Upheld, recommendations

Summary

Mr C complained about the way that the Scottish Prison Service (SPS) handled a form on which he had submitted his comments on the record of discussions held during his integrated case management (ICM) case conference. He had submitted the form through his personal officer, in line with the ICM Practice Guidance Manual. According to the guidance, the form should then have been forwarded to relevant parties who had attended the case conference for their comments. Mr C did not hear anything further for several weeks and, after he followed matters up with the ICM co-ordinator, he was advised that the form had not been submitted within the required timescales and so there would be no action from the prison based social worker.

Mr C submitted a complaint to the SPS, and after escalation the complaint was heard by an ICC (Internal Complaints Committee). The ICC found that the form had been submitted within the timescale and as such it should be considered. They did not set a timescale within which this should happen, and when nothing further appeared to happen Mr C brought his complaint to us.

We found that there were several stages at which the process had broken down. First, there was a delay in the receipt of the form being acknowledged, then there was a failure of the ICM co-ordinator to oversee the process by which the form was sent out to relevant parties for comment. Despite Mr C having raised concerns with the SPS, and failings being identified by the ICC, the SPS missed the opportunity to resolve matters at an early stage.

As well as not having imposed a timescale for action to be taken, the ICC failed to confirm what they would recommend as a result of the failings identified in Mr C's case to ensure that the matter was resolved appropriately. We upheld the complaint. An apology had already been made to Mr C, but we made a number of other recommendations.

Recommendations

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

• The ICM co-ordinator should ensure that comments from relevant parties are sought within a reasonable timeframe, following up where necessary, with a view to ensuring that an accurate record of the ICM case conference discussions is entered onto the relevant computer system as soon as reasonably practicable after the ICM case conference has taken place.
• Consideration should be given to imposing a set timeframe within which to acknowledge forms of the type that Mr C had submitted, and to obtain comments from relevant parties.

In relation to complaints handling, we recommended:

• If the ICC are recommending actions, where possible they should specify the timescale within which action is to be taken.
• Where failings are identified, the ICC should confirm in their response the steps to be taken to resolve the failings.

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 had a decree granted against him at court for a debt. The court sent a notification of this to the organisation that maintains the register of decrees. Mr C paid the debt, and was told that his name was taken off the register. However, some time later, it became apparent to Mr C that his name had not been taken off the register. Mr C complained to the registry organisation, who explained that his name had been entered on the register twice, as the court had sent them a duplicate record of the decree. Mr C complained that the Scottish Courts and Tribunals Service (SCTS) unreasonably sent a duplicate record to the registry organisation. He also complained about SCTS' handling of his complaint.

We looked at a copy of the information that the court sent to the registry organisation, which showed that SCTS had sent a duplicate record. We found that there was a responsibility on SCTS not to send a duplicate record, and so we upheld this aspect of Mr C's complaint.

Regarding complaints handling, we found that SCTS had mistakenly treated Mr C's complaint as if he were making a claim for financial compensation, rather than as a complaint about an administrative matter. SCTS acknowledged that they did not keep Mr C updated with the progress of his complaint, and that there had been a breakdown in communication between the court and SCTS headquarters. SCTS said that they would address this problem, and we asked them for evidence that they have done this. We upheld this part of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Mr C with a written apology for sending a duplicate record to the registry organisation. The apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.
• Provide Mr C with a written apology for failing to handle his complaint reasonably. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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 delays in the council's response to her request for them to fix a leak. She complained that the work was not completed until seven months after her request. Miss C was also unhappy as she felt the level of communication from the council during this time was poor.

The council told us that the delay in repairing the leak was caused by difficulties in accessing the property above Miss C's, as this was the source of the leak. However, they acknowledged that the delays in completing the repair were unacceptable. They also recognised that it took a significant amount of time to complete decoration and plastering work after the leak was fixed, although they believed this was down to Miss C not being readily available. The council acknowledged that they did not make attempts to explore alternative arrangements to access the property in Miss C's absence. The council also accepted that Miss C had not received appropriate communications throughout her experience, and they advised that staff training had been planned to address failings in this area.

We upheld both of Miss C's complaints. We found that the delays in carrying out the work were unreasonable, and we noted insufficiencies in the council's process. We found that Miss C was given conflicting information from different members of staff, and that she was not regularly updated on what was happening with her repair. As the work had been completed by the time Miss C brought her complaint to us, we did not make further recommendations on this aspect of the complaint. As the council had committed to undertake training to address failings in communication, we did not make further recommendations in this regard, though we did ask the council for evidence that this training had been carried out.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the delay in dealing with the repair and for the poor level of communication throughout the process. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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's handling of a planning application to extend a restaurant near his home. Mr C was concerned that a parking policy had not been taken into account when determining the application and that the planning service had not waited on a consultation response from the roads service at the council before approving the application. During their own consideration of the case, the council accepted that parking had not been covered in the planning officer's report for the application and they apologised for this failing.

