Upheld, recommendations

Summary

Mrs C complained on behalf of her husband (Mr A) about the care and treatment he received at Dumfries and Galloway Royal Infirmary. Mr A became unwell and was admitted to hospital. A heart scan identified that he had a gathering of fluid around his heart. Staff inserted a chest drain (a tube to remove fluid) but the next day staff discovered that the drain had become blocked. They made multiple unsuccessful attempts to insert another chest drain which resulted in significant bleeding. A decision was made to transfer Mr A to a hospital out with the board, which took place late in the evening.

Mrs C complained that the board failed to provide Mr A with appropriate medical care and treatment. She raised particular concerns about the actions of the staff in inserting chest drains and about the time taken to transfer Mr A to the other hospital. Mrs C also complained that the board failed to communicate appropriately regarding Mr A's condition.

We took independent advice from a consultant cardiologist. We found that bleeding is a recognised complication of the chest drain procedure and that it appeared reasonable. However, we found that records showed evidence of poor communication between staff and concerns about skills in relation to some members of staff. Regarding the transfer of hospitals, we found that the time taken to transfer Mr A to the hospital outside the board was unreasonable. We also found that the discharge arrangements were inadequate, given the complicated nature of Mr A's admission. Therefore, we upheld this aspect of Mrs C's complaint.

In relation to communication with Mrs C, we found that there was evidence of poor and limited communication with both her and Mr A, particularly surrounding the procedure to insert the chest drain and the transfer of hospitals. We upheld this aspect of Mrs C's complaint. However, we noted that the board had taken action to address a number of these problems.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A and his family for the failings in care, discharge arrangements and communication. 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 similar cases, consideration should be given to ensuring appropriate out-patient follow-up on discharge.

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

Summary

Mr C complained on behalf of his partner (Ms A) about the care and treatment Ms A received following an operation to her knee at Borders General Hospital. Ms A had been admitted for a planned day surgery but was kept in overnight for observation. In particular, Mr C complained that the board had failed to exercise proper care and attention to Ms A immediately after her operation, as no doctor or consultant saw her prior to discharge despite Ms A having been admitted overnight. He was also concerned that Ms A was advised to fully weight-bear following the operation.

We took independent advice from a consultant orthopaedic surgeon and a nursing adviser. The consultant orthopaedic surgeon indicated that, while there are a number of published protocols recommending non weight-bearing initially, the surgeon performing the operation was best placed to judge this, and that in this case the surgeon's recommendation to weight-bear was reasonable.

We were concerned about the lack of communication with Ms A during her overnight stay in the hospital, which the board had accepted and had apologised for. The advice we received from the consultant orthopaedic surgeon was that the delay in communicating Ms A's surgery details would not have an adverse impact of her prognosis. However, we considered that it would have been in line with established practice for Ms A to have been seen on a post-operative ward round during her hospital stay.

We also found that a hand-written operation note was inadequate in that it lacked detail, but we noted that Ms A had been managed in line with the post-operative instructions contained in the hand written note. Both the consultant orthopaedic surgeon and the nursing adviser were of the view that the overall the care and treatment Ms A had received had been reasonable. However, given our concerns about the lack of a post-operative ward round, the lack of detail in the hand written operation note and the lack of communication with Ms A, we upheld Mr C's complaint.

Recommendations

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

• A post-operative ward round should be part of routine surgical care.
• Post-operation instructions should contain adequate detail to allow the transfer of information.

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 us that the practice had failed to provide appropriate care and treatment to her late mother (Mrs A). She said that her mother had attended the practice on a number of occasions and was given a diagnosis of a chest infection, whereas she was in the final stages of lung cancer. Ms C was concerned that the practice had concentrated on a chest infection being the cause of her mother's symptoms. In addition, a chest x-ray which was taken showed signs of a cavity in her lung which was not followed up or mentioned to Mrs A or her family.

We took independent advice from a GP adviser and concluded that there were some failings in the level of care provided. During the initial consultations it was appropriate for the GP to arrive at a potential diagnosis of a chest infection and we found that appropriate investigations including an x-ray and blood tests were performed. However, we considered that once the chest x-ray result had been received which showed a cavity on the lung, then further action should have been taken. This would either have been to repeat the chest x-ray within a defined time frame with a view to onward referral to a chest specialist, or to make a direct referral at that time to a chest specialist. Further action should also have been taken as Mrs A's blood results revealed that she was anaemic. We also concluded that, although the final outcome would not have altered, the diagnosis would have been reached sooner and this would have allowed Mrs A and her family to make decisions regarding future care and support which would be required. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to follow upon the blood results and x-ray result.

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 failed her exams and was advised by the university that she could not resit them. Ms C appealed this decision and went through three stages of the appeal process. Ms C complained that the university failed to deal with all stages of the appeals process within a reasonable period of time.

We found that in relation to the second stage of her appeal, which was to the senate office, Ms C had to prompt the university to advise her that there was a delay. The university did not tell her the reason for the delay, and the decision was not issued within the timescale set out in the university's code of procedure for appeals to the senate office. 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 deal with the appeals process within a reasonable period of time. 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:

• Where an appeal is being considered, the university should ensure that the applicant is advised of any delay and the reason for that delay.

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 had unreasonably refused to progress his complaint about social work matters to a complaints review committee (CRC). The council said that a CRC was not the appropriate route for the issues raised by Mr C and did not fall within the remit of the committee. Mr C was unhappy with this response and brought his complaint to us.

We took independent advice from a social worker. We found that Mr C's complaint was eligible to be progressed to a CRC and, therefore, we upheld his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not holding a CRC. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• The council should now progress Mr C's complaint to a CRC.

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 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.