Upheld, recommendations

Summary

Mr C was fourth on the waiting list for a taxi plate from the council and had been on the list for many years. However, when a plate became available it was given to a day-to-day manager who was not on the waiting list. Mr C was unhappy with this decision and complained.

We found that the council had no record of the decision taken to issue the plate to someone not on the waiting list. The staff who dealt with it were unavailable and there were no records. We also found that there was no clear policy in place which explains what should happen and what factors should be considered, when the council choose not to follow the normal allocation process. We considered that it was unreasonable that the council had no record of the decision that was made. Therefore, we upheld Mr C's complaint.

Recommendations

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

• The council should now determine, without ambiguity, whether they were obliged to issue the plate to the day-to-day manager in these specific circumstances.
• The council should record all decisions to depart from the waiting list. This should include what evidence was considered and how the decision was made. The council should have a list of situations that could be considered as exceptional circumstances. This list should be made easily and publically available.

What we asked the organisation to do in this case:

• Following the council's consideration of our first recommendation, they should tell Mr C where he is placed on the list. If they were not under a legal obligation to issue the plate to the day-today manager, then they should confirm Mr C's place on the list.

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 first on the waiting list for a taxi plate from the council and had been on the list for many years. However, when a plate became available, Mr C did not receive it. He found that this had gone to a day-to-day manager who was not on the waiting list. Mr C complained that this decision was unreasonable.

We found that the council had no record of the decision taken to issue the plate to someone not on the waiting list. The staff who dealt with it were unavailable and there were no records. We also found that there is no clear policy that indicates what should happen, or what factors should be considered when not following the normal process of allocating a newly vacant plate to someone on the waiting list.

We decided it was unreasonable that the council had no record of the decision that was made or their reasoning for that decision. Therefore, we upheld Mr C's complaint.

Recommendations

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

• The council should now determine, without ambiguity, whether they were obliged to issue the plate to the day-to-day manager in these specific circumstances.
• The council should record all decisions to depart from the waiting list. This should include what evidence was considered and how the decision made. The council should have a list of situations that could be considered as exceptional circumstances. This list should be made easily and publically available.

What we asked the organisation to do in this case:

• Following the council's consideration of our first recommendation, they should tell Mr C what their decision is. If they were not under a legal obligation to issue the plate to the day-to-day manager, then they should consider how to remedy the injustice done to Mr C.

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 owns a property in a block of four. Some of the other properties in the block were believed to be owned by the council. Miss C complained that work undertaken on her property was not in line with the agreed mandate and that the council failed to provide her with appropriate information in relation to the works.

The council's Shared Repairs - Mutual Owners procedure provides information on the steps to be followed when a repair has been identified as shared with the owner of a private property. The council contacted all owners in Miss C's block giving a quote to paint the exterior of the property. The letter said that it was a notification of shared repair, and it enclosed a mandate which, when signed, indicated agreement to the council taking the lead on the repair. The council ultimately painted the exterior of Miss C's property, but none of the others in her block as the other occupiers had not agreed to the work being carried out. Miss C complained to the council that she only agreed to the work being carried out because she understood that all of the properties in the block were going to be painted. She said that if she had been made aware that the work was not going to be carried out on the whole block, she would not have signed the mandate, and that at no time had she agreed to being the only property to be painted.

The council said that the mandate signed by Miss C was not conditional on the agreement of other owners in the block. We found that the work carried out was not in line with the original mandate, as the original mandate had confirmed Miss C's agreement to shared repairs being carried out. We considered that, when it became clear that the other owners were not going ahead with the work, the council should have checked whether Miss C still wanted to go ahead. During the course of our investigation, it became clear that in fact none of the properties in Miss C's block were owned by the council. Therefore, the council were not in a position to invoke their Shared Repairs - Mutual Owners Procedure. We considered that there had been maladministration at every step in the process, and we upheld both of Miss C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the work carried out on her property not having been in line with the agreed mandate, ensuring that the apology meets the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Apologise for failing to provide Miss C with appropriate information in relation to the works, ensuring that the apology meets the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Apologise for unreasonably following their Shared Repairs – Mutual Owners Procedure in relation to repairs at Miss C's block, despite not owning any properties in the block. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Cancel the invoice for the works, or reimburse Miss C for any sums paid in relation to the work carried out at her property.

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

• The Tenement Management Scheme should be followed appropriately, ensuring that the Shared Repairs - Mutual Owners procedure is not unreasonably followed.
• The Shared Repairs - Mutual Owners Procedure and associated letters should be reviewed, and revised in the event that this is necessary.

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, who works for an advocacy and support agency, complained on behalf of her client (Miss A) who felt that she had been financially disadvantaged by delays in the council completing a kinship carer assessment. Miss A was undergoing assessment to be a kinship carer but was looking after the children while the assessment was ongoing. Miss A received payments from the council but believed some of these were calculated incorrectly. Specifically, she felt that one-off payments made prior to the referral for kinship care being made should not have been included in the calculation of financial support. The council acknowledged that there had been delays in the completing of the kinship care assessment but did not feel that Miss A had been financially disadvantaged during the process. Miss A was unhappy with this response and brought her complaint to us.

