Not upheld, recommendations

Summary

Mr C complained that his prison unreasonably reversed their decision to allow him to move into a shared cell. We found that, as they acknowledged, the prison had made the wrong decision in allowing Mr C to move to a shared cell and, therefore, they were correcting their mistake when they returned him to a single cell. Therefore, we did not uphold Mr C's complaint. However, we decided that the prison should have been more open with Mr C about what had happened. We were also of the view that the Scottish Prison Service should take action to prevent such a mistake from happening again. We made recommendations to address these points.

Recommendations

We recommended that Scottish Prison Service:

• apologise to Mr C for the initial decision to move him to a shared cell being taken without consideration of all relevant information and for failing to be open with him about this when dealing with his complaint; and
• remind hall staff at the prison that in appropriate cases they should consider seeking the opinion of professionals involved in case management before making the decision to move a prisoner to a different cell.

Summary

Mr C complained that the prison's handling of his request to have a phone number added to his account was unreasonable. He said an officer told him that his request would be actioned the same day he submitted it but that did not happen. Instead, Mr C's request was actioned within three days. The directions to the prison rules say the governor may allow a prisoner to change their list of pre-approved phone numbers (referred to as a PAN list) as soon as practicable. In addition, the request form clearly states amendments will be processed within five working days. Therefore, we were satisfied the prison's handling of Mr C's request was reasonable and we did not uphold his complaint.

Mr C also raised concerns about the prison's handling of his complaint. It was unclear if steps were taken by the prison to explore whether the officer had given Mr C misleading information in relation to the time it would take to deal with his request. We asked the prison about that and they told us that the chairperson of the internal complaints committee (ICC) had checked the position and was advised that the information Mr C said he received from an officer was out-of-date but that was not recorded in the written response. In addition, the ICC chairperson agreed to allow the officer Mr C had named as a witness to attend the discussion of the complaint but the officer refused to attend which Mr C said was inappropriate. We were satisfied that the evidence Mr C wanted the officer to bring to the discussion was available to the ICC without having the officer attend. Overall, we were satisfied that the handling of Mr C's complaint was appropriate but we did make some recommendations.

Recommendations

We recommended that Scottish Prison Service:

• apologise to Mr C for the potentially misleading information given to him initially about PAN lists being updated on Fridays;
• remind staff of the relevant timescale in place for requests to update phone lists;
• remind those staff acting as chairperson that when a witness refuses to attend an ICC hearing, the chairperson ensures they have all relevant evidence available before reaching a decision on the complaint; and
• remind those staff acting as chairperson to ensure that the written response to a complaint records the steps taken to investigate the complaint.

Summary

Ms C complained that her daughter (Miss A) was incorrectly diagnosed with a viral infection when she was seen by a doctor at the Royal Hospital for Sick Children. Ms C explained that three days after they attended the hospital Miss A was diagnosed with bacterial pneumonia whilst on holiday abroad.

We took independent advice from one of our medical advisers, who said that the diagnosis of a viral infection was reasonable as there was no clear evidence of pneumonia when Miss A attended hospital. We identified that the doctor obtained relevant information about Miss A and that the examination carried out was in line with national guidance. On this basis, we did not uphold the complaint but we found that there were no records to show that Miss A's level of consciousness had been assessed using the Glasgow coma score (a scale for recording the conscious state of a person) or whether the doctor had given any advice to Ms C on what to do if Miss A's condition did not improve, or deteriorated.

Recommendations

We recommended that the board:

• ensure the staff involved in Miss A's care reflect on the adviser's comments regarding the Glasgow coma score and advice to patients and/or their relatives.

Summary

Ms C complained on behalf of her client (Ms A) about the care and treatment provided to Ms A for anorexia nervosa (an eating disorder) when she was admitted to New Craigs Hospital (a psychiatric hospital). Ms A had been placed on a short term detention certificate and her medical records show that on admission she had a low body mass index. It was also noted that she was at high risk of refeeding syndrome (a potentially lethal disorder that can occur when a person is recovering from a period of starvation), and it was decided that refeeding should take place in a medical unit at another hospital. There were, however, no beds available there at that point. Ms A was sipping water and was aware of the plan to transfer her to the other hospital, where she might be fed with a nasogastric tube (a narrow tube passed into the stomach through the nose). However, she was not admitted there until five days later. By this time her mental and physical state had deteriorated, and she had lost weight and become unresponsive.

