Not upheld, no recommendations

Summary
Mr C, who is a prisoner, complained to us because the deputy governor did not meet him in person to discuss his complaint. He also said the deputy governor failed to provide a reasonable response to his complaint. Mr C had complained to the prison about a mix-up in him being seen by the progression board.

After making enquiries with the prison, we were satisfied the issues raised by Mr C in his complaint were investigated properly and that the deputy governor provided a reasonable response. We were also satisfied that, in choosing not to meet with Mr C to discuss his complaint, the deputy governor exercised her discretion and took the decision because the complaint appeared to be resolved.
 

Summary
Mr C complained that the Scottish Prison Service (SPS) were unreasonably requiring him to share a single occupancy cell with another prisoner. He did not believe that the cell was an adequate size to accommodate two prisoners.

The prison rules provide the SPS with discretion to require two or more prisoners to share accommodation where circumstances require. The SPS advised us that due to current prisoner numbers, they have had no option but to introduce cell sharing arrangements. The rules also require a risk assessment to be carried out in advance of two prisoners being asked to share, to ensure that they are suitable to do so. The SPS provided us with copies of the risk assessments relevant to Mr C and advised that they were satisfied there were no security or compatibility issues which would have made the sharing arrangements unsuitable. The SPS were satisfied that they were providing an appropriate regime, including reasonable out of cell time and activities.

We did not establish any legal basis to support Mr C's concerns that his cell was not of an adequate size. We took into account that the prison regime allows prisoners a reasonable amount of out of cell time and activities and, on balance, we did not uphold the complaint.

Summary
Mr C complained that the Scottish Prison Service (SPS) failed to explain the outcome of a risk assessment he had undergone.

Mr C said that he had asked the psychologist who completed the risk assessment for further information, but that she failed to respond. We were, however, unable to find any evidence of this. Mr C told us that a prison officer had subsequently provided him with some limited information about the data used for the risk assessment.

SPS guidance in relation to risk assessments says that they should explain the process and the data that has been used to inform the risk assessment. However, we considered that it was reasonable for them to take the view that if they gave too much information in relation to the type of risk assessment that Mr C had undergone, this could be used to manipulate the answers in future assessments.

In such cases, there is a difficult balance to strike between providing too much and too little information about a risk assessment. In this case, we found no clear, objective evidence to indicate that the prison's actions were unreasonable.

Mr C also complained that a prison officer had acted unreasonably at a meeting with him. He said that the officer had searched his papers and had been intimidating and overly aggressive.

The SPS told us that prison officers were concerned that Mr C had information that prisoners were not allowed to have. The prison rules at that time stated that any item of property belonging to a prisoner may be searched by a prison officer, at any time. The prison officer, therefore, had the authority to search Mr C's belongings. Again there was no clear, objective evidence that the officer had been intimidating or overly aggressive.

Summary
Mr C complained that the Scottish Ambulance Service (the Service) transported his wife from their shower room to their bedroom by dragging her there on a blanket. Mr C said this was an unreasonable way to have moved her. Mr C also said that the lifting equipment which the Service brought with them was faulty.

Our investigation took into account all relevant documentation and we also sought advice from one of our medical advisers. The Service told us that the ambulance crew initially planned to use lifting equipment to move Mr C's wife, who was acutely ill. Given the restricted access in the shower room, however, they decided in consultation with the attending doctor that it would not be appropriate to use the equipment. With the help of the doctor and his driver, the crew, therefore, used a blanket to move Mr C's wife from the shower room to the bedroom. They explained that it was felt that this would be a quicker way of getting Mr C's wife into a more comfortable position before taking her to hospital. Taking account of all the information provided, we took the view that this decision appeared to have been reasonable based on the situation at the time and taking into account the best interests of Mr C's wife.

The Service were clear in their view that the lifting equipment was not faulty, but it was not possible for us to prove this one way or the other. We could not, therefore, say whether there had been a failing by the Service in this respect.

Summary
Mr C complained that the housing association failed to adequately answer his questions about who was responsible for enforcing the burdens over his and his neighbour's property. (Burdens are conditions relating to the land in question.)

Our investigation found that the initial information they provided was, at times, unclear. However, we also noted that this area of the law is particularly complex and found that a subsequent response from the housing association did provide a detailed and clear explanation of their point, supported by relevant legal information.
 

Summary
Ms C complained that NHS 24 refused to send an emergency ambulance to take her to hospital but instead referred her to the local out-of-hours service. She said that this was despite her step-daughter and her requesting an emergency ambulance.

Having obtained the recordings of the telephone calls during our investigation, however, it was clear that Ms C and her step-daughter did not request an ambulance nor did they raise objections to being advised to visit the local health centre.

We did not uphold this complaint.
 

Summary
Miss C complained that, over a number of years, the board's staff had failed to listen to her or obtain her previous medical records. She said that these would have shown that she had suffered from epileptic seizures and that she should have been diagnosed with post-ictal psychosis (a rare complication that can occur after a series of seizures). As a result Miss C felt she had been unreasonably detained under the Mental Health Act.

