South of Scotland

Overview
The complainant (Mr C) had part of a lung removed following a diagnosis of cancer at Crosshouse Hospital (Hospital 1). He was subsequently found not to have cancer and Mr C complained that the treatment had been unnecessary. Mr C also said that staff at Hospital 1 had delayed in communicating the change in diagnosis to him and had not answered his questions fully. In addition, Mr C complained that there had been a delay in putting him back on the kidney transplant waiting list and that the response to his complaints by Ayrshire and Arran NHS Board (the Board) had been inadequate.

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

• (a) there had been an error in the diagnosis of cancer, which led to an unnecessary operation (upheld);
• (b) there were problems with the communication to Mr C about the new diagnosis and the response to his questions about this (upheld);
• (c) there had been an unreasonable delay in ensuring Mr C was put back on the kidney transplant list (upheld); and
• (d) the responses to Mr C's complaints were inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) undertake a short, focussed audit of lung fine needle aspirations (FNA)s carried out by the department;
• (ii) review, as a matter of urgency, the clinical use of such FNAs by Hospital 1;
• (iii) emphasise to clinical staff involved the importance of taking and documenting a full clinical history; this matter should be confirmed with Consultant 1 as part of his annual appraisal;
• (iv) emphasise to staff involved the importance of timely and open communication;
• (v) alert staff to the need to ensure appropriate communication with patients and file management, in an effort to prevent the situation recurring, where a patient could be concerned about information placed in his/her file which has not been discussed with him/her;
• (vi) undertake a full review of the operation of their complaints process and the relationship of this to clinical governance, as a matter of urgency;
• (vii) establish why an incident review was not considered and this matter not re considered by the lung cancer multi-disciplinary team and take appropriate steps to ensure that their own policies and procedures are followed by clinical and complaints handling staff; and (viii) make a full apology to Mr C for the failings identified in this report.

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

Overview
The complainant (Mr C) raised a number of concerns about the care and treatment he received during three Accident and Emergency admissions at Campbeltown Hospital (Hospital 1) on 24 and 26 August 2008.

Specific complaint and conclusion
The complaint which has been investigated is that Highland NHS Board (the Board) failed to provide Mr C with adequate care and treatment at Hospital 1 on 24 and 26 August 2008 (upheld).

Redress and recommendation
The Ombudsman recommends that the Board apologise to Mr C in writing for the failing identified in this report and their failure to provide him with adequate care and treatment on 24 and 26 August 2008.

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

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment provided by Western Isles NHS Board (the Board) to her and her daughter (Baby C) before, during and after labour over 29 and 30 April 2007.

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

• (a) did not provide adequate care to Mrs C before and during labour (upheld);
• (b) did not provide adequate care to Mrs C after delivery (not upheld); and
• (c) did not provide adequate care to Baby C after delivery (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mrs C for the failure to provide adequate care to her before and during labour;
• (ii) reviews the guidelines for the use of electronic fetal monitoring to ensure that they are appropriate; and
• (iii) ensures that clinical staff take note of the findings of this report and make any necessary adjustments to clinical practice accordingly.

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

Overview
Mr C complained on behalf of his son Child A. Child A was being home-educated. Mr C had asked Comhairle nan Eilean Siar (the Council) about access to exams. After discussion, it was agreed Child A could attend the nearest school (School X) for specific classes so that he could sit exams in those subjects at the end of the school year. Child A attended school but teaching staff objected. Child A was sent home. Mr C complained to the Council and was unhappy with the delay in their response and the response itself.

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

• (a) failed to honour a commitment to admit Child A to a class at School X (upheld);
• (b) acted unreasonably in refusing to consider enrolling Child A in individual classes (upheld); and
• (c) handled a complaint about these matters inadequately (upheld).
   

