South of Scotland

Overview
The complainant (Mr C) raised a number of concerns about the way in which The Highland Council (the Council) dealt with an allegation of examination malpractice against his son (Mr A).  In particular, he said that they failed to follow Scottish Qualifications Authority (SQA) guidance.

Specific complaint and conclusions
The complaint which has been investigated is that the Council failed unreasonably to follow SQA guidance on candidate malpractice when dealing with an allegation involving Mr A (upheld).

Redress and recommendations
The Ombudsman recommends that the Council:

• provide Mr A with a letter of apology for the failures identified;
• make their secondary schools aware of the outcome of this complaint and of the importance of following available guidance; and
• liaise with SQA about the means by which they should document their procedures for dealing with such matters.

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

Overview
The complainant (Ms C), an advocate, raised a number of concerns on behalf of Mr A. Mr A’s late wife (Mrs A) was referred urgently by her GP for the investigation of symptoms suggestive of breast cancer on three occasions within a period of seven months. Mrs A was referred urgently to the Breast Clinic at the Western Isles Hospital (the Clinic) in Stornoway three times between May and November 2008 but she was not referred on to the Highland Breast Centre in Inverness (the Breast Centre) until December 2008. Cancer was diagnosed in January 2009. Mrs A was a young woman whose first child was under two years old when she first reported her symptoms to her GP. By the time the cancer was diagnosed, she was some 12 weeks pregnant with her second child. Although the child was delivered safely and Mrs A was treated for her cancer, the cancer later returned and she died aged 33 years in June 2011.

Specific complaint and conclusion
The complaint which has been investigated is that the Board unreasonably delayed diagnosing Mrs A's breast cancer (upheld).

Redress and recommendation
The Ombudsman recommends that the Board:

• (i) issues a written apology for the failings identified.

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

Overview
The complainant (Mrs C) complained that a lengthy list of errors and omissions by various specialist services and a failure to co-ordinate her care and treatment caused her stress and ultimately led to a delay in her being diagnosed with multiple sclerosis and her starting treatment.

Specific complaints and conclusions
The complaints which have been investigated are that Ayrshire and Arran NHS Board (the Board) unreasonably failed to:

• adequately assess Mrs C's condition (not upheld);
• ensure that the various departments involved in Mrs C's care monitored her care and treatment appropriately (upheld);
• ensure that the various departments involved in Mrs C's care co-ordinated and communicated appropriately with each other (upheld); and
• ensure that the responses Mrs C received to her complaints were accurate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• issue a written apology to Mrs C for the failings identified in this report;
• provide evidence of the improvements that have been made to the Board's out-patient's appointment systems;
• consider developing a pathway regarding all suspected genetic disorders seen within Dermatology Services, so as to streamline access to geneticists;
• ensure that the comments of the Dermatology Adviser, in relation to record-keeping and the Board's action plan, are brought to the attention of the relevant staff within Dermatology Services;
• in cases involving several health boards, consider implementing the copying of clinical correspondence to a patient, so as to improve communication and provide the patient with the opportunity to be aware of the progress of their care;
• consider reviewing the systems for Radiology referrals between hospitals;
• review spinal magnetic resonance imaging (MRI) protocols to:  identify which part of the recall protocol failed in Mrs C's case; ensure where abnormalities are detected they are appropriately reported; and ensure appropriate consideration is given to examining the patient's whole spine in one scan;
• carry out an audit to ensure there is a clear system for prioritising MRI scan requests according to the degree of clinical urgency;
• ensure that communication protocols between Radiology Services and other clinicians are optimal;
• ensure that the comments of the Radiology Adviser and the Neurology Adviser are shared with the appropriate staff; and
• advise of the present position in respect of the planned move to digital case notes.

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

Overview
The complainant (Mrs C) raised a number of concerns about the handling by East Ayrshire Council (the Council) of a planning application for a wind turbine development of 15 turbines near her home.

