Upheld, recommendations

Summary

Mr C complained that his shoulder dislocations went undiagnosed for around eight months after he attended the emergency department on a number of occasions at Crosshouse Hospital and during an in-patient stay. After Mr C's shoulder dislocations were identified at an orthopaedic (the branch of medicine specialising in the treatment of diseases and injuries of the musculoskeletal system) clinic appointment, he underwent shoulder replacement surgery. Mr C also complained that he was not informed about heart problems he experienced whilst he was an in-patient and that the board failed to handle his complaint appropriately.

We took independent advice from a consultant in emergency medicine and a consultant in acute medicine. We found that the board had acknowledged that Mr C's injury should have been picked up during his admission and had apologised to him. The board also took steps to share Mr C's case with medical staff for learning and improvement. However, we found that there was no evidence to demonstrate that Mr C's shoulders had been examined on one occasion when he had attended the emergency department.

In terms of Mr C's concerns that he was not informed about the heart problem he suffered during his admission, we found that there was no records to show that this had been explained to him and understood given he had memory loss.

In relation to the board's handling of Mr C's complaint, we found that the board took ten months to respond. We acknowledged that Mr C's case was complex, however, we considered that this delay was unreasonable. We also found that the board took four months to arrange a meeting to discuss his complaint and that the written response lacked detailed explanation. We upheld all of Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to examine his shoulders and failure to discuss with him and document the heart problems he had during his admission. 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:

• Patients attending the emergency department should receive a full assessment of their presenting symptoms.
• Staff should ensure that a patient's care is fully explained and that such discussions are clearly recorded in the clinical records.

In relation to complaints handling, we recommended:

• Complaint meetings should be arranged in a timely manner; and written responses should provide sufficient explanation and address all the points raised in line with the NHS Complaints Handling Procedure.

Summary

Mr C, a solicitor, complained on behalf of his client (Mr A) that the university unreasonably removed Mr A from his course. Mr A was studying at the university and was required to attend monthly meetings with his Director of Studies (DoS). Mr A was withdrawn from his course for failing to attend three out of four of the monthly meetings. Mr A said that he had only had one unauthorised absence, the other two absences were due to medical emergencies, which could not be predicted, and he was able to provide supporting evidence of these.

The university provided evidence that Mr A would have been aware of the importance of the monthly meetings and that he should have rearranged his missed meetings. We found that Mr A could and should have rearranged two of the three missed meetings. Mr A had raised a concern that his DoS was unable to rearrange meetings, however, this was not raised in his appeal or complaint, so was not considered further.

However, we were concerned about a number of aspects of how Mr A's case had been handled. We found that the third missed meeting had occurred when Mr A was on authorised leave, and did not believe this should have been counted against him. We found that the communication with Mr A both before and after his withdrawal to be confusing. In addition, the record of the decision to withdraw Mr A did not note what evidence was considered or how it was assessed. When Mr A appealed on the basis of 'New Evidence' it was not possible to know whether the evidence was new or not, as there was no record of what was originally considered. We were concerned that this meant Mr A was not given a fair chance to appeal. Finally, the university continued to be unclear with our office about exactly why Mr A had been withdrawn from his course. For these reasons, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the poor communication and lack of clarity about his withdrawal from his course. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Reconsider Mr A's appeal, inviting him to present evidence at a hearing as he requested to do.

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

• Sufficient information about what evidence was considered and how the decision was reached should be recorded when deciding to withdraw students.

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 university's communication regarding his complaint was unreasonable and that they failed to conduct their investigation of his complaint to a reasonable standard.

We found that there had been delays in the university's communication and that inappropriate and unprofessional language had used by a key staff member in internal communication about Mr C. We saw evidence of Mr C's concerns having been minimised or dismissed, rather than being taken seriously with efforts being made to address them. We considered that the poor communication in respect of Mr C's complaints had a significant impact on his learning experience. Therefore, we upheld this aspect of Mr C's complaint.

In relation to the complaint investigation, we noted that the investigator had not consulted the supporting evidence Mr C submitted with his complaint. We considered that these documents should have been read and understood before investigative interviews were carried out, so that there was a full understanding of the matters Mr C complained about. We also found that the investigator had been overly reliant on subjective statements. We considered that the investigation fell below a reasonable standard and failed adequately to address Mr C's 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 standard of communication (with a recognition of the impact this had on him), for failing to consult the evidence he had submitted in support of his complaint and for being overly reliant on subjective statements. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Staff involved with complaints should communicate in a professional manner at all times.
• Staff investigating complaints should ensure that their conclusions can be supported by evidence.

In relation to complaints handling, we recommended:

• Staff involved in complaints should refer to the SPSO's Report: Making Complaints Work for Everyone. Additional support in dealing with complaints, if required, can be requested from the Complaints Standards Authority: http://www.valuingcomplaints.org.uk.

Summary

Ms C said that she was subjected to hate crimes in prison. She complained that the Scottish Prison Service (SPS) unreasonably failed to retain CCTV footage for the periods of time in question and that they failed to handle her complaints about the matter appropriately. Ms C also complained that the SPS unreasonably failed to respond to her equality and diversity complaint.

