Upheld, recommendations

Summary

Mrs C complained about the care and treatment provided to her late mother (Mrs A) at Forth Valley Royal Hospital. Mrs A was admitted to the hospital following a collapse at home. During her admission, she fell and sustained serious injuries. Mrs C believed that the fall in hospital contributed to Mrs A's death a few days later, and that healthcare professionals failed to take appropriate action to minimise the risk of Mrs A falling, particularly in light of her complex medical history. Mrs C also raised concerns about complaints handling issues, including a failure to respond thoroughly and a delay.

We took independent advice from a nursing adviser who specialises in falls prevention and a medical adviser who specialises in acute medicine. We found that, while there was evidence that nursing staff had highlighted Mrs A's risk of falling and had put in place a number of interventions to address it, there were shortcomings in this. Mrs A's condition deteriorated shortly before her fall and we found that a further review of her needs should have been carried out then. We also found that, in the lead up to the fall, the amount of time that Mrs A was left on a commode with little supervision was excessive. Having said that, the advice we accepted was that the fall did not directly lead to her death. On balance, we upheld this aspect of Mrs C's complaint.

With regards to Mrs C's concerns about complaints handling, we found that the board's investigation was thorough and their position that they could not give Mrs C a definitive account of how Mrs A fell because nobody saw it was reasonable in the circumstances. However, we upheld the complaint because the time it took the board to respond to Mrs C was unreasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to take all reasonable steps to minimise the risk of Mrs A falling.
• Apologise to Mrs C for failing to deal with her complaint within a reasonable timescale.

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

• All reasonable steps should be taken to minimise the risk of patients falling.

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

Summary

Miss C complained about the dental care and treatment provided to her after she was diagnosed with gum disease. She complained that the dentist did not offer to refer her to a specialist for treatment, and instead recommended that she have her teeth professionally cleaned every three months. Miss C also complained that the dentist had not taken x-rays to assess for bone loss in the four years since she was diagnosed with gum disease. Miss C felt that as a result of the dentist's ineffective treatment of her gum disease, her condition had become worse.

We took independent dental advice. We found that whilst the treatment provided by the dentist to Miss C was reasonable in some respects, we found that they had not offered Miss C the opportunity to see a specialist for her gum disease when she was first diagnosed. We also found that the dentist had failed to follow guidelines with regards to charting the progression of the gum disease. We further found that the dentist had failed to record basic periodontal examination (BPE) scores, which according to the relevant guidance should be recorded at every appointment. We also found that the dentist failed to follow good practice and take radiographs when Miss C's BPE score was four (any score of four or above is considered to require monitoring and/or treatment). On this basis, we upheld Miss C's complaint.

Miss C also complained that the dentist did not reasonably respond to her complaint. We found that the complaint response did not tell Miss C that she could bring her complaint to us if she remained dissatisfied. Therefore, we upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to provide her with appropriate dental care and treatment for her gum disease.
• Apologise to Miss C for failing to respond reasonably to her complaint.

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

• When appropriate, offers to refer should be made. The offer and the response should be recorded.
• Charting should be carried out annually for patients who have undergone periodontal treatment.
• BPE scoring should be undertaken at least annually for all patients, in line with guidance.
• Radiographs should be taken for patients with a BPE score of four, in line with good practice.

In relation to complaints handling, we recommended:

• Complaint responses should include details for the SPSO.

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 the board unreasonably made changes to the arrangements for her to see the board's community psychiatric nursing (CPN) service. She said that her appointments with the CPN service had been changed from weekly to once every three weeks and that the appointments were held in a hospital rather than at her home. We took independent advice from a mental health nurse. We found that the board did not adequately listen to Ms C and did not take her views into account when it was decided to make these changes to her appointments. We upheld this aspect of Ms C's complaint.

