Upheld, recommendations

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.

Summary

Mrs C complained about the care and treatment given to her late husband (Mr A) on a number of occasions that he was admitted to Southern General University Hospital. Mr A suffered from a number of medical conditions, including heart failure, vascular disease, kidney impairment and epilepsy. Mrs C said that he was not treated holistically and she complained that her concerns about this were ignored. Mrs C said that this had severe consequences and that, when Mr A died, the family were totally unprepared and shocked as they had been given no indication of the seriousness of his condition. Mrs C also complained that Mr A had not been offered palliative care towards the end of his life.

The board accepted that communication with Mrs C and the family had been poor, but said that the nature of Mr A's condition meant that it could change very quickly. The board considered that Mr A had been treated and cared for reasonably.

We took independent advice from consultants in acute medicine and cardiology and from a senior nurse. We found that communication with the family was limited and that there was very poor documentation of what was said. We found that staff did not respond to the issues Mrs C and her family raised with them. We further found that there was no evidence to suggest that Mr A's seriously deteriorating condition was discussed with the family, and that opportunities to do so were lost. As a consequence, the family were unprepared for Mr A's death. Finally, we found that there were no discussions about palliative care. Had these taken place, there would have been an opportunity to establish what Mr A's wishes were and how to best manage his symptoms. We upheld all of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for:
• failing to respond to her concerns
• failing to advise her and the family about Mr A's condition
• missing opportunities to start a discussion about palliative care
• 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:

• Any concerns raised by a patient's family should be recorded appropriately in the notes.
• Where appropriate, families should be kept fully informed of a patient's medical condition and the options for treatment.
• Unless otherwise indicated, patients and their families should be given clear and honest information about the severity of illness and risk of death.

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 raised concerns about the care and treatment she received for urinary incontinence at a number of hospitals within the board's area.

Mrs C complained that there was a failure to provide her with a reasonable standard of care and treatment and a failure to provide her with a treatment plan. We took independent advice from a consultant urologist. We found that it was clear that Mrs C had struggled with severe urinary incontinence for several years. While the initial care and treatment that she received was managed correctly, there was subsequently unreasonable delays in her treatment and in providing her with an appropriate treatment plan. We therefore upheld these aspects of Mrs C's complaint.

Mrs C also complained that there was a failure to communicate with her appropriately about her treatment. The adviser found that the board had not been supportive of Mrs C, considering the unnecessary delays which she had experienced and the impact this had evidently had on her. The adviser concluded that, as Mrs C did not appear to have an understanding of the cause of her problem, she should have been offered an urgent discussion about this and should have been told about the best treatment to restore urinary control. We considered that this should have been recognised by the board at an earlier stage and we upheld this aspect of Mrs C's complaint.

Mrs C further complained that there was a failure by the board to respond to her complaint appropriately. The board accepted that their complaint response letter did not make it clear to Mrs C that they could only consider her treatment covering a specified period of time. We found that the board should have explained this to Mrs C and should also have explained the reasons why this was the case. Therefore, we upheld this part of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings identified in our investigation, including:
• delays in Mrs C's care and treatment
• a delay in providing Mrs C with an appropriate treatment plan
• failing to communicate with Mrs C appropriately about her treatment
• failing to respond appropriately to Mrs C's 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.

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

• Measures should be in place so that other patients are not affected similarly by delays in treatment.
• Measures should be in place so that patients are provided with a treatment plan without delay.
• Staff should be reminded of the need to be supportive and to show empathy to patients, where there are delays in treatment.

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 (Mrs A). Ms C complained that the board had failed to provide a reasonable standard of nursing care to Mrs A's late husband (Mr A) when he was a patient at Inverclyde Royal Hospital. Ms C further complained that the board failed to provide Mr A's family with a definitive cause of death, and that their significant clinical incident investigation was not completed in a timely manner.

