Upheld, recommendations

Summary

Ms C complained about the care and treatment she received at Borders General Hospital. Ms C suffered from lower abdominal pain and appeared to have diverticular disease (disease of the colon). Ms C attended the emergency department at hospital on six occasions over a number of months. She complained that over this period of time the board did not treat her reasonably and failed to carry out suitable investigations. As a consequence, she said her diagnosis was delayed and her treatment options were reduced. Ms C also complained about the actions of nursing staff and about the way the board dealt with her complaint.

We took independent advice from a consultant general and colorectal surgeon (a specialist in the medical and surgical treatment of conditions that affect the lower digestive tract) and from a registered nurse. We found that Ms C's initial investigations had been satisfactory. However, she continued to present with similar symptoms and persistent pain which, therefore, should have indicated that her diverticular disease had progressed and she should have received a scan earlier. Had this been the case, her distress and symptoms could have been managed earlier, although her surgery options were unlikely to have been different. We upheld this aspect of Ms C's complaint.

In relation to the actions of the nursing staff, we found that there was a great deal of confusion about where Ms C's future treatment was to take place; an appointment had been cancelled at extremely short notice and she was incorrectly advised that treatment would be given in England. Therefore, we upheld this aspect of Ms C's complaint.

Finally, we also found that this incorrect information about Ms C's future care was included in the board's complaint response. We considered this to be unreasonable and upheld this aspect of Ms C's complaint. However, we noted that the board has already taken remedial action in relation to the issuing of the incorrect information and we made no further recommendations in light of this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to consider further investigations despite the persistance of pain. 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:

• In circumstances similar to Ms C, consideration should be given to making further investigations.

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

Summary

Mrs C complained about the care her late son (Mr A) received from the board's mental health team. Mr A was discharged home on a community based compulsory treatment order but completed suicide around 18 weeks later. Specifically, Mrs C complained that the conditions of the compulsory treatment order were not adhered to by staff, that there was insufficient communication with Mrs C as Mr A's named person, and the board's review of Mr A's death did not include certain information which Mrs C considered relevant.

The board carried out a significant adverse event review (SAER, a structured approach to learning from an adverse event) and in their response to Mrs C, they concluded that the care Mr A received was person-centred. The board also identified some learning points in relation to managing the expectations of the named person. Mrs C was unhappy with this response and brought her complaint to us.

We took independent advice from a mental health nurse and a consultant psychiatrist (a specialist in the diagnosis and treatment of mental illness). We found that there were significant gaps and numerous retrospective entries in Mr A's medical records which were unreasonable and not in line with national guidance on record-keeping. We considered that this likely impacted on the team's ability to fully understand Mr A's health and wellbeing. There was evidence to show that Mr A did not receive the planned number of weekly visits from the team, either because he missed appointments or because the visits were not carried out. Given Mr A's complex care package, we also considered that escalation to the responsible medical officer should have taken place when there had been a nine day gap in contact or when there was a significant deviation from his care plan (only one visit a week instead of three). Therefore, we upheld this aspect of Mrs C's complaint.

In relation to communication with Mrs C, we noted that the rights of the named person are limited and there was no requirement for the team to have shared all aspects of Mr A's care with her. However, we considered it is generally good practice to communicate with the named person/family which had been part of Mr A's care plan. We found that the mental health team did not communicate reasonably with Mrs C and upheld this aspect of her complaint. However, we noted that the board had acknowledged these failings.

In relation the the SAER, we did not have significant concerns about the information Mrs C felt was missing. However, we were critical that she had not been provided with the opportunity to raise such concerns. We were also concerned that the SAER should have identified the failings in record-keeping as part of the review of Mr A's care. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in Mr A's agreed care plan and poor record-keeping. 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:

• When significant deviation from an agreed care plans occurs, this should be escalated to the responsible medical officer for discussion and a record made of what the response to this should be.

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

Miss C complained about the college's handling of her complaints about being abused on a college-created social media page by another student, and about plagiarism of her work by other students. Miss C also raised concerns about the way the college handled her complaint about their complaints handling.

In relation to Miss C's complaints about online abuse and plagiarism, we found that the college failed to provide her with clear explanations at the outset about exactly what policies were being used to deal with her complaints; how long they might take to investigate; and what information, if any, she would be able to receive about the outcomes, given the need to protect other students' personal data. The college did not proactively keep Miss C updated about the progress of their investigations, and did not tell her the outcomes. Miss C was only told the outcomes by the college after we became involved. In responding to our investigation, the college failed to provide us with a copy of evidence, even heavily redacted, to show that investigations into online abuse and plagiarism took place.

