Some upheld, recommendations

Summary

Mr C complained that a prison manager had refused to contact the on-call doctor after Mr C was sick and got something stuck in his throat, causing him chest pain. Mr C said that the prison did not act in accordance with the prison rules because a healthcare professional must be notified of any prisoner whose physical or mental condition appears to require attention. He also complained that staff removed various items from his cell contrary to the prison rules that set out that sufficient bedding must be provided for a prisoner's warmth and health. He said he was cold during the night and suffered pain the next morning.

In responding to the complaint, the prison governor explained that Mr C was being managed under a suicide risk management strategy because of self-harming, which meant staff had to carry out 15 minute observations in accordance with his care plan. As Mr C had hidden under the bed, staff had to remove various items that were considered potentially harmful. This allowed staff to maintain their duty of care to him by being able to freely observe him.

We found that the officers who were observing Mr C raised an incident report that he had handed them an item which he had apparently vomited. However, there was no evidence to show that they had witnessed him being sick or were aware of anything stuck in his throat. Nevertheless, we were concerned that staff did not check in more detail and question why Mr C had the item, given that for safety reasons he was not allowed anything in his cell at this time. Had staff properly investigated this, it is likely they would have established what had happened and so, on balance, we upheld the complaint.

We did not find any evidence to show that the prison acted unreasonably in removing items from Mr C's cell, as staff were required to clearly observe him for his safety, in line with his care plan. We were, however, critical that the governor had not responded to Mr C's complaint about staff not contacting the on-call doctor and made recommendations about this.

Recommendations

We recommended that the Scottish Prison Service:

• take appropriate steps to ensure similar incidents are fully investigated and documented in the observation records;
• share our findings with the governor to ensure that full responses are provided to complaints; and
• apologise to Mr C for the failings we identified.

Summary

Miss C was the victim of a road accident in 2009. Charges were brought in relation to the accident and Miss C was cited to appear in court. Due to an error by the Procurator Fiscal in court in August 2010 the case was not called, and proceedings could not be re-raised because of the time that had elapsed. Miss C made enquiries about the progress of the case and, for the next five months, was advised that it was being rescheduled. At the end of January 2011, however, she was advised that the case had ended the previous August. Miss C complained to COPFS about this and received a final response in April 2013. She was dissatisfied with the response and raised her complaints with us.

We did not uphold Miss C's complaint that COPFS had not reasonably advised her of the progress of the case as there is no requirement for them to do this, and she was advised that she did not need to attend court in August 2010, although she was given incorrect information about the reason for this. We did, however, uphold her complaints that COPFS did not reasonably advise her of the conclusion of the case, provided inaccurate information to her between August 2010 and January 2011 and did not respond reasonably to her enquiries and complaints from January 2011 onwards.

Recommendations

We recommended that COPFS:

• provide us with evidence that all staff were reminded about the provision of appropriate and accurate information to those involved in cases, and that notes of all phone conversations are now added to case records so it is possible to ascertain who provided information to enquirers;
• provide us with evidence of how their move to scanning correspondence has improved their handling of general correspondence; and
• consider, as a tangible expression of regret in exceptional circumstances, making a small payment to Miss C in recognition of the unnecessary costs, inconvenience and upset caused by their administrative errors.

Summary

Mrs C complained that, after she objected to her neighbour's planning application, the council allowed significant amendments and changes to it without telling her or allowing her to comment again. They approved the changed application, and Mrs C said that this seriously compromised her privacy. She also complained about the information the council provided in responding to her concerns and about the way they handled her complaint.

We obtained independent advice on this case from one of our planning advisers. Our investigation found that, because of Mrs C's original objections to the planning application, the council required the applicant to make changes to ensure that Mrs C's property was not overlooked. These changes were not, however, significant in terms of planning legislation and were to ensure that the development complied with the council's guidelines. The law did not require the council to advise Mrs C about the variations, there was no requirement for her to be re-notified about them and we found no evidence of any shortcoming in the way in which the planning application was handled. However, we found that a report of handling was not included in the planning register, which is a statutory requirement, and so we upheld the complaint. There was no evidence to suggest that any of the information from council officers was faulty, although their complaints handling was poor, as she was not correctly signposted to the next stage and their final letter to her was not sufficiently specific.