We took independent advice from a nursing adviser and a consultant physician. We found that there were failings in the nursing care provided to Mr A and we upheld this complaint. However, we considered that the board had appropriately identified and apologised for these failings, and had carried out a large number of improvement actions. We did not make any recommendations in relation to this aspect of Ms C's complaint.

We found that, whilst it was reasonable that clinicians were initially uncertain as to Mr A's cause of death, it was unreasonable that they disagreed about it in front of Mrs A and other family members at a meeting. Therefore, we upheld this complaint. We noted that the board had apologised for this matter, and we made a recommendation in relation to this aspect of the complaint.

Finally, we found that the board had unreasonably failed to complete their significant clinical incident investigation report in a timely manner, and we upheld this aspect of the complaint. However, we found that the board had taken appropriate action to address this failing and so we did not make any recommendations in this regard.

Recommendations

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

• When appropriate, a preparatory meeting of the staff involved should be carried out prior to meeting with families about complaints, in order to allow meetings to go more smoothly and to avoid potential disagreements amongst staff in front of families.

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 cardiology care and treatment given to her late husband (Mr A) when he was a patient at Aberdeen Royal Infirmary. Mr A was admitted to hospital and reported having chest pains and shortage of breath. During his admission, Mr A was also seen by the diabetic team and urology advice was taken.

The next month, he attended the cardiology clinic and he was noted to have continuing and increasing breathing difficulties. It was recommended that he be admitted for tests. However, in order to first rule out an infection, he was referred to the Acute Medical Initial Assessment Unit (AMIA). A few months later, Mr A was admitted to the AMIA for the second time as he was reporting chest pains and breathlessness. The cardiology team were contacted and it was decided only to manage his medical conditions, and not for him to have a clinical review at that time. He was later discharged.

Mr A died the following month and Mrs C believed that this was as a result of the pills he had been taking and she said that she felt he had not been treated properly. She also said that communication had been poor and that Mr A's unexpected death came as an enormous shock. She complained to the board and they considered that Mr A had been treated appropriately. Mrs C then brought her complaints to us.

We took independent advice from a consultant cardiologist and we found that Mr A's cardiology care had not been of a reasonable standard. We found that Mr A and Mrs C had not been given the opportunity of cardiac rehabilitation education. We found that a diuretic (a drug that enables the body to get rid of excess fluids) was recommended to Mr A during his treatment, but that he declined this. The adviser was concerned that this was not discussed further with Mr A during subsequent admissions to hospital. We found that after his second admission to the AMIA, it may have been preferable for Mr A to have been reviewed by the cardiology team. We also found that during Mr A's final admission to hospital, his follow-up should have been more timely. For these reasons, we upheld Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in Mr A's care and treatment, and for the failings in communication. 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:

• Patients should receive appropriate medical management including where appropriate, diuretic treatment. Contact between the acute medical and cardiology units should be improved.
• Information and education should be available to long-term cardiac patients.
• To avoid breakdowns in communication, staff should listen to patients and/or their carers and consider any concerns they express.

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 to the council following an upgrade to her heating system. She told us that after the work was carried out she noticed that her furniture, carpet and other personal items had been damaged and she submitted an insurance claim to the council. The council denied responsibility for causing damage to her property. She complained that the council unreasonably delayed in the handling of her insurance claim. The council offered to have her carpet re-laid as a goodwill gesture. Mrs C complained that the council delayed in repairing her carpet.

Regarding the insurance claim, our investigation found that the insurers requested a report from the council. However, the council employee that received the request was on sick leave and this was not picked up by another member of staff. We upheld this complaint and fed back to the council that they should consider reviewing their internal procedures to ensure cases are progressed while a member of staff is on leave. Our investigation also found that the council took 19 weeks to repair the carpet and we considered this to be unreasonable. We upheld this complaint and asked the council to provide Mrs C with a written apology.

Recommendations

What we asked the organisation to do in this case:

• Write to Mrs C to apologise for the unreasonable 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.