Not upheld, recommendations

Summary

Mr C, who is a prisoner, complained about a delay of over three months in providing him with work. He believed he should have been paid a working wage for this period, as opposed to a basic cell wage, as he was willing to work. The prison informed us that Mr C’s work history had been problematic because of his general behaviour. They provided us with information which satisfied us that efforts had been made to provide Mr C with employment opportunities and that these had been unsuccessful because he did not comply with the regime. In the circumstances, we did not consider that there had been an unreasonable delay in providing Mr C with work and we did not uphold this aspect of his complaint.

Mr C also complained that, during his period of unemployment, he was attending education classes but not receiving appropriate payment for this. The prison had said that he was attending on a trial basis due to previous behaviour issues and that it had been agreed with him in advance that this would not attract an enhanced payment, but Mr C disputed this. The prison told us that Mr C’s attendance at education was viewed as a trial to give him the opportunity to improve his behaviour, as agreed after a meeting with Mr C and the education manager. However, we noted that this agreement had not been documented. In addition, we noted that the prison, in responding to Mr C’s complaint, concluded that the wages policy had been followed and that Mr C had not been financially disadvantaged. Having discussed this with the Scottish Prison Service (SPS), we noted that this was not correct and that, in line with normal policy, Mr C would have received an enhanced payment for attending part time education. The SPS told us that they were aware of individual prisons potentially misinterpreting the wages policy on such payments and that they planned to issue clear guidance about this.

We did not, however, uphold this complaint. While noting the apparent misinterpretation, we acknowledged the prison’s right to deviate from the policy in exceptional circumstances and, in light of Mr C’s reported behaviours, and the positive steps taken by the prison to try to reintegrate him.

Finally, Mr C complained that he was held up by a week in starting new employment as a result of a delay by the prison in inducting him for a work party. The prison explained that staff could not induct him due to a lack of materials, and that Mr C was kept informed. They confirmed that Mr C was inducted at the earliest opportunity and placed on the appropriate wage for the work party thereafter. They said it would not have been appropriate for Mr C to have received this wage prior to induction as he was not yet qualified to carry out the role. We considered this reasonable and did not uphold the complaint.

Recommendations

We recommended that Scottish Prison Service:

• advise staff to ensure they document any decisions to deviate from normal policy, clearly recording the rationale for doing so and the steps taken to agree this with the prisoner; and
• notify the Ombudsman when they have issued staff guidance on the interpretation of the wages policy in relation to prisoners attending education on a sessional basis.

Summary

Mr C complained that the Police Complaints Commissioner for Scotland (PCCS) (now the Police Investigations & Review Commissioner (PIRC)) unreasonably directed a police force not to deal with further correspondence from him in respect of his complaint. In addition, he believes that before the PCCS report on his case was issued, the Commissioner himself failed to personally read what Mr C believes to be the most important piece of evidence in relation to his case. He also complained that the PCCS unreasonably imposed their unacceptable actions policy on him.

We found that the decision of the PCCS to direct the police not to deal with any further correspondence from Mr C was a discretionary one granted to the PCCS under the terms of their legislation. The only way to challenge this decision was through judicial review. The information Mr C thought the Commissioner himself should have read was a short police report. On reviewing this issue, we found that the PCCS considered Mr C's complaint under their scheme of delegation and, as such, it was entirely appropriate that the investigation process was delegated to the Commissioner's staff. We found no evidence to suggest that the Commissioner was under any duty to personally review all aspects of the evidence. Finally we looked to see whether the PCCS decision to impose restrictions on Mr C's contact with their office, under their unacceptable actions policy, was reasonable. We found that there was no evidence to suggest that these restrictions were imposed incorrectly. Our investigation found no evidence to support Mr C's case and we did not uphold his complaints. We did, however, make a recommendation relating to their contact with Mr C, when this is reviewed.

Recommendations

We recommended that PIRC:

• when next reviewing their decision to restrict Mr C's contact with them, should write telling him when they will be carrying out the review, giving him an opportunity to comment; and on completion of the review, should write to Mr C setting out the reasons for their decision, when the decision will be reviewed and, if appropriate, the period to which any restriction relates.

Summary

Mrs C rents out a flat, which she purchased over ten years ago. Three years after she bought it, the council issued an invoice for an emergency repair to the building. The statutory notice that they had given about this repair pre-dated her purchase, and Mrs C’s solicitors told her that this was not in the information provided by the council during a search before she bought the flat. When her solicitors contacted the collection company dealing with the debt, they were told that the council had withdrawn the account. No further requests for payment were made.

More recently, during conveyancing for another property, Mrs C discovered that the council had taken legal action against her for payment of the old invoice. She paid this, but complained to the council that she was not liable, and that they had not contacted her about it before pursuing payment. The council refunded the expenses, interest and fees involved, but refused to also refund the amount of the original invoice for the repair. Mrs C complained to us that the council were unreasonably refusing to do so.

