Upheld, recommendations

Summary

Mr C raised a number of complaints with the prison about disciplinary reports that were noted on his computerised record. Mr C asked the prison to provide copies of the relevant paperwork in relation to each report or remove them from his record. The prison confirmed that there was no paperwork available to support the particular entries Mr C had complained about. However, the prison said although the paperwork could not be located that, in itself, was not reason to doubt that the reports existed. The complaint we investigated was that the Scottish Prison Service (SPS) unreasonably refused to remove disciplinary reports from Mr C's record.

The SPS disciplinary hearings guide says that the disciplinary paperwork should be retained for the period the prisoner remains in custody or three years after the outcome of the hearing, in case of a subsequent complaint or legal action. In addition, the SPS prisoner records retention schedule confirms that disciplinary paperwork should be retained for five years after the date of the hearing. In relation to Mr C's complaint, the SPS told us the paperwork relating to one of the reports was in storage but they were unable to access it at the time of responding to our enquiries. In addition, they were able to locate some of the disciplinary paperwork in relation to another report but they could not locate other paperwork and were unable to explain why. The SPS told us Mr C had accumulated over 140 disciplinary reports whilst in custody and, because of that, he was more susceptible to administrative errors.

It was clear that the disciplinary paperwork for each of the reports in question should have been retained by the SPS given that the timing of them fell within that outlined by both the disciplinary hearings guide and the records retention schedule. In relation to the paperwork that could not be located, the SPS were unable to provide evidence to support their position that the breaches of discipline occurred because they had been unable to provide copies of the relevant paperwork to substantiate the information recorded on the computer record. Therefore, we considered that their refusal to remove those particular reports from Mr C's record was unreasonable.

Recommendations

We recommended that the SPS:

• remove the reports in question (for which there was no paperwork available) from Mr C's record on their computerised prisoner records system;
• remove a report from Mr C's record on their computerised prisoner records system if the associated disciplinary paperwork cannot be retrieved from the storage facility; and
• remind relevant staff of the terms of the disciplinary hearings guide and the prisoner records retention schedule and how they relate to retaining disciplinary paperwork.

Summary

Mr C kept items of property in a locked storage cupboard on the ground floor of his building. Mr C tried to gain access to the cupboard but the lock had been changed. Mr C discovered that council staff had changed the lock and had given the key to a neighbour. Mr C complained to the council, but was not satisfied with their response. Mr C complained to us that the council failed to check whether the storage cupboard was in use or owned before changing the lock, and that the explanation given to him about why his complaint was rejected was inadequate.

The council confirmed that they did fail to check whether the storage cupboard was in use. We found inconsistencies in the council's investigation of Mr C's complaint, and we felt their decision was based on flawed or incomplete information, which meant their explanation to Mr C was inadequate. We also found that the council failed to respond to Mr C's complaint within the timescales set out in their complaints procedure. We upheld Mr C's complaints.

Recommendations

We recommended that the council:

• reinvestigate Mr C's case in order to clarify the inconsistencies, and provide evidence for a full and accurate account of events, then reconsider Mr C's claim for reimbursement notifying us of the outcome;
• apologise to Mr C for the mishandling of his complaint;
• remind relevant staff of the requirements of the model complaints handling procedure in relation to timeframes, and delays or extensions; and
• raise the complaints handling failings with relevant staff to ensure a similar situation does not recur.

Summary

Since 2011, Mrs C had been raising issues with the council about the damage caused to her boundary fence by the council's grass-cutting contractor. Although her complaints were referred directly to the contractor, she received no response. The damage to her fence continued each year, and each year she contacted the council to complain about the work of the contractor. In September 2014, she complained again when the contractor's machine slipped down a bank beside her fence which was further damaged when the machine was pulled out. She complained again at a later date and a claim was submitted to the contractor who did not uphold her claim, stating that the fence was in a very poor condition. Mrs C escalated her complaint to the council, and they investigated but did not uphold her complaint.

Our investigation considered all the communication between Mrs C and the council, the council's records of their contact with Mrs C, and the complaints handling procedure. We found that, although it was not possible to assess whether the fence had been damaged by the contractor, the council had not ensured that the contractor had provided an adequate level of service and had not dealt reasonably with her complaints.

Recommendations

We recommended that the council:

• apologise for the handling of Mrs C's complaints about the contractor;
• review how complaints referred to contractors are logged and recorded on the council's system;
• consider what steps to take to ensure that complaints to contractors working on the council's behalf are reasonably handled; and
• consider whether some form of financial redress is appropriate to reflect the failings identified.

Summary

Mrs C complained to the council that her child's school had not reasonably addressed reports of bullying or provided support to her child. The council investigated and found that there was no evidence that bullying had taken place or that this was the cause of the anxiety and stress that her child was suffering from.

