Mid Scotland and Fife

Overview
The complainant (Ms C) raised a number of concerns relating to the issue of a Certificate of Completion by Perth and Kinross Council (the Council) for works undertaken to her flat in 2004/2005. She complained that some of the work had not been undertaken properly and that appropriate checks were not undertaken by the Council before they issued a Certificate of Completion. This was issued to the former owner of her flat (Mr F), who had applied for a building warrant for the repairs and work to refurbish the property. Ms C was dissatisfied with the consideration given by the Council to pursue Mr F to undertake the outstanding works, by enforcement or other action.

Specific complaints and conclusions
The complaints which have been investigated are that the Council:

• (a) failed to ensure that grant-aided works were undertaken properly (not upheld);
• (b) failed to carry out appropriate checks before issuing a Certificate of Completion (not upheld);
• (c) failed to provide appropriate advice when a Certificate of Completion was issued (not upheld); and
• (d) failed to take enforcement or other action (not upheld).

Redress and recommendations
The Ombudsman has no recommendations to make.

Overview
The complainant (Ms C) raised a number of concerns that a GP from her mother (Mrs A)'s GP Practice (the Practice) and a consultant psychiatrist working for Fife NHS Board (the Board) prescribed anti-depressants and anti-psychotics to her mother without adequate assessment and had failed to report concerns about potential unprofessional conduct of a nurse to the appropriate organisation.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) the Practice unreasonably prescribed anti-depressants to Mrs A based on information from a third party (not upheld);
• (b) the Practice unreasonably changed a routine psychiatric referral to an urgent referral based on information from a third party (not upheld);
• (c) the Practice failed to refer the actions of another health professional, which they knew had given rise to professional concern, to the appropriate authority (upheld);
• (d) the Board unreasonably prescribed medication to Mrs A based on information from a third party (not upheld); and
• (e) the Board failed to refer the actions of a health professional, which had given rise to professional concern, to the appropriate authority (upheld).

Redress and recommendations
There are no recommendations in respect of the Practice.

The Ombudsman recommends that the Board take steps to remind all clinical staff, including Primary Care staff and Family Health Service providers in the Board area, of their professional duty to act when they have a concern about the fitness to practise of a health professional.

The Board have accepted the recommendation and will act on it accordingly.

Overview
Mr and Mrs C, and Mr and Mrs D (the Complainants) are two sets of parents who raised a number of concerns about a school trip to France that their daughters (Miss C and Miss D) had attended in October 2007. Their concerns were subsequently investigated by the secondary school (the School) and North Lanarkshire Council (the Council).

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) the planning/management of the trip was inadequate (upheld);
• (b) the investigation into an incident on the trip was inadequate in that the School asked students to complete a questionnaire without involving or informing parents; a senior male teacher interviewed female students about sensitive issues; the Head Teacher made unsubstantiated allegations about some of the students and some of them consider that they have been victimised; the matter should have been referred to the police or the other local authority involved; and parents were not kept informed of the progress of the investigation (partially upheld); and
• (c) the Council should have offered counselling to the students (no finding).

Redress and recommendations
The Ombudsman recommends that the Council:

• (i) ensure that the revised draft procedures on excursions and outdoor activities are finalised urgently;
• (ii) ensure that the new procedures contain adequate guidance on agreeing and discussing expected standards of behaviour with parents;
• (iii) consider how they can improve the procedures for notifying parents promptly of changes in the arrangements for school trips and excursions;
• (iv) issue an apology to the Complainants for the failings identified in relation to the investigation into the matter; and
• (v) take steps to ensure that complainants are kept informed whilst an investigation into a complaint is ongoing.

The Council have accepted the recommendations and will act on them accordingly.

Overview
The complainants (Mr C and his partner Ms C) were unhappy about the care provided to Ms C during her pregnancy by Lanarkshire NHS Board (the Board). Sadly, Mr and Ms C's daughter (Baby A) was stillborn on 21 October 2007. Mr and Ms C considered a number of warning signs had been missed and, in particular, a scan at 36 weeks which showed the umbilical cord near Baby A's neck should have been followed up. They also complained about the postnatal care provided and that the response to their complaint was not adequate.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) the care and treatment provided to Ms C during her pregnancy was inadequate (upheld);
• (b) there were failings to ensure appropriate support was provided following the death of Baby A (upheld); and
• (c) the response to Mr and Ms C's complaint was not adequate (partially upheld, to the extent that full information was not provided at the time of Mr and Ms C's complaint).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) reassess the training provided to midwives on cardiotocographs, given the failure to recognise, record or follow up the deceleration correctly;
• (ii) review the use and purpose of the Board's telephone call records, given the failure to complete any record on 18 October 2007 and the presence on file of a badly completed record;
• (iii) apologise to Mr and Ms C for failing to recognise, record and respond appropriately to the deceleration;
• (iv) review their standard care pathway for bereaved parents, in light of the concerns raised in this report and the best practice examples elsewhere in NHS Scotland, and ensure that parents are given timely advice about counselling;
• (v) review the supervision arrangements for their ante-natal clinics taking into account the advice received in paragraph 17 and inform the Ombudsman of action taken as a result of this review;
• (vi) apologise to Mr and Ms C for failing to communicate with their GP, in line with their procedures, and for the time taken to provide them with information about counselling; and (vii) when responding to complaints, take into account the need to provide as full information as possible, particularly where interviews have been held with staff.

Overview

The complainant (Mrs C) raised a number of concerns about the way complaints were dealt with by North Lanarkshire Council (the Council) and the Council's Education Department (the Department).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Council failed to properly handle complaints made by Mrs C and her husband (Mr C) (upheld); and
• (b) procedures in the Department for considering complaints are biased against the complainant (upheld to the extent that there is insufficient independence in the complaints process).