Redress and recommendations
The Ombudsman recommends that the Council:

• (i) ensure that all future responses to the Ombudsman are based on a review of the evidence available;
• (ii) put in place a policy and guidance for dealing with requests for support for home-educated children. As part of the process of creating the policy, they should consult with local teachers; the parents of home-educated children, children themselves and other local authorities. They should ensure that the policy is in line not only with the legislation but the guidance issued by the Scottish Government;
• (iii) remind all staff of the need to ensure that statements about decisions made by the Council are evidence-based and that, where advice is sought in coming to a decision, this is appropriately noted;
• (iv) undertake an audit of their complaints handling processes and procedures. This audit should be undertaken within three months of this report and be reported at quarterly intervals over the next 12 months (15 months in total) to the Ombudsman. The audit should demonstrate significant improvement over this time and show that the recommendations made in this and previous reports about complaint handling have been implemented;
• (v) ensure investigations of complaints are evidence-based; and
• (vi) apologise to Mr C and Child A separately and in full for the failings identified in this report including the events of 20 August 2007 and the distress caused.

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

Overview
The complaint was made by a Primary School Council (the School Council) on behalf of the aggrieved, Mrs C, who is a parent of two children who attend a primary school (School 1) which is due to be closed in 2010, on completion of a new school (School 2) which is being built in its place. Through the School Council, Mrs C complained that Dumfries and Galloway Council (the Council) disregarded the results of the public consultation undertaken in 2004 when they decided to amend the planned accommodation in School 2, without further consultation. She considered that the Council were at fault in failing to provide the public with a further opportunity to make their views known and to vote for or against the amendments. She was aggrieved because she believed that the amended accommodation schedule was inadequate and would result in more than one teacher per classroom. Mrs C complained also that the Council failed to reply to her formal complaint on the matter.

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

• (a) failed to carry out further consultation following a change of specification for School 2 (not upheld); and
• (b) failed to reply to Mrs C's formal complaint in line with their procedures (upheld).

Redress and recommendations
The Ombudsman recommends that the Council ensure that their complaints handling systems which are being reviewed make provision for each stage of the process to be dealt with in the timescales which they have set themselves to respond and that an update will be sent to the customer in the event of a delay.

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

Overview
The complainant (Mr C) complained to the Ombudsman's office that the Highland Council (the Council) had failed to respond appropriately to complaints he had made against his neighbours regarding their alleged behaviour.

Specific complaint and conclusions
The complaint which has been investigated is that the Council failed to provide appropriate responses to Mr C's representations about his neighbours' alleged anti-social behaviour between October 2005 and October 2007 (not upheld).

Redress and recommendations
The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised concerns about the handling by East Lothian Council (the Council) of an application (the Application) for planning consent for a new house on a main road opposite his own property in a conservation village in East Lothian. He was particularly concerned about the likely dominant effect on a former smithy and on parking congestion on the main road.

Specific complaint and conclusion

The complaint which has been investigated is that in recommending approval of the Application, the Council's Transportation Division and planning case officer failed to require compliance with relevant Council planning policy in respect of car-parking provision (partially upheld).

Redress and recommendation

The Ombudsman recommends that the Council review the present procedures for the need for site visits by their Transportation Division officers prior to responding to consultations on planning applications.

The Council accepted that recommendation and will act on it accordingly.

Overview

The complainant (Mrs C) complained that the school, where her son (Mr C) is a pupil, did not bring to her attention that her son was entitled to apply for an Education Maintenance Allowance (EMA) for the academic year 2006-2007. Mrs C says that Mr C, who has learning difficulties, missed out on receiving an EMA because retrospective payments cannot be made.

Specific complaint and conclusion

The complaint which has been investigated is that the School did not bring to Mrs C's attention that Mr C was entitled to apply for an EMA for the academic year 2006-2007 (upheld).

Redress and recommendations

The Ombudsman recommends that Dumfries and Galloway Council (the Council):

• (i) pay to Mrs C the sum of £1,140 in lieu of the basic allowance payment and an additional payment of £300 in lieu of the bonus payment which Mr C would have been entitled to had he applied for and received an EMA for session 2006-2007; and
• (ii) issue Mrs C with an apology for any inconvenience which she may have been caused.