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

• (a) did not reasonably assess the impact of the development prior to determining the application (upheld);
• (b) did not reasonably obtain and consider independent expert opinion prior to determining the application (upheld);
• (c) did not have a reasonable policy in respect of the handling of major planning applications (upheld); and
• (d) unreasonably reached an agreement with the applicants under section 75 of the Town and Country Planning (Scotland) Act 1997 before addressing the local residents' concerns (not upheld).

Redress and recommendations
The Ombudsman recommends that the Council:

• issue a written apology to Mrs C for:  the failure to adequately assess the impact of the development in relation to cumulative noise; the failure to obtain an independent report in relation to this prior to reaching a decision; and, the failure to provide adequate information in the planning report in relation to whether, in the event of a decision contrary to the recommendation, there was a significant departure from the development plan in the case of a major development application;
• refund the local residents for the cost of the report they commissioned from an acoustic consultant, subject to the production of relevant receipts; and
• take steps to ensure that there is clearer reference to relevant statutory procedures in committee reports on planning applications, particularly in relation to whether or not there is a significant departure from the development plan in the case of a major development application.

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

Overview
The complainant (Mrs C) raised concerns about inadequate consultation and involvement of her as a carer for her husband (Mr C) during his admissions to two hospitals run by Highland NHS Board (the Board) in 2011.

Mrs C had Financial and Welfare Power of Attorney (POA) for Mr C and was also Mr C's Named Person for the purposes of the Mental Health (Care and Treatment) (Scotland) Act 2003.  Mr C had a diagnosis of Advanced Alzheimer's Disease.

Specific complaint and conclusion
The complaint which has been investigated is that the Board did not reasonably include Mrs C in decisions about Mr C's care and treatment from February 2011 onwards (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• apologise to Mrs C for the repeated failures to adequately and properly involve her in decision making around Mr C's care and treatment;
• review their approach to carer communication and participation for people with dementia to ensure a coherent, bespoke and planned approach in all cases.  This should be carried out with due regard to the national Dementia Standards, the principles under-pinning the Mental Health (Care and Treatment) (Scotland) Act 2003 and the Adults with Incapacity Act 2000, and the rights of 'Named Persons' and those with POA status.  The Board should advise this office of the outcome of this review; and
• review their current documentation of carer involvement in light of the record-keeping failings identified in this report and advise this office of the steps taken to address these omissions.

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

Overview
The complainant (Mr C) is the father of a young person (referred to in this report as Mr A) who had recognised special educational needs and attended a mainstream secondary school (the School) in the area of Scottish Borders Council (the Council).  After bullying incidents at the School he suffered acute clinical depression (ACD).  The complaint made by Mr C related to how the Educational Psychology Service of the Council dealt with Mr A thereafter.  Mr C considered the Council had failed to implement their duties under the education legislation.  He then sought the intervention of the Scottish Executive[1] Education Department (SEED) and was aggrieved at SEED's reasons for not exercising their default powers.

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

1. the Council failed in their duty under the Standards in Scotland's Schools etc Act 2000, with regard to Mr A's educational needs following an episode of ACD (no finding);
2. the Council failed to ensure good professional management and to follow advice on good practice guidelines (not upheld);
3. the Council failed to disclose a prior 'gentleman's agreement' whereby an adolescent mental health unit rather than the Council's Educational Psychology Service took a lead role (upheld);
4. the Council abrogated their duties and responsibilities as education authority without notifying Mr and Mrs C or Mr A (not upheld);
5. an educational psychologist was directed by her line manager, for specious reasons, not to attend meetings at the School on 6 March 2003 (not upheld);
6. the Council's replies to Mr C's correspondence failed to answer his specific questions (not upheld);
7. in handling Mr C's formal complaint, the Chief Executive rewrote the complaint and failed to answer detailed points (not upheld);
8. the Chief Executive's response of 27 January 2004 to a request from SEED for information contained misleading statements and factual inaccuracies (not upheld);
9. SEED rewrote his letter of complaint to them of 30 September 2003 and failed to address all the issues (partially upheld);
10. SEED repeatedly failed to answer specific questions posed of them (not upheld);
11. SEED failed to address or explain why they did not deal with alleged breaches in duties detailed under the Standards in Scotland's Schools etc Act 2000 (partially upheld);
12. SEED failed to take appropriate action when informed of Mr C's concerns about factual inaccuracies in the Council's Chief Executive's response to them of 27 January 2004 (not upheld); and
13. SEED failed to answer questions posed by Mr C and passed their reply off as being substantive (not upheld).