We took detailed advice from two of our medical advisers on Miss C's complaint. We found that Miss C had complex symptoms, some of which were considered to be caused by epileptic seizures and others by non-epileptic seizures. We found that, over the years, clinicians had carried out appropriate examinations in an effort to reach a definitive diagnosis, and that sight of Miss C's previous medical records would be unlikely to have altered their thinking. Although it did take time to reach a diagnosis, we were satisfied that the clinicians involved had clearly taken account of what Miss C had told them, and in the circumstances had arrived at reasonable diagnoses.

Summary
Mrs C hurt her leg after a fall at home and went to a hospital's accident and emergency unit. Mrs C said she was told her leg was in shock and was given pain killers. She was also told to keep an eye on the swelling and to go to her doctor's surgery if it got worse.

The pain continued to get worse so she went to the surgery. She said that her doctor telephoned the hospital and was told to complete a letter of referral. Nine days passed and as Mrs C did not receive an appointment and was in considerable pain, she went directly to another hospital, where she was x-rayed.

The x-ray revealed that Mrs C had a fractured foot, which was set in plaster for four weeks. As a result Mrs C said she was left in significant pain for months and was unable to work. She complained to us about the care and treatment she received in the first hospital, and was unhappy that her foot was not x-rayed on the day of the accident.

Our medical adviser looked at this complaint. The adviser said that many such injuries result in sprains or soft tissue injuries. A few patients have fractures. However, many fractures are minor and do not require much treatment other than pain relief, support and gentle mobilisation as a patient's injury heals. Others may need a plaster cast for pain relief.

The adviser said that overall, according to NHS guidance and what was in Mrs C's medical records, x-rays were not indicated when Mrs C attended the first hospital. We took the view that clinical staff carried out adequate, appropriate investigations and treatment of Mrs C's injury, according to NHS guidelines, and that she was given appropriate follow-up advice.

Summary
Mr C complained about the treatment his wife (Mrs C) received in two hospitals. Mrs C was admitted to the first hospital complaining of groin pain. She also showed signs of infection. Urologists found that Mrs C had a kidney stone preventing her right kidney from draining properly. A nephrostomy (insertion of a small tube to release the urine from the kidney) was attempted but this was unsuccessful.

Staff at the second hospital failed to insert a stent (tube) to drain the kidney the following day but were, with difficulty, able to complete the nephrostomy three days after her admission. Mrs C subsequently developed internal bleeding and was too unwell to undergo surgery. She died seven days after her admission to the first hospital.

Mr C complained that insufficient time was allowed before the first nephrostomy for antibiotics to take effect and resolve Mrs C's infection. He also felt that urology staff spent too much time attempting the first procedure, which he had been told would be quick. It took several hours and, as a result, Mr C believed his wife had been left overnight with internal bleeding. He felt that this delay left insufficient time for staff at the second hospital to treat her.

Mr C raised further complaints about the communication with his wife's relatives; a lack of involvement in decisions about her treatment; and the accuracy of comments made in response to his complaints.

After taking advice from our medical adviser, we found that the nephrostomy was required urgently as failure to provide treatment could have led to Mrs C developing an abscess and blood poisoning. The antibiotics that she was prescribed were also to help prevent blood poisoning. We found that some bleeding was caused by the first procedure but that this was stemmed appropriately. There was insufficient evidence available to determine the cause of her subsequent internal bleeding, but our adviser said that Mrs C had a number of additional medical problems, some of which could have caused this separate to her kidney treatment.

As Mrs C did not have any mental deficiencies that the board were made aware of, we found that it was appropriate for staff to discuss treatment directly with her. The discussions were documented and Mrs C signed consent for each of the procedures carried out. Although the family were not updated until several days after her admission, there was no evidence to suggest that they were denied the opportunity to discuss Mrs C's treatment with staff.

We were satisfied that the board's responses to Mr C's complaints were accurate.
 

Summary
Mr C complained about his treatment in hospital after a knee replacement operation. He said that he developed an infection and had to attend hospital for some time after his surgery. He felt that if the consultant who operated on him had investigated the infection sooner, then it might have been contained or eradicated. He said that the board failed to adequately treat his ongoing problems of pain or to adequately investigate his complaint.

The evidence in the clinical records showed that Mr C’s follow-up reviews and treatments were held in good time. We took independent advice from one of our medical advisers, who said that infections in prosthetic knee replacements can be difficult to diagnose, and that the clinical judgements made were reasonable. Our investigation found no evidence to support Mr C’s view that the board failed to adequately treat his pain. There was also no evidence that the follow-up care was inadequate or fell short of the clinical standards expected.

We found that the board responded appropriately to Mr C’s complaint. They addressed and answered his questions, demonstrated empathy with his situation, and kept him updated about how their investigation was progressing. Although Mr C was unhappy with the investigation we also took the view that, to answer his questions and concerns, it was appropriate for the board to refer these to the consultant for comment. This is common and acceptable practice when responding to a complaint. We recognise that Mr C is still dissatisfied with the responses he received, but dissatisfaction with the outcome of a complaint does not mean that the board did anything wrong.