Ms C also complained about the care she had received from the CPN service. We also took independent advice from a mental health nurse on this aspect of the complaint. We found that the care Ms C had received had not been of a reasonable standard. Ms C said that she had left messages on the service's answer machine, but that no one had called her back. The board's response to Ms C's complaint referred to restrictions in relation to the frequency of her phone calls, but there was no care plan or documentation within the case notes that outlined what these restrictions should be. We found that a care plan or protocol should have been in place to manage phone communication with Ms C, which could then have been followed by any member of staff. We also found that the board had failed to respond to correspondence from Ms C's GP and had failed to keep the GP adequately informed about her care. In light of these failings, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for not adequately listening to her and for not taking into account her views when it was decided to change her CPN appointment arrangements. Also apologise for the failings in CPN care and treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Arrange a discussion with Ms C about her needs and wishes. A care plan should be created which reflects these. A mutually suitable location for visits should also be agreed between Ms C and a member of the CPN team. If Ms C does not wish to engage with this process, a care plan should still be created to guide the interventions of the team and this should be shared with Ms C.
• The care plan referred to above should be put in place and within it there should be:
• risk assessments
• agreements on phone use and any limitations around this
• what can reasonably be expected in terms of return of any messages left for staff to ensure no misunderstanding
• the frequency and location of visits
• identification of goals
• any psychological therapies.

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

• To ensure that care is provided to a reasonable standard, the pathway and available interventions for people with Ms C's conditions should be reasonable, evidence-based and appropriate. The board should ensure that staff are implementing them appropriately.
• To ensure that care is provided to a reasonable standard, the arrangements for clinical and case load supervision of CPNs should be adequate and should enable staff to reflect upon their performance and discuss individual cases in depth.
• There should be regular and timely communication of any changes to care to relevant GPs and other health care providers who are part of the wider multi-disciplinary team.

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

Summary

Mr C contacted Revenue Scotland (RS) for clarification on whether Additional Dwelling Supplement (ADS) (a tax supplement on most purchases of additional residential properties in Scotland) would apply to him when purchasing a property. RS's initial response was that it did not apply. When Mr C was in the final stages of purchasing a property, he discovered that ADS did apply and that he would have to pay it. Mr C complained to us that RS failed to advise him of their opinion request process at the point of his first enquiry, that they failed to provide him with correct advice about the application of ADS in his situation, and that they failed to handle his complaint appropriately.

We found that RS mentioned the opinion request service to Mr C when they responded to his complaint, but that they did not inform him about it when he first contacted them asking for advice. Had they done so, he would have been able to request an opinion on the application of ADS at an earlier stage in the conveyancing procedure. We upheld this aspect of Mr C's complaint.

RS said that they do not provide advice on individual tax liability. However it was clear to us that, on this occasion, that RS had done this. Their response to Mr C's first enquiry clearly stated that ADS did not apply to him. This response to Mr C did not ask him for any further detail, did not indicate that Mr C could not rely on the accuracy of this response, did not ask him for any further detail, and did not signpost him to the opinion request service or refer him to his solicitors. As such, we found that RS had provided Mr C with inaccurate advice, and we upheld this aspect of his complaint.

We found that RS's response to Mr C's complaint did not adequately address the financial implications that their failure to give correct advice had had on him. Whilst organisations are entitled to reach their own conclusions on complaints following consideration of the available evidence, the conclusions should be reasonably supported by the evidence. In this case, we found that it was not reasonable for RS to conclude that the evidence did not support Mr C's complaint, at least in part. We upheld this aspect of Mr C's complaint.

We noted that RS had already taken action to ensure that the opinion request service is now referenced in all responses sent out, and that they had undertaken work with their staff to ensure that their responses to enquiries are now consistent with the position that they do not provide advice on individual tax liability. We also found that RS had apologised to Mr C more than once for their failings. As such, we did not make any further recommendations with regards to these aspects of Mr C's complaint.

RS told us that they have no discretion over whether to charge ADS, and that there is no legal mechanism under which they can waive or repay tax which is legally due. We accept this is the case. However, given that Mr C suffered financial detriment because of the inaccurate advice they provided to him, we made a recommendation to address this point.

