Some upheld, recommendations

Summary

Mr C complained about the handling by the Scottish Prison Service (SPS) of his brother (Mr A)'s sentence management. Mr C was concerned that there had been a lack of clarity between two prisons regarding Mr A's eligibility for offending-related coursework which hampered his progression and release from prison. Mr C said that there had been a change in policy in 2013 which meant that prisoners who denied their offence were now eligible for coursework.

We identified that there had been no change in policy and that guidance on coursework had been issued across the prison sector in 2013 to ensure consistency. We found that the SPS had followed their written guidance when deciding whether Mr A met the selection criteria for participating in coursework to address his violent behaviour. We concluded that Mr A's sentence management in terms of his coursework was reasonable and in line with guidance.

Mr C was also dissatisfied with the SPS's handling of his complaint. We found that while the SPS attempted to provide Mr C with responses to his ongoing correspondence over a year, clearer information could have been provided in relation to Mr A's eligibility for coursework in respect of his offence and the criteria for coursework to address his offending behaviour. We also noted that the SPS had not responded to one of Mr C's letters. We upheld this aspect of Mr C's complaint and made two recommendations.

Recommendations

We recommended that SPS:

• draw the findings regarding the handling of Mr C's complaint to the attention of the governor and life liaison officer; and
• apologise to Mr C for the failings identified in the handling of his complaint.

Summary

Miss C complained about escorting services provided on behalf of the Scottish Prison Service on two occasions. Miss C said that on the first occasion, escort staff physically and verbally abused her and on the second occasion, staff undertook a lengthy diversion when taking her to a medical facility for assessment. Miss C also complained that her complaints about the escort service were not fully investigated.

The escort service did not agree with Miss C's account of the first journey and they provided escort logs and incident reports made at the time. We also obtained a statement from court staff whom Miss C said witnessed the events, which supported the escort service's account. We did not uphold this aspect of Miss C's complaint.

In relation to the second journey, the escort service explained that staff took a different route to pay for a petrol bill but that the diversion would not have added much time to the journey. They also said there was not enough time to catch the ferry (for the preferred route), due to the time that court finished. However, when we asked for further details about this, they said the reason for the diversion was to pay for the petrol bill. During our investigation, the escort service acknowledged that staff should have made other arrangements to pay for the petrol and they apologised to Miss C. We agreed with their assessment of this and we upheld Miss C's complaint.

We also upheld Miss C's complaint about complaints handling. There was no record of staff being interviewed, although the escort service said they have now addressed this. We were also concerned that the escort service gave us conflicting information about whether ferries were available, and that their apology was prompted by our investigation. We considered this reflected a lack of rigour in their investigation as they should have established the key facts and made any apologies when Miss C first complained. We therefore upheld this complaint.

Recommendations

We recommended that Scottish Prison Service:

• ensure the escort service put in place an investigation planning tool so that officers investigating complaints are prompted to note and consider the evidence available on each complaint; and
• ensure the escort service share the findings of this investigation with relevant complaints handling staff for learning purposes.

Summary

Mr C complained about the handling by the Scottish Children's Reporter Administration (SCRA) of his correspondence and complaint.

We found that SCRA did not fail to answer Mr C's questions, and they did not misrepresent his concerns. We did find that SCRA failed to respond to Mr C's initial correspondence and SCRA acknowledged and apologised for this. We also found that SCRA's response to Mr C's complaint did appear to end email correspondence with him unreasonably. We upheld these aspects of Mr C's complaint.

In addition, we found that SCRA's final letter to Mr C did not comply with the SPSO Act 2002 in terms of information about the right to complain to us, so we made a recommendation to address this point.

Recommendations

We recommended that SCRA:

• reflect on the messages given to Mr C in their final communications, to ensure that such confusion does not arise in future; and
• ensure that final responses to complaints comply with section 22 of the SPSO Act 2002.

Summary

Mr C complained to us about parking tickets that he had received from the council. Mr C had appealed some of the charges but the council had rejected his appeal. He then appealed the charges to the independent body that deals with appeals but at that stage, the council decided not to contest his appeal.