Mrs C was unhappy and brought her complaint to us. Our investigation found that the council did not consider the incidents to be bullying as the other pupil involved had significant additional support needs which caused their behaviour towards Mrs C's child. We considered that this was in line with the anti-bullying policy in place at the time. We also found that the school was small and that, although it was clear that steps had been taken to keep the children apart, this was difficult to achieve. There was evidence that support had been provided to Mrs C's child for his specific needs, including the difficult relationship with the other pupil.

However, we considered that the council had inappropriately made reference to Mrs C's relationship with the school in their complaint report rather than centring on her child. We found evidence of an incident between the children that had not been included in the Council's report and considered that this did not provide reassurance that all matters had been included when assessing Mrs C's concerns. We also considered that there was no evidence that the school had assessed the potential impact on Mrs C's child before proposing a strategy to inform visiting staff of the difficulties in the class. Finally, we found that the council's complaint investigation had not fully considered the impact of the situation at the school on Mrs C's child in terms of their anxiety and stress. On balance, we upheld Mrs C's complaint.

Recommendations

We recommended that the council:

• apologise to Mrs C for the failings identified.

Summary

Between 2007 and 2012, Mr C said he lived in five different properties in the council's area. Mr C complained that the council unreasonably failed to refund him overpaid council tax at one of the five properties and instead used the money for his outstanding council tax liabilities at the other properties. Mr C questioned the dates the council said he was resident at the properties as he said for much of the time he was in prison.

Our investigation established that the council were entitled to offset an overpayment of council tax at one property to settle an outstanding amount on another property. However, we would have expected the council to take appropriate steps to ensure their calculations were accurate prior to doing so.

The council provided us with copies of the documentary evidence they relied on regarding the dates of Mr C's tenancies and the dates he was in prison. This information was supplied by Mr C and the owners of the properties where he resided and it was therefore reasonable for the council to have relied on this.

However, we had concerns about the council's handling of the issue. There appeared to have been failings in the way in which Mr C's council tax liability was calculated which meant a refund of overpaid council tax may have been payable to Mr C from the outset. There also appeared to have been discrepancies in the start dates for one of Mr C's tenancies and the transfer of monies to this account. On balance, we upheld Mr C's complaint.

Recommendations

We recommended that the council:

• review their calculations of Mr C's council tax liability after giving him the opportunity to provide any further documentary evidence of his periods of detention and notify him of any adjustments in his council tax balance; and
• provide Mr C with a written apology for the failings identified.

Summary

Ms C, a solicitor, complained to the council about the provision of community care for one of her clients. As Ms C had not received a final response to her complaint, just over eight months after writing to the council, she complained to us about the delay.

We found that Ms C did not receive a meaningful response from the council until more than 11 weeks had passed. This was after Ms C had contacted the council twice to enquire about their response. In the council's initial response, they incorrectly told Ms C that legal advice was being sought in relation to her complaint. However, this was not requested until nine months later (during the time that we were investigating the complaint). It was clear to us, and it was accepted by the council, that there was an unreasonable delay in dealing with Ms C. We upheld Ms C's complaint.

Recommendations

We recommended that the council:

• apologise to Ms C for the unreasonable delay in dealing with her complaint; and
• provide Ms C with a response to her complaint.

Summary

Ms C, a solicitor, complained to the council about the provision of community care for one of her clients. As Ms C had not received a final response to her complaint, just over eight months after writing to the council, she complained to us about the delay.

We found that Ms C did not receive a meaningful response from the council until more than 11 weeks had passed. This was after Ms C had contacted the council twice to enquire about their response. In the council's initial response, they incorrectly told Ms C that legal advice was being sought in relation to her complaint. However, this was not requested until nine months later (during the time that we were investigating the complaint). It was clear to us, and it was accepted by the council, that there was an unreasonable delay in dealing with Ms C. We upheld Ms C's complaint.

Recommendations

We recommended that the council:

• apologise to Ms C for the unreasonable delay in dealing with her complaint; and
• provide Ms C with a response to her complaint.

Summary

Ms C, a solicitor, complained to the council about the provision of community care for one of her clients. As Ms C had not received a final response to her complaint, just over eight months after writing to the council, she complained to us about the delay.

We found that Ms C's complaint was acknowledged the day it was received by the council, but she did not receive a meaningful response until more than 11 weeks had passed. This was after Ms C had contacted the council twice to enquire about their response. In the council's initial response, they incorrectly told Ms C that legal advice was being sought in relation to her complaint. However, this was not requested until nine months later (during the time that we were investigating the complaint). It was clear to us, and it was accepted by the council, that there was an unreasonable delay in dealing with Ms C. We upheld Ms C's complaint.