Our investigation found that the council made the payment as a goodwill gesture, in recognition of their mistakes in handling the invoice, including sending it to the wrong address. However, Mrs C was held liable for the amount of the repair because, although she was not the person on whom the statutory notice was originally served, she owned the property when the council issued the account. Any failure in the search undertaken when Mrs C bought the flat was for her to take up with her legal representative, as it appeared that her solicitors did not pursue this with the council when this became known. We did not find that the council had issued the invoice incorrectly, but we did think that they should have explained why a refund for the invoice was not given.

Recommendations

We recommended that the council:

• formally apologise to Mrs C; and
• review the handling of her complaint and whether any lessons can be learned to improve procedures.

Summary

Miss C is a council tenant. She complained that the council failed to acknowledge that there was a noise nuisance from her nextdoor neighbour’s house and to take reasonable steps to resolve the matter.

Our investigation found evidence that the council had investigated Miss C’s complaint. Visits had been carried out and no nuisance was identified. The view taken was that any noise came from normal household activities. It was clear that the council had not found a problem and this was why no further action had been taken. We did not, therefore, uphold the complaint but because it had been almost a year since the last visit by the council, and Miss C told us that she was continuing to experience a problem, we decided that it was reasonable to make a recommendation about this.

Recommendations

We recommended that the council:

• arrange a visit to Miss C's home to investigate her complaint about noise nuisance.

Summary

Miss C, who has a complex eye condition requiring regular ophthalmology (the branch of medicine that deals with the anatomy, physiology and diseases of the eye) interventions, complained about the process for accessing these services. Her condition can flare up at short notice requiring her to seek an urgent ophthalmology appointment.

The board's previous process for seeing an ophthalmologist involved attending an eye casualty service which was very busy and could involve waiting the full day to be seen. In order to improve this service, and try to filter out patients whose conditions could be treated by a GP or optometrist (at a community optician practice), the board changed the system. Patients are now required to attend either their GP or optometrist for initial examination and onward ophthalmology referral if required. This should still lead to an ophthalmology appointment within 24 to 48 hours. Miss C complained that she has to re-start this process from the beginning each time, despite her flare ups being regular and onward referral to ophthalmology being inevitable. In responding, the board indicated that, where required, Miss C could obtain repeat appointments by contacting her consultant’s secretary. However, Miss C said that this only applies during normal weekday working hours and only while she was under a specific consultant.

Our enquiries revealed that the old eye casualty service was open seven days a week from 09:00 to 16:30. The new clinic hours are the same but it is not open on a Sunday. As prior referral to this clinic is required, this means that Miss C has no direct access to the clinic at weekends when her consultant’s secretary is unavailable. We acknowledged that this might be frustrating for her but noted that the provisions in place will still result in Miss C being seen within the 48 hour target timescale. We also noted that emergency intervention at weekends could still be sought via NHS 24 or direct presentation at an accident and emergency department. As such, we did not uphold the complaint. However, we noted that when Miss C complained to the board, she expressed concern that she might lose her eyesight if she did not receive immediate treatment. Although the board appeared to have noted this while considering the complaint, they did not respond to it. We were critical of them for this and made a recommendation about it.

Recommendations

We recommended that the board:

• respond to Miss C's concerns about the long-term effect of the condition on her eyesight should she not receive immediate treatment.

Summary

Mr C lives near an open cast coal site which has been subject to several applications for planning consent, covering specific areas of the site. Mr C complained that the council had inappropriately permitted overnight working by the operator on part of the site that was only authorised for 12 hours’ day-time working, and failed to adequately investigate his complaint about work starting early. Mr C also complained that when the latest application for planning consent was made, the council unreasonably refused to allow members of the local community to address the planning committee.

Our investigation did not uphold any of Mr C’s complaints. Our investigation found that it had not been established that the operator was working overnight in an area of the site that only had planning consent for day-time working. The council had found that early morning site noise was explained by the operator as being linked to having drivers and other staff in place to start work at 07:00, and the council did not regard that to be a breach of the relevant planning condition. In refusing the request of residents' representatives to be heard before the committee considered the most recent application, officers had complied with the council’s published guidance (which allows third parties to address the committee only where there is a substantial body of objection to the matter under discussion). Our investigation did not uphold Mr C’s contention that this was discriminatory to objectors in rural areas. We did, however, make a recommendation in relation to Mr C's concerns.

Recommendations

We recommended that the council:

• liaise with Mr C to ascertain the pattern of working leading to his main complaints of noise, and agree three times when they should pay unannounced visits to ascertain the validity of his claims that there is unauthorised working between 19: 00 and 07: 00.

Summary

Mrs C moved back to the council's area to care for family. She accepted the council’s offer of an upper villa flat which had an intercom service to wardens in a nearby sheltered housing complex, although she was fit and active and had no need of the service. The council upgraded the intercom service at the start of 2012. Mrs C then began to be disturbed each morning with switchovers of warden shifts and an early call from the wardens to her downstairs neighbour, who was deaf. This caused her stress and she requested a house transfer. When Mrs C complained, the council disconnected her intercom service and insulated the cable conduit to reduce noise leakage between the two flats. The remaining problem was a matter of acoustic noise transference of conversations between the two properties.

Our investigation did not find grounds to uphold Mrs C’s complaint that the council had unreasonably failed to deal with the problems of the intercom system but in the circumstances, given Mrs C’s wish to move, we made a recommendation to address her concerns.