Recommendations

We recommended that the council:

• provide us with evidence that the software problems that caused the situation with registration of the report of handling have now been remedied to their satisfaction;
• make a formal apology for the failures identified; and
• ensure that the officers concerned are aware of the necessity of complying with the council's stated complaints process.

Summary

Mr C complained about the council's handling of a planning application for a development in his area. He was concerned about the council planning and transportation officers' relationship with the developer and their agent, and believed that officers had acted inappropriately by advising the developer/agent how to circumvent the local plan for the area. Mr C said the planning department had misinterpreted Scottish Government guidance on whether a transport assessment was required for the development and that the planning and transportation departments colluded with a developer's agent to avoid a full traffic assessment.

We obtained independent advice on the case from a planning adviser. Our adviser said that Scottish Government guidance and planning policy made it clear that pre-application discussions between a developer and a council were actively encouraged, and were viewed as adding value at the start of the development management process. The fact that pre-application discussions took place between the developer's agent and the council in this case was, therefore, entirely reasonable.

We found no evidence of the planning department using inappropriate language in communications with the developer or that they became too friendly with the developer or their agent. Not did we find any evidence that the department exceeded their remit in the advice they provided on the local plan. To ensure transparency in the planning process, however, we considered that meetings with developers, including welcome meetings, should be minuted. We found that, on balance, the transport department did not collude with the developer's representative to avoid a traffic impact assessment.

In terms of the requirement for a transport assessment, we concluded that the interpretation of planning guidance was a matter of professional judgment for the council as planning authority. However, before exercising that judgement, the planning committee should have had full information to ensure that their decision was both transparent and well documented. This was a major planning application and the issue of increased traffic was a key matter. We considered that the information was incomplete, both in the report to the committee about the Scottish Government guidance on such assessments and in an external consultants' assessment commissioned by the council on the transport methodology used.

Recommendations

We recommended that the council:

• amend their website to ensure that it accurately reflects the content of their complaints procedure on planning complaints;
• feed back our decision on this complaint to the officers involved to prevent the failings identified occurring in future;
• make sure that their planning and transport departments ensure that relevant Scottish Government guidance and its application is clearly represented in planning reports; and
• provide Mr C with a written apology for the failings identified.

Summary

Some years ago, Mr C received a lifetime ban from council facilities. He complained to us that this was unfair, and that the council had a duty to provide him with access to such facilities.

We upheld his first complaint, as our investigation found that the council should have offered Mr C a date when the ban would be reviewed. We noted that the council had agreed to meet Mr C to review the ban and that they had noted the gap in their policy, and were also reviewing this. However, we saw no evidence to suggest that the council had a duty to provide Mr C with access to leisure facilities, and did not uphold this aspect of the complaint.

Recommendations

We recommended that the council:

• provide us with a copy of the updated policy, considering the failings identified; and
• apologise to Mr C for the failings identified.

Summary

Mrs C complained to us about her dissatisfaction with the council's investigation into her complaints about bullying of her children at their former school. She said that the school had failed to make her aware of their anti-bullying policy; had not contacted her when one of her children was hit during a playground incident; failed to properly manage bullying against another of her children; and that the head teacher had not tried to speak with Mrs C's husband when he notified the school that the children would not be returning. Mrs C told us that the head teacher's own investigation had contained glaring inaccuracies, but the council had not upheld her complaints.

Our investigation found that Mrs C had been made aware that the school had an anti-bullying policy, as it was summarised in the handbook that she would have received when her children were enrolled. We did not uphold that complaint, although we made a recommendation. We also did not uphold the complaint about the council's investigation of Mrs C's complaint about the head teacher. They had found that the head teacher dealt appropriately with the matter, and we agreed that this was something for the council to decide.

We did, however, uphold her complaints about the investigation into lack of communication and failure to manage bullying. On communication, we found that the investigation was flawed, as the council's files showed that they initially found fault with the school's handling of the playground incident, but then changed their decision and did not uphold the complaint. We found no evidence of new or further information having been provided before the decision was changed, and we took the view that the investigation relied too heavily on interviews, and did not seek to verify the facts with evidence. On bullying, we found that the council's investigation placed too much reliance on the head teacher's assurances that the school had properly managed the bullying. Again, the investigation had not tried to verify this as they should have done by checking the school records etc.

