Upheld, recommendations

Summary

Mrs C complained on behalf of her son (Mr A) about the care and treatment provided to him by the board in relation to his Crohn's disease (a chronic inflammatory disease of the intestines). Mrs C had a number of concerns, including that one of the medications he was prescribed resulted in him developing steroid-induced diabetes and that this had not been monitored appropriately. She was also concerned that Mr A was not appropriately prepared prior to surgery to remove the colon. Mrs C felt that Mr A should have been offered support and counselling on the seriousness and potential consequences of the surgery.

We took independent advice from a gastroenterologist, a GP, and a colorectal surgeon. We found that there were aspects of Mr A's care that were reasonable, including the care provided to him prior to his surgery. However, we found that there was a failing of a consultant to clearly delegate the monitoring of Mr A's blood sugar levels to his GP. We also found that the board had not followed the UK Inflammatory Bowel Disease standards when managing Mr A's care in that they did not discuss him at a multi-disciplinary meeting. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for failing to provide reasonable clinical treatment. 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:

• Any instructions from a consultant to a GP should be communicated to the GP in a clear manner.
• The board should consider adopting the UK Inflammatory Bowel Disease standards in the management of similar patients.

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 standard of pressure area care which his mother (Mrs A) received while she was a patient in Woodend Hospital. Mrs A was in hospital for a number of months and, due to her reduced mobility, developed a grade two pressure ulcer which progressed to a grade four pressure ulcer. A grade four pressure ulcer is the most severe kind, and people with grade four pressure ulcers have a high risk of developing life-threatening infections.

We took independent advice from a nursing adviser who noted that appropriate risk assessments were not carried out and incorrect equipment had been used in an effort to prevent the development of and healing of pressure ulcers. While the staff had taken action to change Mrs A's position in bed and when she was sitting in a chair, these were not changed frequently enough. There was also a delay by the staff in referring Mrs A for an assessment by the tissue viability service. We upheld the complaint.

However, we did note that the board have since carried out an investigation and audit which identified learning opportunities for staff in regards to knowledge and awareness of pressure area care.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for the failings in pressure area care. The apology should meet the standards set out in the 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

Mrs C complained about the medical treatment and nursing care that her late mother (Mrs A) received at Victoria Hospital. Mrs A had been diagnosed with advanced lung cancer and was admitted to hospital with symptoms of nausea and persistent vomiting. The issues Mrs C raised concern about related to a lack of blood testing to monitor Mrs A's kidney function as she had chronic kidney disease, that no intravenous (IV) fluids were given over two specific days and that fluids were not appropriately monitored, that there was a delay in a urinary catheter being inserted and that communication with the family was poor.

We took independent advice from a consultant in respiratory medicine and from a nurse. We found that there were a number of unreasonable delays in relation to Mrs A's medical care and treatment. We considered that if IV fluids had been administered in a timely manner, this may have delayed or prevented the development of an acute kidney injury (the inability to turn waste material into urine) and may have allowed Mrs A to spend more time with her family. We upheld Mrs C's complaint about medical care and treatment.

In terms of the nursing care, we found that there was a lack of comprehensive monitoring of Mrs A's fluid intake and urine output which the board's complaint investigation did not identify. We considered that such monitoring may have helped assist medical staff identify issues with urinary output sooner. We upheld Mrs C's complaint about nursing care.

We noted that the board had accepted that there were problems with the way in which staff had communicated with Mrs C and the family. Therefore, we have asked the board to provide evidence of the action that they said they would be taking to address this. However, we also recommended that the board take further action to address how they review the care and treatment of patients as their response to the complaint contained inaccurate information.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in Mrs A's medical and nursing care, and for the fact that the board's complaints investigation was not thorough enough.

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

• Review by a senior doctor for patients admitted as an emergency should be carried out in a timely manner.
• Difficulties with IV access should be escalated in an appropriate and timely manner.
• Fluid balance charts should be fully completed when indicated.
• Appropriate clinicians should be involved in the review of patient care to ensure that comprehensive responses to complaints are provided.

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 and treatment she had received from the board. However, during our investigation we were advised that Mrs C had commenced legal action against the board. We must not investigate any matter which has been, or is being, considered in a court of law. Therefore we did not take these aspects of Mrs C's complaint forwards.