Ms C complained that despite suffering from anorexia and a low body mass index, Ms A was not offered anything to eat or drink for four days. She said that as Ms A was under a short term detention order, staff could and should have started nasogastric feeding. Ms C also said it was inappropriate to transport Ms A in a patient transport vehicle instead of an ambulance, given her serious condition.

We took independent advice on this case from two of our medical advisers. We found that the medical records indicated that Ms A was offered food and fluids, and that it was reasonable to monitor her and allow voluntary feeding instead of nasogastric feeding, particularly in light of the risk of refeeding syndrome. Although, given the nature of her medical needs, our advisers said that Ms A should have been admitted to the medical unit sooner, we were satisfied that the evidence showed that her care and treatment at New Craigs Hospital were reasonable. In the circumstances, we did not uphold the complaint but made a recommendation in light of the advice we received.

In relation to whether Ms A should have been transferred by emergency ambulance, we found that the medical records showed that her condition, while significant, did not indicate that this was required and that it was reasonable to provide the patient transport vehicle, with ambulance assistants.

Recommendations

We recommended that the board:

• review the response from the other hospital in light of one of our adviser's comments to see if any lessons can be learned.

Summary

Mrs C contacted her medical practice to get the flu vaccine for her young son. The practice provided an appointment three weeks away, but Mrs C asked if an earlier appointment would be available as her son had some outstanding health conditions. The practice said there was no urgency for the appointment so an earlier appointment was not offered.

Mrs C complained that the practice had not considered her son's individual health conditions, as they should have. She also complained that they had unreasonably told her she could leave the practice and did not respond to her complaint reasonably.

We took independent advice from one of our medical advisers. The adviser was satisfied that Mrs C's son did not exhibit any of the conditions which would qualify him as a priority patient to get the flu vaccine. For this reason, we did not uphold this complaint.

We also could not establish from the evidence available, the context in which the option to leave the practice was brought up and did not uphold this complaint. While we decided the practice had, on balance, reasonably responded to the complaint we did note areas for improvement and made a recommendation to address this.

Recommendations

We recommended that the practice:

• include, in final complaint replies, information about how a patient can progress their complaint if they remain unhappy.

Summary

Mr C complained about the fixed charges Business Stream applied to his client company's account, which were based upon the physical size of the water meter. He said that the company's water meter was larger than was needed for day-to-day use because their water supply also served fire hydrants. He complained that Business Stream were not allowed to charge for water used for fire-fighting and requested that the charges be adjusted. Business Stream exchanged the meter and amended the charges. However, Mr C wanted this backdated to the time of the original meter's installation.

Business Stream confirmed that water used for fire-fighting should not be charged. However, the meter had been installed several years ago – before Business Stream existed - as part of a Scottish Water project to try to ensure meters were the appropriate size for customer needs (which also meant that fixed charges were appropriate). Business Stream said there were almost no records going back that far, although the company would have signed giving their agreement to the original meter when it was installed. In addition, although Business Stream said Scottish Water would have carried out surveys at that time, they also relied upon information provided by customers. Business Stream said that the company would have paid for the original meter installation (it had actually replaced an even larger meter) and neither they nor Scottish Water would know their customers' specific requirements after installation. Business Stream said the issue was not raised until Mr C recently got in touch with them, at which point Business Stream had the meter exchanged and the billing addressed. They acknowledged a slight delay in processing the request and offered a credit on the account, which Mr C rejected.

Given the passage of time, there was very little evidence on which we could base our decision. Although we took Mr C's concerns into account, our role was to consider whether the evidence available indicated maladministration by Business Stream. They could not confirm if any information was given to the company at the time of the original swap or provide the original paperwork relating to their water needs at that time, but Mr C could not provide this either. We took account of the fact that the company would have agreed to the historic swap. In addition, as this was done under a project relating to the size of meters for fixed charges, we felt they could reasonably be expected to have known there was a relationship between fixed charges and meter size. Despite this, they raised no concerns about the situation until some 11 years after the original meter exchange. On balance, and although we took account of the costs involved, we considered there was insufficient evidence to uphold Mr C's complaint. In the circumstances, however, we made one recommendation.

Recommendations

We recommended that Business Stream:

• consider reissuing their account credit offer to Mr C.

Summary

Mr C was placed on report for breaching prison rules, for which he was found guilty at a disciplinary hearing. Mr C complained that he did not think the prison followed the correct process because the officer that placed him on report was not called to the hearing.