Redress and recommendations

The Ombudsman recommends that the Council:

• (i) apologise to Mr and Mrs C for the failings identified in the handling of the complaints; and
• (ii) review their complaints process and include an independent element in the final stage of the process for handling complaints about education. Additionally, the Ombudsman suggests that the Council should ensure that information about how to make a complaint about a school or their staff is made available in the Council's schools.

Overview
The complainant (Mr C) raised a number of concerns about Fife Council (the Council)'s handling of an application for planning consent by a community group to upgrade a children's play area in a public park adjoining his home which he did not consider had been installed according to the approved plans.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) in reaching a decision to grant planning consent for the application, the Council failed to have proper regard to the amenity of neighbours (not upheld);
(b) the Council's planning enforcement team had not properly investigated the issue of whether the development as built complies with the approved plans (upheld); and
(c) the Council had not taken appropriate steps to secure for the public record a copy of the approved plans (partially upheld).

Redress and recommendations
The Ombudsman recommended that, in light of the failure to obtain a copy of the approved plans, the circumstances be reported to the appropriate committee as a potential enforcement action issue.

The Council have accepted the recommendation and will act on it accordingly.

Overview
The complainants (Mr and Mrs C), raised a number of issues relating to South Lanarkshire Council (the Council)?s handling of a planning application for the formation of a first floor extension above an existing garage and the erection of a one and a half storey extension to the rear of a neighbouring property.

Specific complaints and conclusions
The complaints which have been investigated are that the Council:
(a) failed to consider properly objections relevant to the application (not upheld);
(b) included misleading and incorrect information in their report to the planning committee (not upheld);
(c) granted planning permission against relevant planning policies (not upheld);
(d) failed to apply Building Research Establishment guidance properly in relation to sunlight (not upheld);
(e) failed to calculate correctly sunlight availability in relation to Mr and Mrs C?s property (not upheld);
(f) failed to allow Mr C to give personal statements to the planning committee (not upheld); and
(g) failed to handle Mr and Mrs C?s formal complaint in line with the Council?s complaints procedure (not upheld).

Redress and recommendations
The Ombudsman has no recommendations to make.

Overview
The complainant (Mr C) raised a number of concerns about the way in which Falkirk Council (the Council) had dealt with the development of land to the rear of his home and, in particular, the development of the nearest plot (the Plot). He also complained that the Council had failed to respond in a timely manner to his correspondence.

Specific complaints and conclusions
The complaints which have been investigated are that the Council:
(a) in considering the planning application for the Plot and in treating requests for variations in the finished floor and ground level as non-material, failed to have proper regard to the effect on the amenity of Mr C and his immediate neighbour (Mr B) (upheld); and
(b) failed to acknowledge Mr C's correspondence and respond in a timely manner (partially upheld).

Redress and recommendations
The Ombudsman recommends that the Council:
(i) explore further with Mr C and Mr B whether steps can be taken at the Council's expense to mitigate the detriment to their privacy as a result of overlooking from the house constructed on the Plot; and
(ii) take steps to ensure that they keep complainants updated when they are unable to respond to their complaints within the published timescales.

Overview
The complainant (Ms C) raised four specific complaints about the inadequate handling of a planning application by Falkirk Council (the Council), submitted by a Planning Consultant (the Agent) on her behalf.

Specific Complaints and conclusions
The complaints which have been investigated are that:
(a) the Council failed to deal adequately with the pre-planning application enquiry (upheld);
(b) the Council failed to handle the outline planning application adequately and within statutory deadlines (partially upheld);
(c) there were delays by the Council in submitting information in connection with Ms C's appeal to the Scottish Executive Inquiry Reporter's Unit (SEIRU) (upheld); and
(d) the Council failed both to respond and to respond adequately to reminder letters, emails, faxes and telephone calls (not upheld).

Redress and recommendations
The Ombudsman recommends that the Council:
(i) offer Ms C a full apology for the shortcomings identified, and consider whether it would be appropriate for this to be reinforced by a modest payment in recognition of the effect of those shortcomings on her;
(ii) apologise to Ms C for the delay in submitting information to SEIRU and explain why it occurred.

Overview
The complainant (Mrs C) raised a number of concerns about the information provided to her about the extent of her late husband (Mr C)'s ill health and the operation of a Do Not Resuscitate (DNR) order. Mrs C was also concerned about the adequacy of steps taken to protect Mr C in hospital.

Specific complaints and conclusions
The complaints which have been investigated are that Fife NHS Board (the Board) failed to:
(a) communicate adequately with Mrs C and in particular failed to follow the procedure for instituting and implementing a DNR order (upheld); and
(b) keep Mr C safe using appropriate restraint (partially upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) review the DNR policy, the use, and value added by the use of, the resuscitation box in the Unitary Patient Record; followed by an ongoing audit (or similar improvement methodology) to ensure that there is clarity about when the policy applies and whether it is sustained in practice. The audit should measure the completion of the DNR form and associated documentation in the patient record;
(ii) review how Cardio Pulmonary Resuscitation status is communicated at ward level, to ensure nursing staff are aware of the importance of robust communication at handover and transfer. The national 'Leading Better Care' policy may be helpful here;
(iii) consider including DNR orders in both induction and Basic Life Support staff training. This is already done in some parts of NHS Scotland and is endorsed by the Scottish Palliative Care Society;
(iv) review the mechanisms in place to ensure that communication between patients, their relatives and carers and staff is recognised as an important part of the patient experience; and
(v) develop a specific policy for the WanderGuard bracelet to ensure that its use complies with the Adults with Incapacity (Scotland) Act 2000 to ensure patients are treated with dignity and respect.

The Board have accepted the recommendations and will act on them accordingly.