Mrs C also raised concern about the board's handling of her complaint. We found that the board failed to provide updates and delayed in advising Mrs C that her complaint was out of time and would not be investigated, in line with the complaints procedure. We upheld this aspect of Mrs C's complaint.

Recommendations

In relation to complaints handling, we recommended:

• The board should review their arrangements for assessing new complaints to ensure that, where a complaint is out of time, this is identified in line with the model complaints handling procedure. Guidance and standards for good investigations are set out in the SPSO Investigations toolkit, available at http://www.valuingcomplaints.org.uk/learning-and-improvement/best-practice-resources/decision-making-tool.

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 that she had been unreasonably withdrawn from her university course due to lack of attendance at classes. She also complained that communication before and after her withdrawal was unreasonable in that it was confusing and unclear.

We found that the university's procedure for withdrawing students for non-engagement was not sufficiently robust. We found that evidence to support their decision to remove Ms C from the course was unsatisfactory. We also found that, when she appealed the decision, Ms C was disadvantaged by the poor explanation for their decision to withdraw her. We upheld both of Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Reconsider Ms C's appeal of the decision to withdraw her.

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

• The university should have a robust process which gives students clear information about their attendance requirements and warnings when their attendance falls below an acceptable level. Responses from students should be followed up and support and advice should be offered.
• Decisions to withdraw a student for non-engagement should be noted and key evidence should be retained.

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 removed from his PhD studies following his annual review on the basis of his academic knowledge and performance not being of the required standard to complete his studies. Mr C appealed the decision through the academic appeals process and in supporting his appeal, he complained that the university had not responded appropriately to his requests to change his academic supervisor. He considered that the university's failure to support him in this matter had had an adverse impact on his studies. The university considered this matter, together with a consideration of his academic performance, as part of the academic appeals process. The university considered that Mr C had access to supervisory support during his studies and that his academic performance was not impacted by the relationship with his supervisor. They upheld their original decision to remove him from the course. Mr C was not satisfied with this response and brought his complaint to us. Mr C complained to us that the university had failed to respond reasonably to his requests for a change of supervisor.

We requested relevant documentation from the university relating to their consideration of Mr C's concerns about his supervision. The university delayed in providing information to us, and were unresponsive to several communications requesting information. The university's response explained that they had failed to appropriately consider Mr C's concerns about his relationship with his supervisor and that the university's policy was to encourage the relationship to develop over the first year and review matters at the annual review. The university acknowledged that this was not appropriate in the circumstances and that they missed signs that Mr C's relationship with his supervisor had broken down. The university accepted that the concerns about Mr C's supervisor should have been addressed through their complaints procedure rather than at an annual review and through the academic appeals process. Given the issues highlighted, and the delays caused by their failure to respond to our requests for information, the university wished to offer Mr C a sum of money in compensation. We accepted the university's acknowledgement of their failures in this case and we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide an apology to Mr C for failing to properly consider and respond to his requests for a change in supervisor. This apology should comply with the SPSO guidelines on making an apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Offer Mr C the agreed sum of money in recognition of the failings in responding to his concerns and the delays in assisting us with our investigations.

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

• Requests for a change in PhD supervisor should be properly considered and managed regardless of when they were raised. The university should adopt a more appropriate policy for considering requests for changing supervisors and this should be available to students.

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

Summary

Ms C, who is an advocacy and support worker, complained on behalf of her client (Ms A). When Ms A moved between local authority areas she was unhappy about aspects of how her new council had handled that transition. Complaints were raised on her behalf about this, and these were eventually determined by a social work complaints review committee (CRC). The CRC made recommendations that the council accepted. However, Ms A was unhappy with how the council had handled her complaints and the actions they took to carry out the recommendations of the CRC. Ms C brought these complaints to us.

We found that the council had not responded to a significant complaint that had been raised on Ms A's behalf and had not carried out the recommendations of the CRC in a reasonable way, or in the way they had told Ms A that they would. We found that they had not considered Ms A's situation at a specific meeting when they said they would, and that they did not inform Ms A that her case was not discussed at the meeting. In light of this, we upheld Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Provide Ms A with an apology for:
• her poor experience during her initial transition of local authorities
• their failure to provide her with an apology for her poor experience in their previous apology letter
• not promptly alerting her and apologising to her that her case was not considered at a specific meeting where they said it would be discussed.