Recommendations

What we asked the organisation to do in this case:

• Make a payment to Mr C as redress for the unanticipated financial loss he suffered as a result of their incorrect advice. The payment should be made by the date we have indicated. If payment is not made by that date, interest should be paid at the standard interest rate applied by the courts from that date to the date of payment.

In relation to complaints handling, we recommended:

• Complaint investigation decisions should be supported by, and make reference to, the available relevant evidence.

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 about the council's failure to empty her communal food waste bins and their failure to investigate her complaint.

Ms C told us that the communal bins were overflowing and that there was no bin liner in the bin. The problem continued to persist for a long time and Ms C tried to raise a formal complaint with the council. The council did not provide Ms C with a final response to her complaint.

We found that the council failed to empty the communal food waste bins on numerous occasions over a protracted length of time. We also found that the council failed to thoroughly investigate Ms C's complaint and failed to provide a satisfactory response for their failings. We upheld Ms C's complaints.

The council told us that they had been in touch with Ms C regularly to ensure that the service was now satisfactory. We asked for evidence of this and did not make any further recommendations regarding bin pick-ups. However, we did make recommendations regarding the handling of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Write to Ms C to apologise for failing to investigate her complaint in line with their procedures. They should provide an explanation for their failings.

In relation to complaints handling, we recommended:

• Complaints handling staff should be reminded of the complaints handling procedure.

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 applied for, and was granted, planning permission to create a pavement crossing and a parking area within his garden. An additional permit was required for the excavations needed to lower the kerb. The council, having initially given Mr C verbal approval, did not issue a permit for the dropped kerb. Mr C complained to us that he was unreasonably given conflicting information in relation to the dropped kerb application. Mr C said he had already paid a contractor to lay paving slabs to make the parking area, which he was unable to use. Mr C also complained that the council took too long to respond to the complaint.

We found that the planning process and the process by which permission can be sought to carry out excavations to a road are governed by entirely separate legislation. The council's roads service failed to submit an objection to Mr C's planning application by the deadline date. Their objection related to the impact that Mr C's plans would have on other residents, in particular that it would reduce the number of available on-street parking places. It was not clear what impact, if any, this objection would have had on the planning committee decision.

The relevant roads legislation says the council may give permission to excavate the public road. In this case the council did not do so. We found that there was unreasonable confusion in respect of the permit application. Verbal permission should not have been given until any concerns about it had been properly considered by the council. We upheld this aspect of the complaint.

We found that the council failed to issue responses to Mr C's complaints within the timescales set out in their policy. We took into account that the council had already offered sincere apologies for the lengthy delay. We upheld this aspect of the complaint.

The council told us they were in the process of carrying out a review of the planning process where a separate permit to carry out excavations in the road or footway are subsequently required. We asked the council to let us know the outcome of this review.

The council told us they had invited Mr C to make an insurance claim for reimbursement of the cost of work already carried out before the permit was refused. We asked the council to let us know the outcome of any claim Mr C submitted.

Recommendations

We recommended that the City of Edinburgh Council:

• advise us of the outcome of the review already underway in relation to the planning process in cases where Section 56 permits are subsequently required; and
• advise us of the outcome of the insurance claim.

Summary

Mr C complained about the council's handling of a planning application for a two-storey extension, which had been submitted by his next door neighbour. Neighbour notifications had not been sent out, and Mr C only found out about the application after planning permission had been granted.

Mr C complained that a council case officer had failed to identify significant visual intrusion into his property from a balcony on the extension. The report of handling made no mention of the balcony, and the case officer had not retained any calculations on the file.

The council provided new calculations, which they said confirmed that the proposal was acceptable. However, in view of shortcomings in the way the application was handled, they agreed to contact the developer to request that the height of a privacy screen at the end of the balcony next to Mr C's property was increased, which was agreed and approved.