Mr C complained to us that the council had failed to action his report of faulty ticket machines. We found that the council had delayed in correcting the signs on the machines about the coins they would accept and we upheld this part of Mr C's complaint. He also complained about the council's handling of the appeals. We found that although Mr C had been inconvenienced by the fact that he had to submit a second appeal to the independent body, the decisions taken on the appeals by the council were decisions they were entitled to take and there was no evidence of procedural failings. Mr C also complained that the council had not told him why they had decided not to contest his appeal. However, this was also a decision they were entitled to take. We did not uphold these aspects of Mr C's complaint.

Mr C complained that the council had failed to respond reasonably to issues he had raised about the legal position of the parking spaces. We found that the council's response to him on this matter had been reasonable and proportionate. We did not uphold this complaint.

Finally, Mr C complained that the council had not followed their complaints procedure when dealing with his complaints. We found that there had been delays in dealing with Mr C's complaint. The council had only recorded the matter as a complaint after this office became involved. We also found that the council had not adequately responded to all of the issues he raised. We upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the council:

• issue a written apology to Mr C for the delay in correcting the signage and the failures in relation to the handling of his complaint;
• provide evidence to confirm that in future, where required, the signage on parking meter machines will be updated promptly; and
• confirm that the staff involved in handling Mr C's complaints have been made aware of our decisions.

Summary

Ms C's neighbour applied for planning permission to build a porch extension which Ms C considered blocked her light. She complained to the council after permission was granted and was told that the plans had passed the daylight test. Ms C complained that the plans to which the daylight test was applied were inaccurate. The council responses indicated that they had tested the plans for accuracy but despite repeated requests for the information, the council could not offer proof of this test. Ms C continued to complain after she had had a final decision and the council reinvestigated her concerns concluding in a second final response. Ms C was unhappy that the plans were inaccurate, the council failed to provide her with proof of their test of accuracy and issued her with numerous responses after a supposedly final response.

We concluded that the council were reasonably entitled to assume the plans were accurate but should have provided Ms C with the information about this (or any test used to check accuracy of plans) and should not have continued to consider Ms C's complaint after issuing a final decision.

Recommendations

We recommended that the council:

• provide Ms C with either the mathematical method used to check the accuracy of the plans or an explanation as to why they were satisfied that the plans were accurate;
• apologise to Ms C for not providing the information or an explanation despite repeated requests; and
• take steps to ensure that planning department staff discuss the outcome of this complaint at a team meeting to raise awareness of the correct process for dealing with repeat complaints.

Summary

Mrs C complained that the council had failed to adequately address the concerns she had raised with them regarding water penetration at the home of her mother (Mrs A). Mrs C also felt that the council had acted unreasonably in their response to her complaints.

The council did not accept that they had failed to adequately address the water penetration, but did concede in the course of this investigation that they should have recognised Mrs C's initial complaint as such, instead of dealing with it as a request for service.

We agreed with the council that their response to the water penetration concerns at Mrs A's home had been reasonable and we did not uphold this complaint. We did, however, uphold Mrs C's complaint about the council not responding reasonably to her complaint to them.

Recommendations

We recommended that the council:

• apologise to Mrs C for their failure to deal with her correspondence as a complaint.

When it was originally published on 25 January 2017, this case referred to a pharmacy in the Lanarkshire NHS Board area. This was incorrect, and should have read a pharmacy in the Greater Glasgow and Clyde NHS Board area. This was due to an administrative error which we have now corrected, and we apologise for any inconvenience that this has caused.

Summary

Mrs C contacted a pharmacy by phone for an emergency supply of her prescribed medication. She told us the pharmacist refused her request a number of times and that she was treated rudely and asked unreasonable and irrelevant questions. Mrs C complained to us that the pharmacy had not responded reasonably to her complaint. We were satisfied that the pharmacy had investigated her complaint in a reasonable manner. Their response was made within a reasonable timescale and contained a reasonable level of detail. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained about the lack of a suitable response to the issues she raised during the complaints process. We upheld this complaint because the pharmacy did not signpost Mrs C to this office at the end of their complaints process. They also caused confusion in setting out Mrs C's options for escalating the complaint and continued to correspond with her after they said their complaint process was at an end.

Recommendations

We recommended that the pharmacy:

• review their complaints process demonstrating compliance with the requirements which apply to NHS complaints in Scotland, and which will ensure the correct escalation advice is given to complainants, and provide us with a copy of the written process and evidence of its circulation to relevant staff.