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

• The council should undertake a meaningful review of their processes for clients transitioning from other local authorities, supported at corporate level.
• The council should re-issue guidance in relation to communication and a person-centred approach towards transitions from one local authority area to another.

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, who is an MSP, complained on behalf of his constituent (Mr A). A council operative was instructed to clear a number of garages and dispose of the contents. The council operative opened Mr A's garage in error, cleared it and disposed of the items within it. Mr A realised that this had happened two days later and contacted the council. Mr A complained and the council admitted the error and advised Mr A to submit a claim for compensation for the disposed of items. This was handled by the council's claims handlers. They offered Mr A less than he had claimed for, as he could not provide proof of exactly what was in the garage.

Mr C complained to our office that the council had not taken reasonable precautions to ensure the correct garage was cleared and had not reasonably investigated his complaint.

We found the council had not carried out a sufficient investigation into how the mistake had occurred and it was still not clear how it had happened. We also determined that the council's claims handlers had therefore not been provided with sufficient information about the incident. We upheld both aspects of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to take reasonable precuations to prevent the incorrect garage from being cleared. Also apologise for failing to carry out a detailed eough investigation to identify what had happened. These apologies should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Re-investigate the course of the error and provide a copy of their report to the claims handlers. They should also include what appears to be a reasonable list of items provided by Mr A that were removed from the garage.

In relation to complaints handling, we recommended:

• Complaints should be investigated thoroughly.

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 reported longstanding problems with her heating and hot water and had raised previous complaints with the council about this. The council had attended Miss C's property when repair requests were raised, but did not find any issues and left with the heating in working order. Miss C made a formal complaint as she was unhappy with these findings and was of the view that the problem remained unresolved. The council responded initially by advising that, as a full inspection of the heating system had been conducted four months previously, there was nothing further that they could do. Miss C escalated her complaint which prompted an inspection from the housing area team leader and a plumber. They identified several parts which needed replaced and arranged to do this. The council's complaint response offered an apology to Miss C for the delays and stress this had caused. Miss C was unhappy at the level of service she had received and she brought her complaints to us. Miss C complained to us that the council had:

unreasonably delayed in carrying out appropriate heating and hot water repairs, in line with their obligations

failed to communicate reasonably with her throughout the process

failed to carry out a reasonable investigation into her complaints.

We obtained information from the council and were of the view that, whilst the responses to individual repair requests were prompt, the level of investigation was not proportionate to the longstanding nature of the problem. When the council had the opportunity to review their practice at stage one in the complaints process, they declined to take further action based on information obtained four months previously. They also were late in acknowledging Miss C's complaint, and late in responding to her. The council explained that an extension had been agreed with Miss C, but acknowledged that they had not confirmed this in writing and therefore had no evidence of this. We upheld all aspects of Miss C's complaint and recommended that a full and sincere apology was offered for all failings by the council. We also noted that the council had advised that training on communication had been carried out and we asked them for evidence that this training was undertaken.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for:
• the unacceptable delay dealing with her repair
• the poor level of service provided, including the failings in communication and the failings in their response to her complaint
• the level of stress and upset this caused Miss C.
• 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 is a council tenant and complained to the council about their failure to respond appropriately to his reports of his neighbour's anti-social behaviour. Mr C had been reporting anti-social behaviour for a number of years and the council started to take formal proceedings against the neighbour, however they stopped the action at a point, as they said that they received no further reports of anti-social behaviour from Mr C.

Mr C disputed this and received confirmation from Police Scotland of a number of reports that they had passed onto the council after the point when they had stopped the formal proceedings against the neighbour. Mr C complained that the council failed to inform him that they were no longer pursuing formal action against his neighbour.

In response to our investigation, the council acknowledged that they failed to investigate Mr C's reports of anti-social behaviour. They also acknowledged that they should have informed Mr C that they were no longer pursuing formal action against his neighbour. The council confirmed that they were reviewing their anti-social behaviour procedures and they invited Mr C to a meeting so that they can apologise and discuss his concerns. We upheld Mr C's complaints and asked the council to provide evidence of the action they said they would take.

Recommendations

What we asked the organisation to do in this case:

• The council should apologise to Mr C for their failings and invite Mr C to a meeting to discuss his concerns further should he wish to accept.

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.