Regarding Miss C's complaint about the college's complaints handling, we found that the college failed to follow their complaints handling procedure, for example in relation to contacting Miss C after she submitted her formal complaint to ensure everyone involved was clear from the start about exactly what was being investigated. The college said they did not provide the social media service and had no control over its operation; we concluded this statement was unreasonable, as the social media page was created by a member of college staff for a college course, it was self-moderated by students, also moderated by staff, and staff were able to remove the abusive posts Miss C complained about.

We upheld Miss C's complaints and made a number of recommendations, including asking them for evidence of actions they said they had taken already.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the college's communication with Miss C at the outset not being clearer; the unreasonable delay in the college providing Miss C with information about the outcome of their investigations into her complaints of online abuse and plagiarism; and the college's handling of her complaint, under the complaints handling procedure, being unreasonable.

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

• The college should consider adding sections on the use by students and staff of such college-created social media pages to their existing policies.

In relation to complaints handling, we recommended:

• College staff need to know what information can be given to students, who have complained about other students, for example with regards to other students' behaviour or plagiarism of work.
• College staff should explain to students when they first submit their complaint: what procedure is being used to deal with their complaint (in particular if it is not a CHP complaint); the mandatory, guideline or likely timescales for their complaint being dealt with; and what information, if any, the student will receive about the outcome.

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 was found guilty of a breach of discipline for refusing an order to return to his cell. He submitted a disciplinary appeal, claiming that he had refused to return to his cell as he was being bullied and victimised by other prisoners in the residential hall. He also submitted a complaint that his bullying allegation had not been adequately investigated. His appeal was barred by the Scottish Prison Service (SPS) as it was not submitted within 14 days of the decision, as per prison rule 118. The SPS responded to Mr C's complaint, noting that their investigation had found no evidence to substantiate his bullying allegation. Mr C was unhappy with this response and brought his complaint to us.

Mr C complained that the SPS failed to appropriately investigate his complaint. The SPS were unable to provide us with evidence that an appropriate investigation had been carried out. They said that the investigating officer had not produced a written report and had since left the organisation. They told us that they had since improved their process and it is now compulsory for investigating officers to provide a written investigation report. We upheld Mr C's complaint and asked the SPS to provide evidence of their new process.

Mr C also complained about the decision to time limit his disciplinary appeal. The SPS confirmed that they have no discretion to consider an appeal submitted later than 14 days from the date of the decision. They acknowledged that existing guidance and forms do not make this clear and confirmed plans were in place to revise these. As an interim measure, they proposed to issue a Governors  &  Managers Action Notice (GMA) and amend prisoner notices to highlight the 14 day time limit. While the SPS had made it clear to Mr C that they had time limited his appeal as it was outwith the 14 days, they subsequently entered into discussion with him regarding the circumstances he put forward for the late submission. This gave the impression that his late appeal could potentially have been considered had the SPS deemed his circumstances exceptional, when that was not the case. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the lack of evidence of an appropriate investigation of his complaint having been carried out. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Re-investigate Mr C's complaint, ensuring that the findings are appropriately documented.

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

• Until the SPS are able to complete their review of the disciplinary appeal guidance and planned review of the relevant forms, the SPS should raise a GMA highlighting to staff the time limit set out in rule 118, and reminding them of the importance of making prisoners aware of this; and update the prisoner notices on disciplinary appeals to highlight the time limit set out in rule 118. In both instances, it should be made clear that appeals will not be considered outwith this time limit, irrespective of circumstances.

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 lives near a recycling centre, and complained about the way the Scottish  Environment Protection Agency (SEPA) dealt with complaints of noise and dust coming from there. He complained that SEPA had failed to take appropriate sanctions against the site operators, saying they had been responsible for increased pollution coming from the site for the last few years. SEPA said that they had engaged with Mr C through a number of processes in seeking to address his complaints and concerns. They said that they were actively working to modify the existing licence to include prescriptive noise limits and operator monitoring to demonstrate this.

We took independent advice from an environmental health adviser. They confirmed SEPA's obligations in the circumstances of this case, both as a regulator and a waste management licensing authority. The adviser noted that SEPA had not taken the opportunity to put prescriptive noise levels in the waste management licence at the outset, but had now taken steps to rectify this.