We took independent advice from a social worker. We found that the council was correct to include some of the one-off payments when calculating the financial support. However, we noted that the kinship assessment was delayed by a number of weeks. This meant that Miss A did not receive her kinship carer allowance as early as she would have if the assessment was completed on time. Therefore, we considered that Miss A had been financially disadvantaged due to the council's delay and upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Pay Miss A the outstanding amount caused by the delay in completing a kinship care assessment.

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

• The council should amend their kinship care policy to clearly reflect the legislation.

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 an elderly relative (Mrs A) that the council unreasonably charged her for a replacement front door after she left her council tenancy, and about the council's response to his complaint.

Mrs A changed the front door for one of her own preference several years ago. Upon leaving the tenancy, the council did a premises check. A year after leaving the tenancy, Mrs A was sent an invoice for a replacement front door stating that the door was damaged. Mr C queried this on Mrs A's behalf, stating that this was the first time they had been informed of any damage. Mrs A received a final demand for payment from a debt recovery agency working at the council's request.

We found that the council had no evidence of the inspection carried out before Mrs A left her tenancy, to show that they noticed and recorded the door as needing replaced, and informed Mrs A of this. Since Mrs A was a council tenant for over 30 years, and because of her age and state of health, the responsibility should have been on the council to remind Mrs A, at the time of the inspection, of her obligation to replace the door. There was no evidence that the council did this, or that they gave Mrs A the chance to replace the door before they charged her. The council could also have used their discretion not to charge Mrs A for the door, given her age and health. The council did not properly explain their discretion to Mr C, and gave him and us contradictory and conflicting information about it. The council said that they considered their discretion in Mrs A's case, but provided no evidence of this. Therefore, we upheld Mr C's complaint.

In relation to complaints handling, we found that a council officer did not make notes of phone calls with Mr C, and was unable to recall what was said when we asked. It was not clear which process the council used to deal with Mr C's complaint. In addition, we found that the council did not respond to key points of Mr C's complaint, and did not respond at all to his final email. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Cancel the invoice to Mrs A for the door and instruct the debt recovery agency to take no further action.
• Apologise to Mrs A for unreasonably charging her for a replacement front door. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Apologise to Mr C for the unreasonable handling of his complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Acknowledge that they had the power/discretion to consider waiving the charge.

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

• Housing staff should make a note of phone calls querying invoices, and retain evidence that they told the caller to contact the repair team with details of the dispute, so that the issues can be investigated.
• Housing staff should make a record of their consideration of such cases, including requests for discretion to be applied, and the rationale for the conclusion(s) reached.
• Housing staff should advise tenants, or their representatives, how to ask for the application of discretion for elderly and infirm people, advise what evidence is needed to support any such claim, and explain how their request will be considered.

In relation to complaints handling, we recommended:

• Housing staff should advise tenants, or their representatives, under which procedure their dissatisfaction is being handled.
• Housing staff should respond to all key points of a complaint.
• Housing staff should not ignore emails, but should provide an appropriate response.

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

Summary

Ms C complained about the care and treatment provided to her son (Mr A) by the partnership after he was diagnosed with psychosis. She considered that there were issues with his treatment plan which led to him having relapses. She complained that, when Mr A was admitted to hospital, he was not able to consent for information to be shared with her. She said that this was not addressed for several weeks. Ms C also complained that, after an occasion when Mr A came close to attempting suicide, there was a delay in meeting with her to discuss this. Ms C also raised concerns about how closely Mr A was monitored in the lead up to this occasion. In particular, she had concerns that Mr A was allowed to leave the hospital unchallenged, after she had raised concerns about his mood.

We took independent advice from a consultant psychiatrist. We found that Mr A's treatment plan was reasonable, as it took into account Mr A's own wishes about his treatment. However, we found that Mr A's ability to consent to share information with Ms C was not reviewed regularly after his admission to the hospital. The partnership had acknowledged this and had apologised to Ms C. We upheld this aspect of the complaint and we made a recommendation to improve this in the future.

We noted that the partnership had acknowledged an unreasonable delay in meeting with Ms C after the occasion when Mr A came close to attempting suicide. Although we upheld that aspect of the complaint, we found that the steps they had since taken to improve communication with Ms C were reasonable, and so we did not make any further recommendations in this regard.

We found that Mr A was appropriately monitored in the days leading up to the occasion when he came close to attempting suicide. However, the day before, Ms C raised concerns about Mr A's condition with hospital staff, which we found were not recorded. We also found that Mr A had briefly gone missing from the hospital on the night before he came close to attempting suicide and that he had been noted as being agitated. Given the concerns that Ms C had raised about Mr A earlier that day, and his agitation, we considered that a suicide risk assessment should have been carried out at that time. However, we found no record that this had been done. Therefore, we upheld this aspect of the complaint and we made recommendations in light of our findings. However, we did find that it was reasonable that Mr A was allowed to leave the hospital unchallenged that day, as he was allowed unaccompanied time out of the ward as part of his rehabilitation.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to record the concerns that Ms C raised about Mr A's condition. Also apologise that a suicide risk assessment was not carried out. The apology should comply with the SPSO guidelines on making an apology, available at: www.spso.org.uk/leaflets-and-guidance.

