Upheld, recommendations

Summary

Mrs C complained about a number of aspects of the care and treatment she received in A&E at Dumfries and Galloway Royal Infirmary. These included concerns about the examinations and investigations carried out and whether doctors should have identified that she had a pulmonary embolism or embolus (a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream), which was discovered when she attended hospital again ten days later.

We obtained independent medical advice on the case from a consultant in general medicine. Our adviser explained that the level of investigation during Mrs C's attendance at A&E was not sufficiently detailed to justify the exclusion of the diagnosis of pulmonary embolus and that in this regard, Mrs C's care fell below the level that she could have expected.

The adviser said it was not possible to say that Mrs C's pulmonary embolus would definitely have been diagnosed if more care had been taken during her attendance at hospital. However, he said it was much more likely to have been diagnosed if doctors had carried out a sufficiently detailed assessment and investigation. The adviser also explained that, overall, he considered it likely that Mrs C's pulmonary embolus was present when she first went to A&E, and should have been considered as a diagnosis at that time.

Recommendations

We recommended that the board:

• feed back the failings identified to the staff involved and ask them to complete reflective commentaries for their educational/appraisal portfolios; and
• provide Mrs C with a written apology for failing to perform an adequate assessment of her in A&E.

Summary

Ms C was admitted to Borders General Hospital (hospital 1), then Knoll Hospital (hospital 2) after being involved in an accident. She was given pain relief at the scene of the accident and taken to hospital 1. On arrival, there was a mix-up over patient details and Ms C told us that on that day and the following day, staff tried to give her medication meant for another patient. Ms C told us that this took some time to resolve and, as a result, she said she was not given pain medication in a timely manner or when requested. She also believed she was given an overdose of morphine, which affected her ability to pass urine. She alerted nursing staff who then identified a urine retention issue. Ms C was transferred to hospital 2 the following month. She said that nursing staff there were institutionalised in their attitudes and treated her as if she was an elderly patient. Ms C discharged herself five days later.

We took independent advice on this case from our nursing adviser, who said that pain charts were not fully utilised at hospital 1 to manage Ms C's pain. Although pain was recorded there was no record of any action taken. In addition, Ms C was known to the pain team but they were not alerted until four days after her admission. We also found that although Ms C was already known to have chronic pain, she was not assessed for this in a proactive manner, and that in this instance care was not reasonable. Moreover, we were concerned that her patient details were incorrect. This was rectified and did not result in any medication errors, but could potentially have had more serious consequences. We were satisfied that the nursing care in relation to urine monitoring and that provided by staff at hospital 2 including their attitude was reasonable, and were satisfied Ms C was not given an overdose of morphine. However, in light of the failings identified, we upheld the complaint.

Recommendations

We recommended that the board:

• review how pain is assessed and monitored in Borders General Hospital and how instruments such as early warning system charts are used;
• inform us of the steps taken to ensure patient details are correct; and
• apologise for the failures this investigation identified.

Summary

Mr C complained about care and treatment provided to his late mother (Mrs A) by the board. Mrs A attended the A&E department at University Hospital Ayr and was admitted to the hospital, where she was diagnosed with a urinary tract infection. Mrs A had a number of longstanding conditions including spinal curvature and lymphoma (a type of cancer). An x-ray was taken which showed a large abnormality at the top of the right lung. This was reviewed by a doctor who considered the progression of Mrs A's lymphoma as a possible diagnosis. After being advised that Mrs A's x-ray showed deterioration, Mr C and his family decided to take her home and she was discharged the following day. The doctor's reading of the x-ray was incorrect as the abnormality was caused by Mrs A's head resting against her chest. The family were advised of this after her discharge and she was readmitted two days after returning home. Mrs A died several weeks later.

Mr C complained that Mrs A had not been given appropriate medication for her infection due to the misdiagnosis and that this had hastened her death. Mr C also complained that the response to his complaint was inadequate.