We found that Ms C could have provided SPS with more detail on the allegations when she asked them to retain CCTV footage. However, we considered that there was sufficient information to allow SPS to realise that an unspecified crime was alleged and it would have been reasonable for them to take steps to clarify the nature of the complaint. This would have allowed the SPS to determine exactly what the complaint was about and whether CCTV needed to be retained.

We found that subsequent investigation of the complaints by the SPS had not been sufficiently thorough as only one member of staff had provided a statement in connection with a single date. We did not consider this to be evidence of a full investigation as incidents were alleged to have taken place on two different days and there was no information recorded on why it was considered unnecessary to take statements from other members of staff on duty at the times in question.

We also found that the SPS had not provided a response to the equality and diversity complaint that Ms C submitted. We upheld all of Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to make further enquiries in relation to retaining CCTV footage, appropriately investigate the complaints and respond to the equality and diversity 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:

• Complaints should be appropriately investigated and responded to.

Summary

Mr C complained about the way that the Office of the Accountant in Bankruptcy (AIB) investigated an issue regarding debts in his Debt Arrangement Scheme (DAS - statutory debt management scheme introduced by the Scottish Government) Debt Payment Programme (DPP - a programme that allows a debtor to pay off their debt over an extended period of time) after one of his debts was written off by the creditor. Having investigated this matter, the AIB established that the incorrect debt had been removed from Mr C's debt payment plan. The AIB said that inaccurate information in the DAS application had contributed to this error. The AIB apologised to Mr C for the error and offered reassurance that the removal of the wrong debt had not been of detriment to him.

We found that there was limited documentation of the initial investigation carried out once the AIB were informed of an issue with one of the debts. We were unable to find satisfactory evidence to support the AIB's conclusion that the error had not been detrimental to Mr C. Therefore, we upheld this part of Mr C's complaint.

Mr C also raised concern that the AIB did not provide a full response to his complaint. We found that the AIB had not informed Mr C whether he had overpaid his debt payment programme despite this being a point he raised concern about. We also found that the AIB's complaint response indicated to Mr C that it was their intention to make a complaint to the Financial Conduct Authority (FCA) regarding issues experienced with one of the creditors. The AIB acknowledged that when it subsequently became apparent that this would not be possible, they should have updated Mr C. We upheld this part of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not appropriately investigating his concerns regarding a mistake in his Debt Payment Programme, and not providing him with a full and objective response to 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.
• Provide Mr C with an explanation regarding how the payments made to one of his debts after it should have been removed have been accounted for, including whether the payments have been returned and reallocated to other debts. Revise the spreadsheet used to calculate the balance of Mr  C's DPP and provide him with a copy. Provide Mr C with a summary of the administrative and communication issues experienced with creditors throughout the DPP so that he is able to make an informed decision about whether to make a complaint to the FCA.

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

• Investigations into issues with debts or payments within a debt payment plan should be adequately documented in the customer's case notes.

In relation to complaints handling, we recommended:

• A complaint investigation should aim to establish all the facts relevant to the points made in the complaint and to give the customer a full, objective and proportionate response.

Summary

Ms C complained that the council had failed to respond to complaints about anti-social behaviour and repairs over many years. She also complained that the council had not handled her complaint reasonably.

We found that the council had failed to act on reports of disrepair over a four year period. We also found that the council's complaint investigation had not acknowledged this, or apologised for any failings. We upheld Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to take action following reports of disrepair and for their failure to handle her complaint reasonably. The apology should meet thestandards set out in the SPSO guidelines on apology available atwww.spso.org.uk/leaflets-and-guidance.

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

• The council should review their procedures for monitoring repair work to ensure it is monitored for completion.

In relation to complaints handling, we recommended:

• The council's complaints handling system should ensure that failings (and good practice) are identified, and that they are using the learning from complaints to inform service development and improvement (where appropriate).

Summary

Ms C complained that the council failed to reasonably consider her personal circumstances when determining her request to tarmac a grass space near her home. Ms C said that the existing layout was difficult for her to access as a wheelchair user and that the council's refusal led her to pay for a section of the pavement outside her home to be tarmacked at her own expense. The council refused to reimburse Ms C for this work on the grounds that the street is a designated shared space which means the street layout is shared equally between pedestrians and motor vehicles. The council held the view that an individual assessment of Ms C's needs was not required and they confirmed that the ramp in the road that Ms C needed to cross to leave her street was within the allowed specifications set out in the relevant regulations. Ms C was unhappy with this response and brought her complaint to us.

We took independent advice from an adviser who specialises in equal opportunities and diversity. We found that the council had appropriately considered that Ms C's street was a shared space. However, we noted that Ms  C clearly requested assistance in her application for minor works and we considered that the council should have provided her with the appropriate advice at that stage - that social work could conduct an assessment of need to establish if support or adaptations were required. We concluded that the council should have fully assessed Ms C's circumstances under the Public Sector Equality Duty and the Equality Act 2010. The council failed to recognise these concerns and made a decision that Ms C did not require a reasonable adjustment to be considered without properly assessing her individual circumstances. 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 consider her personal circumstances when determining her request to tarmac a grass space near her home. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsand-guidance.
• The council should consider refunding the charge incurred for the Minor Roadworks Consent as a gesture of goodwill for failing to respond appropriately to Ms C's request for assistance on the application. If the council do not consider this would be appropriate, they should provide us with an explanation why.