In terms of SEPA's role as regulator, we considered that they generally complied with their obligations in relation to having a policy and framework for enforcement. However, we noted that noise monitoring was not carried out sufficiently and promptly by the regulator. With regard to enforcement, the adviser said that regulators have a duty to act when breaches of regulations or licence conditions are found. We considered that SEPA had met many of their obligations, however, noted that SEPA did not take the opportunity to serve notice for repeated non-compliance. We also found that SEPA took enforcement action of providing advice and guidance to limit noise and dust emissions from the centre; however, they did not serve an enforcement notice to limit noise and dust emissions to an acceptable level. 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 appropriate steps following notifications of noise and dust arising from the recycling centre. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• SEPA should reconsider the appropriateness of the enforcement action they have taken following notifications of noise and dust arising from the recycling centre, having regard to their policy and procedures, and all the circumstances of this case. Consideration should be given to the current situation, when deciding on what further action to take (if any).

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

• Staff should be clear on the principles underpinning their enforcement policy, and should be confident in identifying instances of non-compliance in which formal enforcement action would be proportionate.

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 contacted the council's environmental services about a spillage of domestic heating oil (kerosene) in the area near to his home. Mr C had the spillage completely cleaned from his property but his neighbour did not. Mr C was concerned about the potential for recontamination of his property, and about the smell of kerosene, from his neighbour's land. He contacted the council, asking them to take action to deal with his neighbour's failure to have the spilt kerosene cleaned up. The council said that the clean-up was the insurance company's responsibility. Mr C was not satisfied with the council's response to his concerns and brought his complaint to us.

We took independent advice from an environmental health adviser. We found that Mr C's complaint of smell from the kerosene spillage at his neighbour's property could potentially have been deemed a statutory nuisance. The council were unable to provide us with evidence that they had carried out a robust investigation into Mr C's complaint of smell, to determine if it was valid. Instead, it appeared that the council relied on a report prepared by environmental specialists working for Mr C's insurers, in relation to the clean-up at his property. We also found that what the council told Mr C about the matter was, on occasion, at odds with their internal communication. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for their failure to respond reasonably to his reports of kerosene contamination at a neighbouring property. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Carry out a robust investigation into Mr C's reports of kerosene contamination at a neighbouring property, with specific reference to both the potential for recontamination of his property, and smell affecting the reasonable enjoyment of his premises.

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

• Share our decision letter with environmental services staff, who should reflect on their handling of Mr C's reports of kerosene contamination at a neighbouring property, with reference to the adviser's observation that nuisance can include having reasonable enjoyment of premises impeded or restricted.

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

Summary

Mr C complained about the council on behalf of his mother (Mrs A) who is a council tenant. Mr C said that her property had been in a state of disrepair with issues including repeated boiler breakdowns, faulty electrics, persistent roof leaks and draughty windows. Mrs A had been reporting and complaining about these issues for a number of years but the council had only recently brought the property up to a reasonable state of repair. Mr C considered that the time taken to repair the property and provide a final response to Mrs A's complaints had been unreasonable.

We found that Mrs A had been complaining to the council, about a number of similar repair issues, for several years. There were a number of repairs mentioned in the complaints correspondence which were not recorded on the council's repair log, meaning it was difficult to assess whether these were completed within a reasonable timescale. The council told us that they did not record the outcomes of their inspections. This meant that it was very difficult to assess the ongoing condition of the property or evidence whether or not the faults being reported persisted throughout the period in question, or only required repair later in the process due to damage or deterioration.

We considered it was likely that there were unreasonable delays on the part of the council. Additionally, the reason we were unable to confirm this was due to insufficient record-keeping. We also found that the council's complaints handling had been unreasonable as they delayed in referring Mrs A to ourselves. Therefore, we upheld both of Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for failing to appropriately handle the repairs to her property and to both her and Mr C for the failures in complaints handling. 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 repair log should be a full and accurate record of all repairs completed.
• A clear record should be made of repair inspections, detailing the inspector's findings.

In relation to complaints handling, we recommended:

• All complaints should be handled and progressed in line with the complaints policy.

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 unreasonably applied their Unacceptable Customer Behaviour Policy (UCBP, a policy that outlines how an organisation will approach situations where the behaviour of individuals using their service becomes unacceptable, including any actions the organistion will take to restrict contact from the individuals concerned). The council decided to apply their UCBP on the basis that the correspondence received from Mr C placed an unreasonable demand on the business of the council. They confirmed that they would still accept Freedom of Information (FOI) requests.