After taking independent advice from our medical adviser, we found that there had been a major error in the doctor's interpretation of the x-ray and that Mr C and his family should not have been advised that there was a deterioration in her condition. Although we did not find any evidence that Mrs A had been given inappropriate medication or that the incident had hastened her death, we upheld Mr C's complaints due to the significance of the error in reading the x-ray. We also found that the board's investigation of Mr C's complaints did not fully address the doctor's error and that the responses provided were inconsistent. We upheld both Mr C's complaints and made a number of recommendations.

Recommendations

We recommended that the board:

• make staff aware of our adviser's comments on the incorrect diagnosis and determine if there are lessons that can be learned from this incident;
• remind staff of the importance of keeping accurate contemporary records in line with the relevant General Medical Council guidance;
• provide a copy of our decision to the doctor to ensure he is fully aware of the outcome of this investigation and allow any learning points to be discussed at his next appraisal; and
• carry out a review to determine if the doctor's misinterpretation of the x-ray was an isolated incident and provide appropriate training if required.

Summary

Miss C, who has a condition affecting her mobility, complained of a lack of support from the college. In particular, she raised concerns about a fieldwork residential trip, which she was not allowed to attend due to health and safety concerns. Miss C said she was not involved in decisions made about her ability and, although she was provided with notes and recordings from the trip, these were not of a good standard, and she had to seek help from the lecturer to finish the assessment. She also raised concerns about delays in processing changes to her personal learning support plan (PLSP) and personal emergency egress plan (PEEP) in second year.

Because she felt she was not receiving the support she needed, Miss C applied to transfer to a new course. However, this took some time and she was ultimately not able to transfer. Additionally, when Miss C asked her tutor why he thought the transfer was not an option, he suggested that the physical aspects of the course might be too challenging for her.

In response to Miss C's complaint, the college accepted that the notes from the residential trip were not of a good standard. They also explained that the delays in the PEEP and PLSP were due to the unexpected absence of the additional support coordinator, and apologised for this. However, the college considered that Miss C's request for transfer had been handled reasonably. They said that her tutor had told her within five working days that her transfer request had been refused, and they considered that his comments about the physical aspects of the course being challenging were not intended to make assumptions about Miss C's physical ability. Overall, the college said that they had provided reasonable support to Miss C, and they did not uphold her complaints. Miss C was dissatisfied with their response, and complained to us about the additional support provided, the handling of her transfer, and the college's handling of her complaint.

We investigated Miss C's complaints and found that, although the college had involved her appropriately in discussions about adjustments to the residential trip, the arrangements ultimately made were unreasonable, as the college relied on another student for these. We said that the college should have ensured that the notes were made available in good time, and were of sufficient quality to enable Miss C to complete the assignment. We also found that the college failed to make timely arrangements to update Miss C's PEEP, as her classes were scheduled for a different building and no alternative arrangements were made for her until the third week of term when she raised this herself. However, we found that they did make reasonable attempts to review her PLSP, including offering her an urgent appointment early in the next academic year.

We found that the college unreasonably handled Miss C's request to transfer to another course. While the decision to refuse the transfer was made in a reasonable time-frame, this was not appropriately communicated to Miss C for over two weeks. Although her tutor informally told her that he did not think the transfer was an option, the only reason he gave for this was that the course might be physically challenging, and he did not tell Miss C that the head of curriculum had declined the request. We were critical of the failure to properly communicate the decision to Miss C, and of the tutor’s comment.

Finally, we found that while the college generally handled Miss C's complaints well, they did not comply with their policy, as they failed to provide a written response within 20 working days.

Recommendations

We recommended that the college:

• review their templates and procedures for setting up personal learning support plans (PLSPs) to ensure that additional support required for fieldwork is discussed with students at an early stage and there is a clear process for informing module tutors of students' PLSPs and additional support entitlements;
• review their processes for setting up and reviewing personal emergency egress plans (PEEPs), to ensure that PEEPs covering the relevant building are in place before students are expected to attend classes;
• take steps to clarify the roles of different staff in relation to requests for transfer (including who is responsible for liaising with the student);
• raise the findings of our investigation with staff involved for reflection;
• apologise to Miss C for the failings our investigation found; and
• remind staff of the requirement to provide a written response to all complaints which are considered at the investigation stage.