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

• When a member of the public raises concerns about accessibility to footways on publicly adopted roads, the council should consider the individual's personal circumstances and whether any reasonable adjustments are required in line with their Public Sector Equality Duty and the Equality Act 2010.

Summary

Mr C complained that the council failed to address concerns he raised about building works carried out by his neighbour. Mr C felt that the council's failure to take action against his neighbour had allowed the retention of a defective building which had, over time, resulted in water damage to his property.

The council required Mr C's neighbour to submit a retrospective planning application to allow for the works which had been carried out to be assessed. The retrospective planning application was granted planning permission with two conditions, one of which related to the provision of appropriate guttering and rainwater goods to ensure rainwater did not discharge onto Mr C's property. Compliance with this condition was required within three months, however, Mr  C's neighbour failed to comply with this condition in this time and a planning enforcement case was opened. The council carried out further investigations and closed their enforcement case. A number of years later, the council wrote to Mr  C notifying him that his building was considered to be defective and requiring him to carry out works to remedy these defects. Mr C complained that these works were required because of the council's failure to enforce appropriate installation of rainwater goods on his neighbour's development, as required by the condition of the earlier planning permission.

We found that the council unreasonably closed the enforcement case without ensuring that Mr C's neighbour had carried out the works required to comply with the planning condition. We considered that the delay between Mr C initially raising his concerns about non-compliance and the council finally ensuring compliance years later was unreasonable. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to take timely and effective action to ensure compliance with condition two of the planning application. 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 ensure that when it becomes clear an applicant has failed to comply with a planning condition within the required time-frame, they take the necessary steps, including formal enforcement action if necessary, to ensure the requirements of the condition are met. They should ensure this action is taken in a timely manner, in line with the guidance detailed in Planning Circular 10/2009.

Summary

Ms C complained about the care and treatment her husband (Mr A) had received at St John's Hospital following a suicide attempt. Ms C complained that Mr A was inappropriately given diazepam (a medicine used to treat anxiety), as it can be addictive.

We independent advice from a consultant psychiatrist. We found that it might have been appropriate to have given Mr A diazepam on a short term basis but the reason for prescribing it to him was not recorded. We found that when Mr A self-discharged from the hospital, there was a failure to carry out and/or document an appropriate suicide risk assessment. There was no evidence that medical staff considered detaining Mr A. There was also no evidence that they signposted him to any other sources of support or carried out any contingency planning in case his condition or level of risk to himself changed. In addition, we found that a junior medical staff member was not able to reach a senior colleague by phone for advice. Therefore, we upheld this aspect of Ms C's complaint. We also found that the board had not handled Ms C's complaint regarding the diazepam appropriately and we made a recommendation in relation to this.

Ms C also complained that there was a failure to provide Mr A with appropriate follow-up care after he self-discharged from the hospital. Mr A had been offered a follow-up appointment in two months' time. When he was unable to attend that appointment due to his poor mental health, he was offered an appointment for six months later. We found that Mr A was not given follow-up care that was appropriate to his needs, and that, in the circumstances, Mr A should have been offered an appointment within a week of him leaving the hospital. When Mr A could not attend that appointment due to poor mental health, he should have been offered a review at home. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide Mr A with reasonable care and treatment, for failing to provide him with appropriate follow-up care and for the inaccuracy in responding 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:

• The reason for prescribing any medication, including one-off doses, should be clearly recorded.
• If a patient wishes to self-discharge and it is unplanned, there should be adequate processes in place, and adhered to, to manage this. This should involve carrying out appropriate risk assessments, appropriately signposting patients and/or carers to crisis services and carrying out contingency planning.
• Junior medical staff should have adequate supervision from senior medical staff, especially out of hours, and reliable mechanisms should be in place so they can contact senior colleagues for advice.
• Patients should receive follow-up care that is sufficiently timely and robust, which is appropriate to their individual needs. If patients are unable to attend their out-patient appointment, the board should consider alternative arrangements such as home visits.

In relation to complaints handling, we recommended:

• The board's complaints handling system should ensure that accurate responses are issued, which are based on the evidence gathered during their investigation.

Summary

Ms C complained about the way her son (Mr A)'s psychiatrist dealt with communication from Mr A's father (Mr B). Mr A is estranged from Mr B, and the psychiatrist had been in contact with Mr B regarding some communication from Mr A to Mr B's work. Ms C and Mr A subsequently met the psychiatrist whose' contact with Mr B was discussed. Ms C said that the psychiatrist failed to deal with the matter in a reasonable way.

We took independent advice from a medical adviser. We found that the quality of record-keeping in relation to clinical decisions made and the rationale for these in relation to the communication was poor. We also found that the relevant guidelines in relation to consent was not followed. Therefore, we upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for how communication with Mr B was handled. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Relevant staff should follow the General Medical Council guidance in relation to consent.
• Clinical records should be audited regularly.