We found that the council were unable to provide enough evidence to support their decision to apply the policy. We noted that the correspondence recorded from Mr C was mainly based under FOI requests which the council had stated that they did not take into consideration when deciding to implement their UCBP. We also noted that the council were unable to access some correspondence as they had been issued to members of staff who had since left the council. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for unreasonably applying their Unacceptable Customer Behaviour Policy. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Clarify and review the status of the restriction of access under the UCBP.
• Respond to Mr C's emails providing him with the information he requested where they are able to do so and where they have not previously provided it.

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

• The council should take steps to ensure that when correspondence is received it is identified and recorded at the outset which part of the correspondence relates to FOI and non-FOI.
• The council should take steps to ensure that when the UCBP is implemented the correspondence which this refers to is identified and highlighted to the customer.

In relation to complaints handling, we recommended:

• The council should establish how they can retain access to emails issued by customers to members of staff, who leave the employment of the council to ensure that evidence they rely on is retained for the purpose of complaints investigations.

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 ambulance service failed to send an ambulance to him when he phoned to report that he had suffered a collapse at home. When he received a call back from an ambulance service clinical adviser, Mr C reported that he had suffered flashing lights, neck stiffness, headaches for the past three weeks, and that he now also had pins and needles in his right hand side. The ambulance service said that Mr C's reported symptoms did not meet the criteria for an emergency ambulance. However, as Mr C had symptoms for a number of weeks, he did require a medical review and it was agreed that Mr C's sister would transport him to hospital.

We took independent advice from a paramedic and listened to the audio recordings of the phone calls. We found that Mr C's symptoms did not warrant the dispatch of an emergency ambulance and that it was appropriate to arrange for the clinical adviser to phone him back to obtain further information. We found evidence that a number of assumptions had been made by the clinical adviser. At no time did Mr C state that he had had the pins and needles for two weeks but rather that the problems had just started. We found that the clinical adviser did not adequately question Mr C or his sister about how manageable it would be to transport Mr C to hospital, should he suffer another collapse. We also found that insufficient weight had been taken of the severity of Mr C's headache, the visual disturbances, and neck stiffness. We found that it would have been advisable to have dispatched an ambulance crew who would have carried out a face-to-face assessment in Mr C's home and determined the appropriate way to progress matters. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that assumptions had been made regarding his reported symptoms. The apology should reach 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 carrying out clinical assessments the clinical adviser should give sufficient weight to red flag signs and not make assumptions about the reported symptoms.

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 on behalf of her late husband (Mr A) that the ambulance service failed to transfer Mr A to hospital in an appropriately safe manner. Mr A had recently been diagnosed with a cancerous tumour on his femur (thigh bone) and was at risk of fracture. While being admitted to hospital for pain management, Mr A sustained a fractured femur while he transferred himself from a trolley cot to a hospital trolley. Mrs C was also concerned that the ambulance crew did not stay with Mr A in the accident and emergency department until he was attended to by hospital staff and did not complete an incident report regarding the fracture.

We took independent advice from a paramedic clinical team leader. We found that good practice should have dictated the use of transfer equipment or, as a minimum, the supporting of Mr A's leg during his efforts to self-mobilise. We also considered that the ambulcance crew should not have left Mr A in hospital without ensuring treatment had commenced and should have completed an incident report regarding the fracture. Therefore, we upheld Mrs C's complaint.

Mrs C also complained about how the ambulance service handled her complaint. We found that there was an unreasonable delay in responding to the complaint and a failure to keep her updated. We also noted that Mrs C only received a copy of the internal investigation report document. No formal, personalised complaint response letter was issued and she was not informed of her right to appproach us with her complaint. We upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to adhere to best practice when transferring Mr A to the hospital trolley; failing to stay with Mr A until active treatment commenced; and failing to complete an incident report in line with protocol.
• Apologise to Mrs C for failing to respond to her complaint within 20 working days; failing to proactively inform her of the delay and keep her updated; and failing to issue a formal, personalised written response (including details of her right to approach the SPSO). 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:

• The ambulance service should demonstrate organisational learning to try to prevent similar future failings – they should complete and share with staff an anonymised case study highlighting the identified failings in this case.

In relation to complaints handling, we recommended:

• The ambulance service should ensure their complaints investigations comply with the requirements of the NHS Scotland model Complaints Handling Procedure – they should highlight these requirements to complaints handling staff.

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.