Summary

Mr C submitted four complaint forms to the prison governor alleging assaults by prison staff and issues related to a strip search. He then submitted four more forms the following month, saying that his concerns had not been investigated.

In response to the complaint, the governor told Mr C that the allegations of assault had been referred to the police for investigation. However, because the police did not take matters further due to insufficient evidence, the prison did not undertake a local investigation.

We upheld Mr C's complaint as our investigation found that, although the police investigation did not find enough evidence to pursue criminal actions, the governor had not clearly demonstrated that the prison had dealt with the complaints. We were critical that despite submitting eight complaint forms directly to the governor, it had not been properly explained to Mr C - or to us - whether staff handled him in accordance with the prison rules, and their control and restraint guidance.

Recommendations

We recommended that Scottish Prison Service:

• investigate whether or not staff handled Mr C in line with the prison rules and their control and restraint manual;
• investigate Mr C's allegations that nursing staff were present during a strip search and whether this was in accordance with the prison rules and their standard operating procedure for conducting searches; and
• draw our findings to the governor's attention to ensure that complaints are fully investigated and responded to.

Summary

Mr C complained that his prison refused his request for escorted day absence (EDA) so he could visit a relative who was medically unable to travel to the prison. Mr C said his previous prisons had granted him EDAs to see the same relative, and the situation had not changed, so he could not understand why his request was refused.

The Prisons and Young Offenders Institutions (Scotland) Rules 2011 and the Scottish Prison Rules (Escorted Day Absence) Direction 2011 set out the criteria for EDAs. It is clear from this legislation that prison governors have discretion to decide whether an EDA application is being made in exceptional circumstances. The SPSO cannot challenge this discretion. However, even where there is discretion, such decisions must be justified on the basis of available evidence, and this information should be recorded. This ensures that, where appropriate, the process used to reach such decisions can be scrutinised, to ensure that the process is followed appropriately and, therefore, the decisions are not arbitrary.

In Mr C's case, neither his prison nor the Scottish Prison Service centrally were able to provide us with a copy of his completed EDA application. Therefore, there was no evidence that the EDA process was followed appropriately to its completion. In addition, Mr C's prison did not explain in their responses to his complaints, or in their response to our enquiry, why they did not consider his case to be exceptional circumstances. Given this, we upheld Mr C's complaint.

While we understand the need for prison governors to be able to make decisions in their prison based on local conditions and the specific circumstances of individual cases, the apparent lack of guidance on what might be considered exceptional circumstances for an EDA could lead to apparent unfair inconsistency between individual prisons which is difficult to explain. Therefore, we made a recommendation to address this.

Recommendations

We recommended that the Scottish Prison Service:

• apologise to Mr C for failing to explain why his case was not considered to be exceptional circumstances;
• remind all prisons of the importance of keeping complete, accurate and current information in a prisoner's core file; and
• provide guidance to prison governors on what might constitute exceptional circumstances for an escorted day absence.

Summary

Mr and Mrs C tried to collect their son's property from a prison but were unable to do so. They complained that the prison failed to take appropriate steps to ensure that they could collect the property and did not respond appropriately to their complaint.

In response, the Scottish Prison Service (SPS) had told Mr and Mrs C that they could not collect the property because staff had not taken it to the correct collection area. However, in responding to our enquiries, they confirmed that the prison's actions in handling the property were in fact correct. They explained that the problem occurred because, when Mr and Mrs C tried to collect the property, the member of staff in the collection area was unaware that it was there. Although the SPS confirmed that the prison were reviewing the process, we upheld Mr and Mrs C's complaint and made a recommendation.