Summary

Miss C complained to us that the practice had failed to provide her with appropriate care and treatment when she developed problems following back surgery. In particular, she felt that her GP should have taken a urine sample as she was having difficulty urinating and that as she was suffering from pain and swelling at the surgery wound site, a referral should have been made to a specialist consultant. Miss C continued to be in pain for a number of days before contacting the out-of-hours service where she was admitted to hospital for further surgery.

The practice said that it was not appropriate to take a urine sample as the urinary symptoms which Miss C reported were consistent with a diagnosis of a urine infection and that appropriate antibiotics were prescribed. In regards to the wound site, it was felt that the problem was a build-up of fluid which would resolve naturally over time.

We took independent advice from a GP and concluded that there was no requirement for her GP to take a urine sample as the diagnosis of a urine infection was reasonable. However, we found that the GP should have referred Miss C for an urgent specialist orthopaedic opinion as she had developed an acute complication following the surgery. Miss C's symptoms of swelling and pain at the wound site had only been present for three days but it had been three weeks since Miss C's original back surgery. We therefore upheld this complaint.

Recommendations

We recommended that the practice:

• apologise to Miss C for not referring her for a specialist opinion for her spinal condition.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her clients (Mr and Ms B) about care their daughter (Miss A) received from her medical practice. They also complained about the response to their complaint.

Miss A attended her medical practice on three occasions over two months. On the third attendance she was seen by a locum doctor who urgently referred her to hospital where she was diagnosed with a brain tumour. Miss A died later that month.

We sought independent medical advice. The adviser's view was that no symptoms were recorded at Miss A's earlier appointments that would have indicated a serious neurological problem and that the treatment given was reasonable. The adviser said the only significant symptom appeared in the last consultation, where Miss A was appropriately referred to hospital. For these reasons, we did not uphold this complaint.

However, we did uphold Ms C's complaint about the practice's response to the complaint as there were unreasonable delays in responding and third-party information was included in the response when it should not have been.

Recommendations

We recommended that the practice:

• provide us with a copy of their complaints handling procedure demonstrating compliance with the Patient Rights Act and government guidance 'Can I Help You?';
• reassure us that they have a robust system for recording and storing complaints documentation; and
• ensure that the GP concerned undergoes relevant appraisal with regard to complaints handling.

Summary

Mrs C complained about the care and treatment provided to her father (Mr A), who had been admitted to Southern General Hospital for surgery for a fractured hip. Mr A was initially found not be to fit for anaesthesia because of a lung condition and as he had pneumonia. However, he improved with treatment and underwent hip surgery. Mr A later dislocated his hip and developed further deterioration in his lung function and an infection. Mr A died in hospital.

Mrs C complained there had been a failure to provide Mr A with appropriate clinical treatment once it was found his condition had deteriorated, and that pain relief had not been put in place appropriately. She also complained there had been a failure to communicate adequately with the family about Mr A's clinical condition and prognosis and to provide him with an appropriate standard of nursing care.

We obtained independent advice from a medical adviser and a nursing adviser.

The advice we received from the medical adviser was that the clinical treatment Mr A had received was reasonable and that the pain relief given by the palliative care team was reasonable. However, they considered that control of Mr A's pain should have been managed better and sooner. We therefore upheld this aspect of Mrs C's complaint.

We also found that the level of communication with Mr A's family about his condition and prognosis was unsatisfactory. Whilst the advice we received was that communication by the nursing staff was reasonable, there were shortcomings in the medical staff's communication with the family, in particular a failure to convey effectively to the family that Mr A was dying. Given this, we upheld this aspect of Mrs C's complaint.

The nursing adviser considered that overall the nursing care provided to Mr A was reasonable and so in this regard we did not uphold Mrs C's complaint.

Recommendations

We recommended that the board:

• issue an apology to Mrs C for the failings identified in Mr A's pain management;
• ensure the comments of the medical adviser regarding the management of Mr A's pain control are brought to the attention of relevant staff;
• issue an apology for the failings identified with regard to communication with Mr A's family; and
• ensure the comments of the medical adviser are fed back to the relevant medical staff concerning communication and that they have been provided with adequate training in communication skills, especially in communicating news of a patient's prognosis to their family.