Redress and recommendations
The Ombudsman recommends that the Council should give consideration to ensuring a more formal approach is adopted in informing and consulting with parents of children in future like circumstances, and particularly where there has been a significant absence from school.

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

With reference to SEED, the Ombudsman makes no recommendation on the basis that they have advised her that instructions have been issued to avoid a recurrence of matters where the complaint was partially upheld.  However, she suggests that SEED may wish to take steps to ensure that their policy and practice in relation to exercising their default powers is fully publicised.

Overview
The complainant is a planning consultant.  His complaint to the Ombudsman concerned the handling by a committee (the Area Committee) of Dumfries and Galloway Council (the Council) of his clients' application (the Application) for planning consent for a dwelling house in a rural area.

Specific complaint and conclusion
The complaint which has been investigated is that there were shortcomings in the consideration of the Application by the Council's Area Committee (not upheld).

Redress and recommendations
The Ombudsman has no recommendations to make.

Overview
The complainant (Mr C) complained on behalf of his wife, Mrs C.  He said that although Mrs C had an operation to her spine in June 2012, it was not until February 2013 that it was discovered that the operation had been undertaken in the wrong place.  Mr C said that, as a consequence, his wife suffered unnecessary pain and discomfort which impacted significantly upon her life, particularly as Mrs C was recovering from radiotherapy treatment in respect of breast cancer.

Specific complaint and conclusion
The complaint which has been investigated is that the care and treatment provided in connection with surgery on Mrs C's spine was unreasonable (upheld).

Redress and recommendations
The Ombudsman recommends that Lothian NHS Board:

• ensure that the Consultant Neurosurgeon revisit her procedures for determining the level of surgery and consider doing two x-rays, one before incision and one with the wound open.  Alternatively, do only one x-ray but with the wound open and the spinal elements clearly visible.

The Ombudsman recommends that Borders NHS Board:

• ensure that Hospital 2 review their procedures concerning the timely dispatch of radiology reports.

Overview
The complainant (Miss C) raised a number of concerns about the level of care provided to Ms A by Highland NHS Board (the Board) during her pregnancy and subsequent delivery of her baby daughter who was sadly stillborn.

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed to provide Ms A with an appropriate level of care during her pregnancy and subsequent delivery at Raigmore Hospital in December 2011 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  apologise to Ms A for the failings identified in this report;
• (ii)  review their guidance to staff on the antenatal management of women to ensure that the risks of recurrent shoulder dystocia are discussed with expectant mothers together with birthing options; and
• (iii)  draw to the attention of the antenatal midwife who looked after Ms A, the importance of documenting previous history of shoulder dystocia in the handover note to the labour midwife.

Overview

Mr C, who is a prisoner, arranged for his son (Mr A), who was 16 years old, and his daughter (Miss A), who was 15 years old, to visit him at HMP Kilmarnock (the Prison). Mr C's children were allowed to access the Prison but before accessing the visit, Miss A was searched after the metal detection alarm sounded when she passed through it. Following this, Mr C's children were denied access to the visit because Miss A was not accompanied by an adult.

Specific complaints and conclusions

The complaints which have been investigated are that:
(a) Mr C's daughter was inappropriately searched in the absence of an appropriate adult (upheld); and
(b) the internal complaints committee's written response to Mr C's prisoner complaint form did not accurately reflect the discussion held (not upheld).

Redress and recommendations

The Ombudsman recommends that:

(i)  the SPS update my office on the steps taken to implement a relevant policy in relation to the age a person must be to accompany a child under the age of 16 to a visit within a prison;

(ii)  the SPS consider seeking the views of the Commissioner for Children & Young People before implementing their new policy; and

(iii)  the SPS take immediate steps to ensure staff within all prisons are fully aware of the policy in place in relation to the age a person must be to accompany a person under the age of 16 to a prison.