In considering whether the prison responded appropriately to their complaint, we identified that the response contained a number of inaccuracies and because of that, we also upheld this part of Mr and Mrs C's complaint.

Recommendations

We recommended that the SPS:

• tell us what steps the prison took to review the relevant procedure and confirm what changes, if any, have been implemented; and
• apologise to Mr and Mrs C for the inaccuracies in their response to the complaint.

Summary

Mr C complained that his prison failed to follow relevant procedures in providing him with food; specifically, that one meal provided to him was lower than the required temperature. Mr C said he saw food records which had missing days and dates, and that he spoke to staff who told him a meal had not been probed to check its temperature. Mr C said he had lost trust in the prison's ability to provide meals that were safe to eat.

We have no role in ensuring the health and safety of prison food. Our role in this case was to consider whether the prison acted in line with relevant processes or procedures. We looked at the food records and found that some entries were missed from the daily hot temperature record sheet. This evidence was accepted by the prison when they dealt with Mr C's complaint. It meant that the prison were unable to demonstrate that meals served each day had been probed, to ensure they were above the required minimum temperature of 63°C. As this was not compliant with the prison's food safety manual and The Prisons and Young Offenders Institutions (Scotland) Rules 2011, we upheld Mr C's complaint.

In response to Mr C's complaint the prison carried out an audit of compliance with the food safety manual over a number of weeks, which we found to be reasonable and proportionate in the circumstances. However, we were concerned that one part of the prison did not provide the necessary data sheets for the audit and, therefore, we made a recommendation about this.

Recommendations

We recommended that the Scottish Prison Service:

• ensure that all halls audited or inspected for compliance with the food safety manual provide the necessary data when requested to do so, and copy the results to us.

Summary

Mr C made a claim to the council for damage from a road accident caused by a pothole, saying that they had not maintained the road in line with their procedures. The council refused his claim, as they said they had complied with their procedures for inspecting the road, and repaired the pothole within the required time-frame. They also said the pothole was less than the minimum depth required for them to be liable for the accident. Mr C disagreed with several of these findings, and complained to the council that they had not handled his claim reasonably. They apologised for delays in responding, but did not agree that they had relied on inaccurate information. Mr C was dissatisfied with the council's response, and complained to us about their handling of his claim and complaint.

We found that the council had used inaccurate information when determining his claim, as they had used inspection dates for the wrong route and had relied on a measurement that they acknowledged was probably an estimate rather than an actual measurement. Although Mr C had video evidence of the pothole depth, which he offered to share, the council had not taken account of this. We also found that they failed to deal with his complaints reasonably, as they did not acknowledge or respond within the required time-frames, and did not consider all the available evidence. When Mr C complained that the information was inaccurate, the council double-checked the accident inspection report they had relied on, but did not compare this to documents that would have shown that the information was inaccurate.

Recommendations

We recommended that the council:

• review their procedures for identifying, logging and tracking complaints, to ensure that the time-frames in the complaints handling procedure are met;
• remind complaints handling staff of the importance of considering and testing all the evidence available, particularly where factual issues are disputed by the complainant;
• issue a written apology to Mr C for the failings our investigation found;
• consider amending their job ticket templates, so that it is clear the published 'target date' is for inspection rather than repair, and to include the target date for repairs; and
• reconsider Mr C's claim, in line with their procedures.

Summary

Mr C was involved in correspondence with the council about a transport issue and submitted a complaint. He received an acknowledgement email but no further response from the council that referred to the complaint or dealt with the issues he had raised. Mr C raised his complaint with us. We found that the council had received the complaint but a procedural failure meant that the relevant department had not taken action on it. In light of this, we upheld Mr C's complaint and made recommendations.

Recommendations

We recommended that the council:

• apologise to Mr C for failing to respond to his complaint;
• respond fully to Mr C's complaint; and
• undertake a practical test to confirm that the further training given has been successful in ensuring that no further correspondence is missed.