We took independent advice from a planning adviser. We found that there was no evidence that the relevant policy for parking had been considered when determining the planning application. While there was no statutory requirement to await a roads service consultation response before determining the application, the advice we received highlighted that proceeding without all the relevant information was a key shortcoming. However, there was no evidence that proceeding without the consultation response made any difference to the council's decision to approve the application. On balance, we upheld the complaint. However, based on the advice we received, we did not consider that there was any further action that the council were required to take in respect of the application. We did make a recommendation to ensure that material considerations and relevant policies are taken into account when determining a planning application in the future.

Recommendations

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

• All material considerations should be taken into account when determining a planning application. The correct policies should be identified and referenced in the report of handling.

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 Mr A who is a kinship carer for his nephew (child B). Following the death of child B's mother, Mr A stepped forward and agreed to became his nephew's carer when no other family members were available. Mr A applied to the council for kinship care allowance (financial support which is available for those who are caring for a child who has a looked after status, who has previously had looked after status, who has been placed with involvement from the local authority or who is at risk of becoming looked after). The council did not award the allowance on the basis that child B had not been previously looked after and was not at risk of being looked after. Mrs C complained that this decision was unreasonable.

We took independent advice from a social worker. The adviser noted that the council did not carry out any assessment of Mr A or child B's needs. It was the adviser's view, which we accepted, that had Mr A not come forwards, child B would have undoubtedly have been received into care. For these reasons, we upheld the complaint and made a recommendation to the council.

Recommendations

What we asked the organisation to do in this case:

• Carry out an assessment of child B and Mr A's needs in order to determine whether the family are eligible for, or require, kinship care assistance.

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 is an MSP, complained on behalf of her constituent (Mrs B) about the decision made by Mrs B's daughter (Miss A)'s school to exclude Miss A from attending an overseas trip. Miss A has a condition which is a disability under the Equalities Act 2010. The school understood Miss A's health to be particularly poor and had concerns about safely managing her condition during the trip. The school carried out an additional risk assessment and sought advice from the council, who advised that a parent or guardian should accompany Miss A, otherwise she should be excluded for safety reasons. Ultimately, a parent or guardian could not attend, and Miss A did not go on the trip. Ms C complained that the school failed to take all relevant information into account when they decided to remove Miss A from the trip. Ms C also raised concerns about how the school communicated the decision to exclude Miss A to Mrs B and Miss A.

We found that, due to their concerns about her health, it was reasonable that the school carried out an additional risk assessment about Miss A's attendance on the trip. However, we found that the school should have given Mrs B a timescale to provide medical documents, which they did not. We also found that, during the decision making process, the school should have discussed Miss A's health and the support she may need during the trip with her. We also considered that the decision to remove Miss A from the trip should have been communicated to her directly by the school, and it was not. We therefore upheld these two aspects of Ms C's complaint.

Ms C also complained that the council did not take their responsibilities under the Equalities Act 2010 into account in their handling of the matter. We took independent advice from an equalities adviser. The adviser considered that the school had made a reasonable adjustment by organising medical training for staff attending the trip. However, we found that this should have been organised at an earlier stage in planning the trip. The equalities adviser also considered that the council should have advised the school about their responsibilities under the Equalities Act 2010 and their need to make reasonable adjustments. We found that the council did not advise the school of this. In addition, the equalities adviser said that the council's advice should have been tailored specifically to Miss A and her condition, which it was not. Therefore, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B and Miss A for:
• failing to obtain all relevant information in deciding whether to remove Miss A from the trip
• the shortcomings in how the decision was communicated to Miss A
• not taking their responsibilities under the Equality Act 2010 into account.
• 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:

• Young people should be allowed an opportunity to express their opinions and contribute in the decision making process for decisions which affect them.
• Staff training about managing pupil's health conditions should take place as early as is practical in organising a trip.
• The council's excursion policy should refer to the Equalities Act 2010 and give guidance on making reasonable adjustments to avoid discriminating against pupils with a disability.
• Council staff should be aware of their responsibilities under the Equalities Act 2010 and the need to make reasonable adjustments for pupils with a disability.
• Decisions about reasonable adjustments should be tailored to the individual concerned and how their condition specifically affects them.

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 housing association unreasonably delayed in repairing his windows after he reported a draught coming from them. Mr C said that he experienced delays due to contractors failing to turn up and difficulties in arranging a mutually convenient time for contractors to visit his property. In response to Mr C's complaint, the association visited him and offered him a monetary voucher as a form of redress for their delay in completing the repairs. Mr C also complained that the offer of redress was inadequate.

The association explained to us that they had to go through a process of elimination to find the source of the draught and that this led to the repairs taking longer than they anticipated. We were not critical of the association for this. However, we found that the delays in completing the repairs were also due to the association failing to inform Mr C that their maintenance officer was on sick leave and could not attend his appointment. The association also acknowledged that they failed to ensure that the contractors shared their sense of urgency about the repairs. We found that there was little evidence to illustrate that the contractors made reasonable efforts to contact Mr C to arrange a suitable time to visit his property. We also found that the association's calculation of the offer of redress applicable to Mr C was not entirely accurate and was not entirely in line with their Redress Procedure. We upheld both aspects of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• The association should make a more appropriate offer of redress, in accordance with their Redress Procedure.