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

• When a patient has been deemed incapable, the partnership should regularly review the patient's capacity to give consent about sharing information. Relatives or carers should be kept up to date on those reviews.
• All significant events should be documented in the medical records, including feedback from relatives and carers about a patient's condition.
• In circumstances similar to Mr A's in the future, staff should carry out a suicide risk assessment.

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, who works for an advocacy and support agency, complained on behalf of her client (Mrs B). Ms C raised concerns that the board did not take appropriate action in relation to an ulcer on Mrs B's daughter (Ms A)'s heel. Ms A had a number of complex health conditions, including diabetes, and Ms C complained that neither the podiatrist that saw Ms A, nor the surgeon that saw her, raised any alarm about the fact the heel wound was getting worse.

We took independent advice from a podiatrist and from a surgeon. We found that Ms A should have been seen by the lead podiatrist at an earlier point and that this may have resulted in a swifter referral to a specialist team. We also found that the podiatry team failed to appropriately use diabetic foot screening tools. We further found that the surgeon that saw Ms A recommended a treatment that would not be normal practice and did not document any reason for this. We found that whilst they reasonably arranged a scan for Ms A's foot, this should have been done at an earlier point, and a management plan should have been made. We also found that the board's own complaints investigation did not identify or address the failings in the care provided to Ms A.

We upheld this complaint. However, since the events of this complaint, the board had implemented a detailed and comprehensive action plan to improve the care pathways for diabetic feet, which we found reasonable. We, therefore, limited our recommendations to areas which we felt had not been covered by the board's action plan.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for failing to take appropriate action in relation to Ms A's heel wound and for failing to identify these issues in the complaint response. 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:

• Patients with diabetic foot ulcers should be referred to the lead podiatrist or the vascular service as appropriate in a timely manner, and diabetic foot ulcers should be assessed in line with diabetic foot screening tools.
• In similar cases, surgeons should be aware of what action to take.

In relation to complaints handling, we recommended:

• The board's complaints handling procedure should ensure that failings (and good practice) are identified, and should enable learning from complaints to inform service development and improvement.

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, who works for an advocacy and support agency, complained on behalf of her client (Mrs B). Ms C raised concerns that Mrs B's daughter (Ms A) had not been provided appropriate care and treatment for an ulcer on her heel by practice nurses. Ms A had complex health conditions, including diabetes, and over several months practice nurses were dressing and monitoring the ulcer on her heel. The wound deteriorated and Ms A had to have an above the knee amputation as a result.

We took independent advice from a practice nurse. We found that the dressings and wound cleansing products used by the practice nurses were not in line with guidance, and that the ulcer was not assessed in line with Scottish Intercollegiate Guidelines Network guidelines. We also found that, given Ms A's other health conditions, the practice nurses should have taken steps to involve other specialisms at an earlier point. We found that it was not possible to say whether an earlier referral to a specialist would have prevented the deterioration in the wound, but we found that it would have resulted in a more controlled care experience. We also found that the practice's own complaints investigation did not identify or address the failings in the care provided to Ms A. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for failing to take appropriate action in relation to Ms A's heel wound and for failing to identify these issues in the complaint response. 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:

• Practice nurses and other clinical staff within the practice should be practising in accordance with the agreed wound formulary, unless there is a clear and robust clinical reason for opting for a non-formulary product, in which case, this should be clearly documented.
• Management of diabetic foot ulcers should be carried out in accordance with Scottish Intercollegiate Guidelines Network guidelines for the management of diabetic foot ulcers.
• Expert input should always be asked for if dealing with a difficult wound that is not healing.

In relation to complaints handling, we recommended:

• The practice's complaints handling procedure should ensure that failings (and good practice) are identified, and should enable learning from complaints to inform service development and improvement.

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 he had been refused a patient escort to his hospital appointment. Mr C lives far away from the hospital and said that he could not travel on his own due to his health conditions. The board said that Mr C did not meet the criteria for a patient escort.

We took independent advice from a nurse. They said that there was insufficient evidence to demonstrate that the board had reasonably assessed Mr C's health conditions and their impact on his ability to travel. We considered that it was not clear why Mr C did not meet the criteria and what, potentially, would be sufficient to meet the criteria. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Mr C with a full rationale for the decision not to allow him a patient escort.

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 attended the dentist to receive restoration treatment which included having a filling replaced, and previous fillings smoothed over as they still had overhangs of amalgam (mixture used to fill the teeth). The dentist who provided the treatment was undergoing vocational training, and was supervised by another dentist. Miss C complained that the treatment she received was below a reasonable standard.

We took independent advice from a dentist and found that overhangs of amalgam were still partially present, despite having been smoothed, and a significant gap was created between two teeth. Both the remnant amalgam and the gap were risks to Miss C's dental health, in particular as she had an underlying risk of tooth decay. We found that the treatment provided to Miss C was below a reasonable standard and, therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for providing treatment below a reasonable standard. 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 dentist's supervisor should ensure that the dentist has a periodontal update, concentrating on the impact of poor restoration contouring.

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.