Recommendations

We recommended that the council:

• apologise to Ms C for the unreasonable delay in dealing with her complaint; and
• provide Ms C with a response to her complaint.

Summary

Mr C complained that he was not given his prescribed medications on his first days in prison, and that all his medications were stopped soon after entering prison. Mr C also complained that the board did not investigate when he complained about this.

The board said Mr C's medications were stopped in accordance with his signed medications agreement after he was found concealing suboxone (a medication used to manage addictions) and after he refused to open his mouth to let staff check that he had taken his medication. The board said that, as Mr C had raised these issues with healthcare staff rather than complaining to complaints handling staff, they had treated this as a 'concern' rather than a 'complaint'. They also said that, in any case, they had responded to Mr C's verbal complaints reasonably, by discussing the complaints with him directly on each occasion.

After taking independent advice from a psychiatrist, we upheld Mr C's complaints. We found there was no evidence the health centre had given Mr C his prescribed medication on his first days in prison, aside from one drug, for which there were two conflicting prescriptions (and he had been given one of these). We also found Mr C had been given incorrect medication on several other occasions. However, we found that it was reasonable for the health centre to decide to stop Mr C's medications when they did. Two medications were stopped or reduced soon after Mr C arrived in prison, and the adviser said this was appropriate, as these medications were addictive and not intended for long term use. Mr C's suboxone was stopped after he was found concealing this, and we found this was reasonable, as suboxone is used for addictions management, and there is a risk of overdose or harm if it is taken other than as directed. However, we were critical that the health centre were not able to show that Mr C had been warned about the consequences of concealing medications, as he had been asked to sign the wrong medications agreement (for 'in possession' medications, rather than 'supervised' medications). Mr C's remaining medications were stopped when he refused to comply with instructions to open his mouth. We found this was reasonable, as these medications were not essential for Mr C's condition and there is a risk of harm when medications are taken other than as directed.

We found that the board did not investigate Mr C's complaints appropriately. Although we found it was reasonable for the board to treat these issues as a 'concern' when Mr C initially raised them, when Mr C continued to raise these issues, and was not satisfied with the board's response, they should have been fully investigated.

Recommendations

We recommended that the board:

• remind nursing staff of the need to take care when administering medications (particularly where there are multiple prescriptions);
• review the processes for issuing prescriptions for incoming patients to the prison to ensure that existing prescriptions (from the community and/or time in custody) are continued or amended without delay, and the patient’s agreement is obtained to the applicable medication process ('supervised' or 'in possession');
• apologise to Mr C for the failings our investigation found; and
• take steps to ensure that complaints raised verbally with healthcare staff at the prison are appropriately handled and reported in accordance with the 'Can I help you?' guidance.

Summary

Mrs C complained about the treatment she received from the board in the lead up to the birth of her twins. During her pregnancy she developed HELLP Syndrome (this is the term used to describe a range of symptoms that can affect women with pre-eclampsia or eclampsia; HELLP Syndrome is characterised by the breakdown of red blood cells, elevated liver enzymes and low platelet count). Following diagnosis of her condition, Mrs C's caesarean section was brought forward. Whilst one of her daughters was born healthy, the other was stillborn. Mrs C complained that staff did not monitor her and her babies adequately, and that there was an unreasonable delay to the diagnosis of her HELLP Syndrome and to the delivery of her twins.

We took independent medical advice from a consultant obstetrician (a doctor specialising in pregnancy and childbirth) and gynaecologist (a doctor specialising in the female genital tract and its disorders). We were generally satisfied that Mrs C's condition, and that of her twins, was monitored adequately and in line with national guidance. Blood tests raised concerns for Mrs C's wellbeing but gave no indication of a problem with the twins. When abnormalities were identified, staff acted appropriately. However, we found that one of Mrs C's blood test results was checked and action taken by clinical staff before the full extent of the test results was known. Crucial information about Mrs C's liver enzyme levels was not identified until the day after the information was entered onto the hospital's system. Whilst appropriate action was taken to prioritise Mrs C's delivery once this information was highlighted, we accepted advice from our adviser who considered that the delivery would have taken place sooner had the blood test results been noted on the day they were reported. The available evidence suggested that, had this happened, both twins would likely have been alive at birth.

We were also critical of excessive delays and poor communication in the board's handling of Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for the failings identified;
• review their systems for reviewing blood results to ensure those taken in clinic and those taken on the ward are seen and acted upon in a timely fashion;
• take steps to ensure clear communication of the urgency of non-elective c-sections, and to develop a policy for escalation at times of high workload when c-sections are delayed longer than expected; and
• review their procedures for conducting root cause analyses to ensure they follow a structured process in keeping with the principles of the NHS Scotland complaints handling procedure.