Recommendations

We recommended that the council:

• invite Mrs C to an interview with their letting centre to explore the possibilities of a mutual exchange and other housing options.

Summary

Mrs C's daughter (Miss A) was pregnant, and was admitted to hospital for her baby to be induced. However, her baby was born by emergency caesarian section (an emergency operation) the next day, and Miss A was discharged home a few days after that. On the day she was discharged, she had been reviewed and an ileus (a condition where the bowel stops contracting and relaxing to move the bowel contents) was suspected. However, Miss A was reviewed again later in the day, noted to be well and was discharged. She had to be readmitted to hospital the next day, with vomiting and a suspected bowel blockage. She needed surgery to release a suture which had been around part of her bowel, and the bowel was then re-sectioned (part of it removed).

Mrs C complained on Miss A's behalf that her daughter had not received a reasonable standard of medical care, and that she was released from hospital too early. She alleged that insufficient care had been taken when Miss A's caesarian section was carried out and that her bowel had been perforated because of this. However, the board said that Miss A's emergency section had been carried out in a routine manner and that she had suffered an unusual complication. Overall, they said that her care had been appropriate.

To investigate the complaint, we took independent advice from one of our medical advisers. Our adviser confirmed that Miss A's bowel injury was a rare but recognised complication of a caesarian section, particularly one that was not planned and was carried out in the later stages of labour, and that the records showed that all reasonable care had been taken during the operation. She also said that there had been no reason not to discharge Miss A, although some of the record-keeping could have been better.

Recommendations

We recommended that the board:

• remind all staff of the importance of timing and dating all entries in the record. Also that staff are reminded that when a complication is suspected, the subsequent records are explicit about the progress of the symptoms giving cause for concern.

Summary

Mrs C complained about the care and treatment provided to her brother (Mr A) while he was both an out-patient and an in-patient in hospital. Mrs C also complained about the arrangements for discharging her brother from hospital, and of a lack of communication and/or consultation with Mr A's family.

Mr A had severe learning difficulties, significant health problems, and had developed dementia, but lived in his own home with the assistance of carers. In early 2011 he developed a number of further health problems and was admitted to hospital. After Mr A had been in hospital for some time, Mrs C was told that he was dying and it was recommended that he be transferred to another hospital for end of life care. Mr A's family took steps to surrender the tenancy of his home and to dispose of some of his belongings. However, Mr A's condition improved and about three months later he was deemed fit enough to be discharged. Mrs C complained that because of what she had been told earlier, Mr A was now homeless and had to be discharged to a nursing home. Mr A became unwell again two months later and was readmitted to hospital. He was discharged again but died a few hours later at his nursing home. Mrs C was particularly concerned that, during his transfer to the nursing home on a very cold and snowy day, Mr A was not dressed in the warm clothing she had ensured was available.

Our investigation, which included taking independent advice from two of our medical advisers, found that the care and treatment provided to Mr A had been reasonable overall. There was no evidence to suggest that he had not been adequately assessed or that his nutrition was inadequate, as Mrs C had feared. However, the advisers raised some concerns over a lack of clarity on issues of Mr A's lack of capacity; the waiting times for out-patient investigations; and information for relatives on NHS continuing care provision. Although we did not uphold Mrs C's complaint, we made recommendations to address these points.

Recommendations

We recommended that the board:

• consider implementing guidelines or targets on timescales for the provision of out-patient investigations such as echocardiograph;
• consider reviewing relevant patient documentation to clarify, where a patient lacks capacity, whether a legally appointed Attorney or Guardian is in place; and
• consider reviewing their policy on informing relatives in relevant situations about the option of NHS continuing care, the assessment process and the appeal process.

Summary

Mr C was admitted to a mental health ward in hospital after taking an overdose. A few days after his admission, he was transferred to another mental health ward. Several days later, Mr C was assaulted by another patient. He was examined by medical staff who concluded that he had not suffered a significant head injury but noted that he was upset and distressed by what happened. Mr C suffered from a headache on several occasions in the weeks following the assault and was again examined. Medical staff again concluded that he did not have a significant head injury. A CT scan (a special scan using a computer to produce an image of the body) was carried out shortly after Mr C's discharge and showed nothing abnormal. Mr C said he expressed his concerns about his safety when he was transferred, and received assurances from staff that he would be safe. He complained that he was inappropriately placed in a ward where he was vulnerable to an unprovoked attack and that the after-care provided to him following the assault was inadequate.

Our investigation found that, while there were failures to update Mr C's risk assessment at certain points, there was nothing to suggest that the assessment would have changed or that Mr C was at particular risk of assault from others whilst in hospital. The independent advice from our medical adviser was that it would, however, be helpful if the board's guidelines were more specific in relation to key times when risk assessments should be completed. We found that the transfer was reasonable as was Mr C's care and treatment after the assault. We did not uphold Mr C's complaints, but made recommendations because we had identified failures in relation to record-keeping and risk assessment.

Recommendations

We recommended that the board:

• review its guidelines on risk assessment in light of our adviser's comments; and
• bring the failures in record-keeping to the attention of relevant staff.