to respond to all of her complaints. The council could not provide evidence that they communicated with Ms C about the decisions made regarding Child A's education. While the council upheld part of Ms C's complaint, we noted that they did not provide an apology or any acknowledgement of the impact their failings had on Ms C or Child A. We upheld Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for their failure to communicate regarding Child A and for their failure to properly investigate and respond to the 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:

• The council should ensure that systems are in place to ensure a student's records are maintained and updated to include details of significant decisions.

In relation to complaints handling, we recommended:

• Staff have the knowledge and skills to identify and register complaints in line with the board's complaint handling procedure. Identify any training needs to ensure staff fully and appropriately respond to complaints.

Summary

Mrs C became an informal carer to her two grandchildren when they were removed from their mother's care at the council's request. Mrs C complained to the council about the support they provided to her as an informal carer. Mrs C said that she did not feel the council took seriously the concerns she was raising about the children's wellbeing and behaviour, that they did not recognise her own personal circumstances, such as her own health needs and that they delayed in providing financial assistance.

The council explained that Mrs C received support from a family support worker and that a nursery placement was provided; however they acknowledged that there was a delay in providing financial assistance and in arranging the nursery placement due to it being in another local authority area.

We took independent social work advice. The adviser queried the appropriateness of the statutory powers that the council chose to use when they decided to remove the children from their mother's care. While we noted that Mrs C received support from a family support worker and advice by telephone, we considered it was unreasonable that the allocated social worker did not visit Mrs C and the children until almost three weeks after they were placed in her care. We concluded that the council failed to take a proactive approach to planning the support Mrs C might require and overall, they failed to provide appropriate and timely support. We upheld the complaint and made recommendations for learning and improvement.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide proactive support to her and offer her the opportunity of a meeting to discuss any outstanding concerns. 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 should reflect on the findings of this investigation, identify appropriate further learning, and feedback to staff in a supportive manner.

Summary

Mr C complained about the information which a GP entered on a form for Employment Support Allowance (ESA). The GP had included historical information in Mr C's medical records, which Mr C felt was not relevant.

We took independent medical advice from a GP. We found that although the information was contained in Mr C's medical records, it was not relevant to the reasons why Mr C was unable to work at that time. The form does not ask for a summary of a patient's past medical history but rather about the patient's current medical conditions which may be a barrier to them being fit for employment. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for including information which was not relevant to his current medical condition. 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 GP concerned should ensure that in future only relevant information regarding the patient's current medical condition is entered in the ESA form.

Summary

Ms C complained that the board unreasonably failed to discover an object left in her nasal tissue after surgery at St. John's Hospital. Ms C said that on removal of stents (splints placed temporarily inside a duct, canal, or blood vessel to aid healing or relieve an obstruction), one stent came away in two pieces. Ms C was alerted at the time that a piece of silicone stent may have been retained. Ms C continued to attend the hospital for treatment of chronic rhinosinusitis (a condition where the cavities around nasal passages (sinuses) become inflamed and swollen for a prolonged period). Sixteen months after the surgery, a scan was carried out which identified that a titanium clip had been retained in the nasal tissue. The silicone stent and titanium clip were removed at the same time Ms C was undergoing another surgery, approximately 12 months after the retained titanium clip was discovered.

We took independent medical advice from a consultant rhinologist (a specialist in conditions affecting the nose). We found that the board unreasonably failed to discover and report on all elements retained in Ms C's nasal tissue after surgery. No investigations were carried out until the scan 16 months after the stents were removed, where it was found that the titanium clip was still in place. After it was discovered, it was over a year before it was removed. We found that there was an unreasonable delay in identifying the retained titanium clip. Therefore, we upheld this part of Ms C's complaint.

Ms C also complained that the board failed to provide a reasonable explanation as to how an object was left in her nasal tissue after surgery. The board accepted that they had not provided a reasonable explanation. The communication regarding this issue was poor. When it was found that a titanium clip had been retained as well as the silicone stent, it was over four months before Ms C was informed of this. No explanation was provided as to why the clip was retained or why Ms C was not informed that this was a possibility. We considered that the board could have been more open and detailed about what happened and why. Therefore, we upheld this part of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings identified by this investigation. 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:

• A review of practice to consider best practice to secure silicone tubes for dacryocystorhinostomy (DCR) surgeries.
• A review of the process for selecting patients for DCR surgery.
• Clinicians should review their diagnosis when patients do not respond to treatment.
• Learning from this investigation is fed back to relevant staff in a supportive way.
• The process of discussing options and consent to treatment should be clear in its documentation.

Summary

Mrs C complained about the care and treatment provided to her late mother (Ms A) at the Royal Infirmary of Edinburgh. Ms A had undergone treatment for early stage lung cancer, and was followed up at six-monthly intervals. Mrs C complained that at a follow-up appointment, Ms A had been told there were no signs of cancer, but a few weeks later was found to have liver cancer. Mrs C said that there was a failure to identify the spread of lung cancer and that Ms A had been given false hope.

We took independent advice from a radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and an oncologist (a doctor who specialises in the diagnosis and treatment of cancer). We found that there had been a failure to identify a mass near Ms A's spine on a scan, and that this was unreasonable. However, we noted that it was unlikely that earlier identification of this would have altered Ms A's outcome. We also found that at a follow-up appointment, the clinical examination done was incomplete as it did not include examination of the abdomen. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to identify a mass and the failure to carry out a full clinical examination at the oncology appointment. 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:

• Radiological findings should be accurately reported.
• Full clinical examination should be performed and documented during oncology follow-up appointments in cases of radical lung cancer treatment.

Summary

Mr C complained about the care and treatment his daughter (Ms A) received from the practice. Ms A contacted the practice about severe abdominal pain and was given advice over the phone. Four days later Ms A was admitted to hospital where she had her appendix and part of her bowel removed. Mr C felt that it was unreasonable that the practice did not examine Ms A in person when she called them and that this failure could have led to a potentially serious situation.

We took independent advice from a medical adviser. We found that the practice failed unreasonably to adequately assess and examine Ms A. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in assessment and examination. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsand-guidance.

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

• The doctor involved should reflect on the complaint and findings in their next appraisal.
• The doctor involved should follow the relevant guidance on assessment and management of abdominal pain in women of childbearing age.

Summary

Mrs C complained about the care and treatment her late mother (Mrs A) had received in Raigmore Hospital before her death. Mrs A had been referred to the hospital by her GP. The referral letter said she had fallen at home and referred to acute kidney injury. Mrs A fell on two occasions after being admitted to hospital. It was then identified nearly three weeks later that she had fractured her hip. Mrs A later died in the hospital.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nursing adviser. We found that the care and treatment provided to Mrs A in relation to her kidney function was reasonable and appropriate. In addition, she had not displayed sufficient pain or deformity that meant a hip fracture should have been considered. However, the nursing records indicated that Mrs A was at risk of falling, but there was inadequate information about what action would be taken to prevent any falls. We found that it was reasonable for staff to try to reduce Mrs A's agitation after her first fall by allowing her to walk with a member of staff, but it would have been more appropriate to have had two members of staff with her. Staff should also have told the family about the first fall when they contacted them about the second fall.

In view of these failings, we upheld Mrs C's complaint, although we noted that the board had already apologised to Mrs C and had taken a number of actions to try to prevent similar failings in the future.

Recommendations

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

• Nursing staff should ensure that the relevant nursing documentation is completed appropriately.