We took independent advice from a planning adviser. Although the council had drawn up new diagrams and calculations since Mr C complained to them, the adviser commented that their lack of detailed annotation was such that the adviser was unable to interpret them, so could not say whether the council's conclusion that the proposal was acceptable was reasonable. The adviser did not consider that the council had provided sufficient reason to justify the omission of the balcony from the report of handling, noting that the absence of the balcony was clearly significant in this case.

Although the report of handling gave some consideration to visual intrusion from the extension into Mr C's property, we considered the council's failure to consider the impact of the balcony in the report to be an unacceptable oversight. We therefore upheld this complaint.

Mr C also complained about the council's response to his complaint. He was dissatisfied that they had failed to address his concern about visual intrusion into his property through side windows, which had been omitted from their diagrams. He was also dissatisfied with the council's explanation as to why the overshadowing caused by the property was not a material consideration.

We found that the council's response could have been clearer in relation to some technical points. We also noted the adviser's comments that the lack of detailed annotation made it difficult to assess whether their response was reasonable. The council said it was clear that the case officer had assessed the distance from the balcony to Mr C's sun windows, with regard to the council's policy on home extensions, but given that the report of handling had overlooked the existence of the balcony altogether, and no calculations had been retained, we found this statement disingenuous.

We considered that the council's response to the complaint had been unreasonable. We therefore upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Mr C with a written apology for failing to reasonably evaluate the planning application with regards to the extent of the visual intrusion into his property and for unreasonably responding to Mr C's complaint. These apologies 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:

• Case officers should ensure that their reports are comprehensive, retaining all calculations on file for reference.

In relation to complaints handling, we recommended:

• Complaints handling staff should ensure that complaints responses adequately address all complaints. Where technical matters are being explained, care should be taken to ensure that these can be understood by a layperson.

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 to us that the council failed to take reasonable action in relation to complaints he had made to them. Mr C's home is next to an open area of council greenspace. A nearby school uses the greenspace for organised sports lessons and school team activities. These uses often result in balls arriving in Mr C's garden. He sought information from the council about their designation of the land and the council told him that it was designated as an amenity residential open space. Once Mr C received this information he complained to the council that, given this designation as an amenity residential open space, the use of the greenspace for sports activities was contrary to their parks rules. Mr C was dissatisfied with the council's response and raised his complaints with our office.

The council explained to us that the land in question is not designated as amenity residential open space and that it in fact forms part of a school estate and is part of the school's playground area. The council clarified that the land is designated as open space as it is also accessible by the general public when not in use by the school. During our investigation, we looked at the relevant council policies alongside the history of the land in question and the legal restrictions on its use. We concluded that the council's position was reasonable and that, consequently, no action was required by the council.

However, we were critical of the council as we considered that they had failed to investigate properly and had failed to respond accurately to Mr C's complaints. We made a recommendation in relation to this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to properly consider his complaint.

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 late father (Mr A), who had bowel cancer. She complained that there was an unreasonable delay between a referral being made by Mr A's GP and his treatment starting at Ninewells Hospital. Ms C also complained that the care and treatment provided to Mr A in Ninewells Hospital was unreasonable. She raised further concerns that the standard of communication between the board and Mr A and his family was poor. Finally, Ms C complained that the board's handling of her complaint was unreasonable.

We took independent advice from a consultant gastroenterologist and a consultant colorectal surgeon. We found that there was an unreasonable delay between the referral by Mr A's GP and his treatment starting at the hospital. Mr A's GP had made a routine referral to the board's colorectal service and we found that this referral should have been reprioritised by the board as urgent because Mr A had high risk symptoms. In view of this, we upheld this aspect of Ms C's complaint.

Mr A had elective right hemicolectomy (removal of the right side of the large bowel through keyhole surgery). Four days after this, he returned to theatre for emergency surgery. Following this surgery Mr A was transferred to the intensive care unit (ICU), where he died the following day. We found that the surgery and the care Mr A received in the ICU had been reasonable. However, we found that there was an unreasonable delay in starting Mr A on antibiotics when his condition deteriorated in the ICU. We were also concerned that the frequency of consultant review following Mr A's surgery was not in line with published good surgical practice standards. We also found that the standard of record-keeping was unreasonable, particularly as there were gaps in the medical records. In light of this, we upheld this aspect of Ms C's complaint.