We obtained a copy of the record taken at Mr C's hearing which confirmed that prior to the proceeding starting, he was asked if he was prepared to accept the written evidence presented without requiring the reporting officer to appear in person. Mr C confirmed that he was, however, the record noted that he asked for the reporting officer to attend once the hearing had started. In addition, the record also confirmed Mr C said he understood the charge and the purpose of the hearing.

The prison rules say a prisoner can request that a witness be called and the request must be granted when the prison is reasonably satisfied that the evidence the witness is likely to give will be relevant to the determination of the charge. In addition, the relevant staff guidance says that the reporting officer must be present should the prisoner or the adjudicator consider it necessary. The Scottish Prison Service (SPS) also advised us that a prisoner could request for the reporting officer to be present at any time during the process but if they had already indicated that they were prepared to accept the evidence presented without the need for the reporting officer to be present then the decision on whether to agree to a later request to call the reporting officer was at the discretion of the adjudicator.

We were satisfied that Mr C was given the opportunity to call the reporting officer and because of that we did not uphold his complaint. However, we did ask the SPS to review the guidance to ensure it clearly reflected the position.

Recommendations

We recommended that the SPS:

• review the wording of the relevant paragraph within the disciplinary hearings guide to ensure it clearly reflects the SPS' position in relation to the attendance of the reporting officer at disciplinary hearings.

Summary

Mr C complained that his prison did not allow him to use his personal bedding while in the separation and reintegration unit, a separate part of the prison.

We considered what Mr C told us, as well as comments from the Scottish Prison Service (SPS). In addition, we looked at The Prisons and Young Offenders Institutions (Scotland) Rules 2006. We found that the prison were required to provide Mr C with bedding, which they did. We also found that the system of privileges in prison can be different for prisoners detained in specific parts of the prison, and that the prison had discretion to decide that a prisoner may or may not have certain items in use when in that unit. Mr C did not like the prison-issue bedding but that, in itself, was not evidence of a failure on the part of the prison. We were satisfied that the prison reached a decision they were entitled to take, in line with the rules, and we did not uphold Mr C's complaint.

However, we were concerned about an argument put forward by the prison's internal complaints committee (ICC) in not upholding Mr C's complaint. We were not convinced that, in terms of the prison rules, there was a distinction between storage of property in a prisoner's cell, and items in use, and so we made a recommendation to address this.

Recommendations

We recommended that the SPS:

• reflect on the ICC response to Mr C, to ensure that it was a reasonable reflection of the prison rules.

Summary

Due to health problems, Mr C finds it difficult to climb the stairs in his house. He applied to the council for adaptations to his home, but they declined this. His case was considered at a social work complaints review sub-committee (CRC) but, again, no adaptations were agreed. Mr C complained that the CRC was not carried out in line with the relevant procedure. Specifically, he complained that although he was only allowed to bring one representative to the CRC, the social work department had three representatives. He felt that this was unfair and complained that he was also denied the opportunity to ask questions of the staff involved in his request for adaptations.

We found that the CRC was conducted in line with the relevant guidance. That said, we felt that the council could have provided Mr C with details of the number of attendees in advance of the hearing to avoid surprises. We were also satisfied that Mr C was allowed to ask questions at the hearing. However, we were critical that there was a lack of records showing what questions were asked, who responded and what the response was.

Recommendations

We recommended that the council:

• take steps to ensure that complainants are informed in advance about the number of staff who are normally present at CRCs; and
• share our comments about record-keeping with staff responsible for taking minutes of CRCs.

Summary

Mr C complained that the council decided that some of his complaints were not eligible to be dealt with by the complaints review committee (CRC), which is the final stage of the council's social work complaints process. The council, by law, have a special process for dealing with complaints about social work services. The council said, and we agreed, that the particular complaints Mr C wanted the committee to look at were primarily educational rather than social work matters. The council had, at each stage of their complaints process, told Mr C that he should complain to the part of the council responsible for education, but we found that he had chosen to disregard this advice.

Mr C also complained about the role of a council legal adviser during the committee meeting. He said that the officer had gone beyond her remit by asking him a question which he felt was an attempt to discredit his evidence. We found that the legal adviser had not acted unreasonably in asking the question, and the committee chairperson told us the question was relevant and reasonable. However, we thought it would have been helpful for the council to explain the role of each participant in advance of the committee and we made a recommendation about this.

Recommendations

We recommended that the council:

• consider producing a short guidance note explaining the role and rights of participants. This could be shared in advance of a CRC or explained by the chair on the day of the hearing.