Recommendations

We recommended that the council:

• reinforce with the school the need to ensure that both the council's and the school's own policy on anti-bullying are being complied with;
• apologise to Mrs C for the council's failure to investigate her complaint about this issue properly and fully, and the failure of the school to notify her when the incident occurred;
• consider how best to ensure in the light of our findings that the process for investigation into reports of bullying is clearly set out, including parental involvement, and full records are kept of the investigation and its outcomes;
• apologise to Mrs C for the council's failure to investigate her complaint about the bullying of her child not being managed properly and fully by the school; and
• remind staff of the importance of considering records and evidencing decision-making at Stage 2 of the council's complaints procedure.

Summary

Mr C's father (Mr A) suffered from lung cancer, and was being treated with palliative erlotnib therapy (a drug used to treat some types of cancer) by a consultant at Ninewells Hospital. Mr A became ill while on holiday with his family and was admitted to hospital. When the family returned home, Mr A was transferred to Ninewells as he was too ill to go home.

At a meeting with Mr A and his family, the consultant decided to discontinue the erlotnib therapy and focus on symptom control. Medical staff recommended that Mr A be transferred as an in-patient for palliative care, but Mr A and his family decided that he wished to be discharged home. A package of care was requested to support this, but Mr A passed away on the morning of his planned discharge.

Mr C complained to the board that they had failed to arrange a care package in time to enable Mr A to die at home, as he had wished. Mr C also raised several concerns about Mr A's care, record-keeping and communication with hospital staff. The board responded four months later. Staff from the board then met with Mr C and his mother, and agreed what they would do in response to the complaint. In response to Mr C's enquiries, the board wrote to him about the outcomes of these actions. However, Mr C remained dissatisfied with their response, and their handling of his complaint, and complained to us.

After taking independent advice from our medical and nursing advisers, we upheld some of Mr C's complaint. We found that the board had handled his complaint poorly, and had not complied with their own complaints handling procedure or NHS guidance. We also found evidence of poor communication and record-keeping. However, we did not find evidence that Mr A's medical and nursing care was unreasonable. We also found that hospital staff had taken reasonable and timely steps to try to help Mr A achieve his wish to die at home, although this did not happen.

Recommendations

We recommended that the board:

• issue a written apology to Mr C and his family for the record-keeping failings our investigation identified;
• provide us and Mr C with a copy of the quality improvement loop developed for addressing issues with documentation, and details of the Nursing and Midwifery Council code of conduct and accountability sessions arranged to reinforce the need for accurate record-keeping;
• raise our findings in relation to record-keeping with the doctor concerned, for reflection;
• review their complaint management procedure and practices to ensure they comply with the NHS 'Can I help you?' guidance in relation to responding to complaints within 20 days of receipt of the complaint (including where the complaint is received by phone) and informing complainants that they may approach the SPSO if the final response is not provided within 20 working days;
• review guidance and/or template letters for acknowledging and responding to complaints to ensure that all letters include an accurate date (including year), acknowledgement letters provide accurate information on who will sign the final response, and letters for complaints which will exceed the 20 working day time-frame provide an updated time-frame and inform the complainant that they may now approach the SPSO; review processes for ensuring that they meet any commitments made to contact the complainant following the resolution of the complaint (for example, to advise when outcomes or agreed actions are completed); and
• remind complaints handling staff of the need to accurately record the date a complaint is received (including where the complaint is made by phone or in person), the requirement in the board’s procedures for a deputy to be appointed where staff involved in a complaint will be absent, and the SPSO guidance on apologies - in particular that apologies should identify and acknowledge what mistake has been made, as well as the impact on the person being apologised to.

Summary

Mr C complained about the care and treatment he received from the board when he was admitted to prison. He said that he had consultations with two psychiatrists, but the consultations were too short for them to make reasonable decisions about his medical treatment. We found that there was evidence to show that the assessment completed by one of the psychiatrists was reasonable and that she was able to make decisions based on this. However, the evidence the board sent us had no record of the review by the second psychiatrist, so we were unable to say whether this review was reasonable, and we upheld this aspect of Mr C's complaint.