We found that the communication with Ms C, Mr A and the wider family about Mr A's care and treatment had been unreasonable. We further found that the consent for the initial surgery was not obtained in line with guidance from the Royal College of Surgeons. As such, we upheld Ms C's complaint.

Finally, the board accepted that the handling of Ms C's complaint had been unreasonable and said that they had taken action to improve their complaints handling. In view of the failings identified, we upheld this aspect of Ms C's complaint, but did not make any recommendations about this as the board had already taken action.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for:
• the unreasonable delay between the referral to the board and the commencement of treatment
• the unreasonable care and treatment provided to Mr A
• the unreasonable communication and poor complaints handling.

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

• Referrals to the colorectal service from GPs should be appropriately validated to ensure that patients with high risk symptoms are prioritised. In order to facilitate this, the referral form for GP referrals to the colorectal service should ensure the proper documentation of details of symptoms, such as the extent of weight loss and anaemia.
• Appropriate action should be taken in the event of deterioration of a patient, especially in the event of a rise in early warning signs. Antibiotics should be administered in line with the board's observation chart.
• In-patients should be reviewed by a consultant surgeon (or equivalent), in line with the published good surgical practice standards.
• Surgeons should obtain the patient's consent in the pre-operative clinics, as per guidance from the Royal College of Surgeons. Patients should be provided with a copy of the consent form for reference and reflection at that time.
• Patients and/or their relatives should be kept fully informed after critical illness events.
• Medical staff should maintain reasonable medical records, in line with General Medical Council 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 called 999 when his wife (Mrs A) became very unwell. A paramedic arrived five minutes later, and told Mr C that an ambulance would be on its way. However, the ambulance did not arrive for about half an hour, and only after the paramedic called to request back-up. During this time, Mrs A stopped breathing. The paramedic assisted her breathing and she recovered to some extent. However, after the ambulance arrived, Mrs A suffered a cardiac arrest. Staff carried out cardio-pulmonary resuscitation (CPR - where the heart and/or breathing is re-started if it stops), which was successful at restoring her pulse. Staff transferred Mrs A to the ambulance and took her to hospital. While in the ambulance, Mrs A suffered a second cardiac arrest. Staff again began CPR, and this was continued until Mrs A was handed over to hospital staff. Hospital staff continued the CPR, but this was unsuccessful and Mrs A died in hospital shortly after her arrival. Mr C complained about the delay in the ambulance arriving and the lack of communication from ambulance service staff, including the way they handled his complaints.

The ambulance service upheld Mr C's complaints and apologised. They said there were opportunities to send an ambulance earlier, but these were missed. The ambulance service said they would discuss the communication complaint with the staff involved and senior managers would review their procedures to ensure that ambulance support is provided earlier in future. Mr C was dissatisfied with this response, and he brought his complaint to us.

We took independent advice from a consultant in emergency medicine. We found the delay in sending an ambulance was unreasonable, and a lack of clarity in the ambulance service's policies had contributed to this. However, we noted that the ambulance service have now updated their policies and adopted a new response model, which should prevent a recurrence of the failings in this case. We found the treatment of Mrs A's respiratory and cardiac arrests was appropriate. However, the clinical records were poor so it was not possible to determine whether the overall care and treatment was reasonable. We also found the ambulance service took an unreasonable time to respond to Mr C's complaint and did not provide a detailed explanation of the events, despite the investigating officer telling Mr C they would provide this. We upheld all of Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the poor records kept by the paramedic and ambulance crew as this poor record-keeping meant it was not possible to determine whether the overall care and treatment given to Mrs A was reasonable. This apology should comply with SPSO guidance on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Adverse incidents such as this should be reported and investigated through the ambulance service datix system (a system for tracking and reporting incidents).
• The Ambulance Control Centre dispatcher involved should reflect on and learn from Mr C's family's experience, with appropriate support.

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.