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

Overview

The complainant (Mrs C) complained that her daughter (Child A) had been bullied at her school (the School), and the School had not recorded the incidents of bullying clearly or managed the bullying in line with Shetland Islands Council (the Council)'s procedures. Additionally, Mrs C complained the Council failed to convene a Complaints Review Committee (CRC) to consider a further aspect of a complaint, which related in part, to the remaining issues subject to investigation.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the methods of recording and collating incidents of bullying were unclear (upheld);
• (b) the procedures for managing incidents of reported bullying were not adhered to (upheld); and
• (c) the Council failed to convene a CRC to hear Mrs C's complaints about the social work department (upheld).

Redress and recommendations

The Ombudsman recommends that the Council:

• (i) support the School in a review of their record-keeping to reflect the incidents of new bullying and episodes of continued bullying. This reporting schedule will highlight the progress being made to address new and older reported episodes of bullying within the School;
• (ii) review the School's criteria for first time/new incidents of bullying and the identification of ongoing bullying issues to be clearly set out separately to reduce the confusion and misunderstanding;
• (iii) support the School's development of appropriate contingency plans to be introduced to the policy of handling bullying when a number of incidents are being reported by the same pupil and evidence is difficult to obtain from other children;
• (iv) ensure the local policies are adhered to and explanations are recorded within the documentation when there is a departure from the prescribed procedure;
• (v) apologise to Mrs C and Child A for the confusion caused as a result of diverting from the documented procedure;
• (vi) review their procedures and practices to ensure CRCs can be held within set timescales; and
• (vii) apologise to Mrs C for the delay in convening a CRC.

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

Overview

Mr C has complained about the care and treatment provided to his late mother (Mrs A) prior to and during her last hospital stay in a hospital (the Hospital) within the Shetland NHS Board (the Board) area. Mr C's mother was admitted to the Hospital on 8 March 2005 and discharged to her care home in the afternoon of 9 March 2005. Mrs A died later in the evening of 9 March 2005. Mr C has also complained that Mrs A should have remained in hospital longer.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the reasons for medication, prescribed for Mrs A's suspected clinical condition at the time, were unclear (partially upheld, to the extent that the reason why medication was prescribed in the community for Mrs A's suspected condition was clear and appropriate but the reasons for the prescribing decisions made following admission to the Hospital were not clear and appropriate);
• (b) medical and nursing staff failed to assess and record the treatment and care requirements adequately throughout this particular episode of care (partially upheld, in relation to the actions of the Hospital);
• (c) Mrs A was not provided with an acceptable level of fluids during her stay in the Hospital (upheld); and
• (d) Mrs A should have remained in the Hospital longer (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) share this report with the staff involved in Mrs A's care, so they can reflect on the findings relevant to the prescription of medication when Mrs A was admitted to the Hospital and identify clear and explicit indications for the use of prescribed and administered medication;
• (ii) ensure thorough assessment, recording and treatment is undertaken for the ongoing care of a patient when health remains compromised and discharge is being considered;
• (iii) ensure nursing staff are appropriately trained to record baseline observations and understand the reasons for recording them;
• (iv) ensure a fluid intake and output record is kept for an unwell patient, where feeding and drinking assistance is required; and explanations are recorded when there is a delay in supporting the early, prompt intake of fluids;
• (v) remind staff of the importance of encouraging fluid intake, when a patient is unable to attend to that aspect of care independently;
• (vi) ensure full consideration is given to any potential discharge plan, when observations continue to indicate a level of patient distress or compromise;
• (vii) ensure appropriate family members are given an opportunity to contribute to the discharge planning process of an unwell relative; and
• (viii) provide Mr C with a full formal apology for the failures in care identified in this report.