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

• The association should review their internal procedures to ensure that, when a member of staff is unexpectedly absent from work, their appointments are contacted and rescheduled within a reasonable timescale.
• The association's maintenance staff and contractors should be reminded of their obligations towards tenants regarding repairs and the timescales they are required to work within.

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 care provided to his wife (Mrs A) during out-patient appointments at the cardiology department at Ninewells Hospital. Mrs A was referred to the cardiology department by her GP because of drop attacks (sudden episodes of collapse). Over the following 18 months, Mrs A attended consultations in the department and a number of investigations into her symptoms were carried out. During the period that Mrs A was waiting to be fitted with a cardiac event monitor device (a device to measure the heart's activity), she sustained a stroke and was admitted to hospital for treatment. Tests carried out during this admission indicated that Mrs A was in atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). Mr C complained that the board had failed to provide Mrs A with a appropriate treatment in view of her presenting symptoms and medical history.

We took independent advice from a consultant cardiologist. We found that the board managed Mrs A's condition appropriately, with the exception of the way they handled a referral from her GP approximately five months prior to the date of the stroke. We found that this referral described a change in Mrs A's symptoms and their pattern and the adviser said that the referral should have been considered more promptly and carefully by the cardiologist. The adviser said that further tests could have been considered and that, had these been carried out promptly, atrial fibrillation might have been diagnosed sooner. The adviser said that if atrial fibrillation was diagnosed, then medication would have been started and the likelihood of the subsequent stroke would have reduced. We were unable to conclude that better management would have changed the eventual outcome in this case. However, we upheld the complaint and made recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and Mrs A for the failings to handle the GP referral five months before the stroke in an appropriate manner. 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 should carefully assess whether a referral highlights a change in symptoms and their pattern, before promptly considering whether further investigations or actions are indicated.
• Waiting times for routine investigations, such as a patient being fitted with a cardiac event monitor device, should be minimised as far as possible.

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 that a GP at the health centre had failed to provide her with appropriate treatment during a consultation. She had attended the GP and had reported that a couple of days earlier she had been woken with severe pain on her left side. She wondered whether she had ruptured an ovarian cyst which she was known to have. Ms C said that the GP did not examine her or take her temperature. Ms C said that five days later she began vomiting and was admitted to hospital, where it was found that she had ruptured her bowel.

We took independent advice from a GP adviser. We found that the GP had suspected that Ms C may have ruptured an ovarian cyst and that they did arrange for an appropriate blood test and an ultrasound to be carried out. However, the adviser also said that the GP should have examined Ms C's abdomen and checked a urine sample as she had reported abdominal pain. Although the adviser felt that the GP should have performed a clinical examination, the adviser thought it was unlikely that Ms C had ruptured her bowel at the time she saw the GP as this would normally involve the onset of acute sudden symptoms. Ms C had also reported that her symptoms were improving when she saw the GP. The GP had carried out a Significant Event Analysis and they had recognised that they should have examined Ms C's abdomen. The GP said that they would examine patients' abdomen in future. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide a written apology for failing to carry out an appropriate assessment. 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:

• The GP should ensure that full and appropriate assessments are carried out based on the patient's 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

Mr C attended his dentist over a period of months for treatment for severe tooth pain. The dentist extracted one tooth and referred Mr C to the dental hospital to have a second tooth extracted. When Mr C attended the hospital, they identified a number of issues regarding his teeth. Mr C complained that his dentist had failed to provide the appropriate dental treatment and that, as a result, he had suffered with severe pain over a prolonged period of time.

We took independent dental advice. The adviser noted that the dentist did not keep adequate clinical notes in accordance with the guidance published by the General Dental Council. The dentist also did not appear to carry out some of the more basic investigations available for determining the cause of dental pain, and he did not report the findings of an x-ray he took of his Mr C's teeth, which is a requirement of the Ionising Radiation (Medical Exposure) Regulations (2000). We upheld Mr C's complaint and made recommendations.

Recommendations

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

• The dentist should consider the requirements for good clinical records as stipulated in the General Dental Council Standards and should consider the available guidance for good note taking.
• The dentist should consult Clinical Examination and Record Keeping Standards (FGDP RCS (Eng)), Key Skills in Primary Dental Care (FGDP RCS (Eng)) and the Management of Acute Dental Problems (SDCEP) for guidance on carrying out the more basic investigations available for determining the cause of dental pain and the treatments that are available.
• The dentist should make themselves aware of the requirements for reporting the findings of x-rays under the Ionising Radiation (Medical Exposure) Regulations (2000).
• The dentist should write up this incident as an Enhanced Significant Event Analysis and should include the incident as an agenda item in the next in-house dental practice team meeting so that learning can be shared among the practice.

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.