Mr C also complained that the board failed to prescribe a benzodiazepine class drug (drugs used to treat anxiety, insomnia, and a range of other conditions) that he had been receiving when he was admitted to prison. There was no evidence, however, that staff were made aware that he was receiving this medication at the time. It was also reasonable that they did not prescribe the drug when they were told about it, because there were other ways in which they could manage Mr C's symptoms. He also complained that the board had delayed in providing him with tablets that he had been prescribed to help him sleep, and that he had not received these on some of the dates the board recorded he had been given them. In addition, he complained that it was difficult to get the board's complaints forms. As we found no evidence to support these aspects of Mr C's complaint, we did not uphold them.

Finally, Mr C said that he had to wait some months for a mental health review. We upheld this aspect of his complaint, as we found that an appointment with the mental health team had been arranged, but was cancelled because he was at court that day. The appointment was not rearranged until Mr C complained about the delay more than three months later.

Recommendations

We recommended that the board:

• remind the psychiatrist of the need to ensure that appropriate records of consultations are kept in line with General Medical Council guidance;
• make prison healthcare staff aware of our finding that the delay in rearranging Mr C's appointment was unacceptable; and
• issue a written apology to Mr C.

Summary

Mr C complained about the care and treatment given to his father (Mr A). He said that the board failed to admit Mr A to hospital on two occasions, did not provide him with appropriate medication and infection control measures, and did not communicate appropriately with Mr A's family.

During our investigation, we took independent medical advice from an emergency medicine consultant, a consultant physician and a consultant microbiologist. The advice we received was that the decisions not to admit Mr A to hospital were reasonable, and that Mr A received appropriate medication on both occasions. However, we were concerned that on the first occasion the commencement of antibiotics (drugs to treat bacterial infection) was poorly managed, although we also noted that the board apologised and took action to address this. Our emergency medicine adviser said that there were no failings that would have impacted on the outcome, but commented on the board's action in relation to screening Mr A for sepsis (blood infection) and we made a recommendation about this.

We found that the antibiotics given to Mr A before he was admitted to hospital were appropriate. He also received appropriate antibiotic therapy when he was admitted and this was revised appropriately during his stay in hospital. Our consultant physician adviser said that the decision not to isolate Mr A when he was first admitted was reasonable and that he was later treated with appropriate infection control measures.

We were concerned that there were failures in communication with Mr A and his family, although we were aware that the board had accepted that in several areas communication had not been as they would have expected, and had apologised for this. We also noted that they had taken action to improve communication between medical staff and between hospital staff and relatives. We did not, therefore, find it necessary to make recommendations about this.

Recommendations

We recommended that the board:

• ensure that relevant staff members are made aware of our adviser's comments in relation to sepsis screening and given the opportunity to reflect on these for future practice.

Summary

Mrs C complained that her physiotherapist had not referred her for an MRI scan (a scan used to diagnose conditions that affect organs, tissue and bone). As the physiotherapist had not done this, Mrs C arranged one privately, which did not reveal any abnormalities. Mrs C then sought to recover the cost of her private MRI scan from the board.

As part of our investigation we took independent advice from one of our medical advisers. She said the physiotherapist's decision to refer Mrs C to the pain clinic and not for an MRI scan was reasonable. This was because the notes did not indicate that Mrs C's condition required a referral for an MRI scan, in line with the relevant guidance. Although we took Mrs C's concerns into account, our role was to determine the reasonableness of the care and treatment she received. In light of the clear advice we received that the board had acted reasonably and in line with the appropriate guidance, we did not uphold Mrs C's first complaint.

Mrs C was also unhappy at the time the board took to respond to her complaint. Mrs C had contacted them over a period of months and the paperwork showed they had failed to meet their timescales or keep her updated. We upheld this complaint and made two recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs C for the delay in responding to her complaint; and
• review their handling of Mrs C's complaint and feed back to relevant staff to prevent this from happening in future.