Upheld, recommendations

Summary

Mr C complained that the prison's handling of his complaint about an officer was poor. In particular, he said the prison agreed to arrange a meeting between him and the officer in an effort to resolve his concerns but that did not happen.

Our investigation confirmed that the initial meeting did not take place and Mr C was not given any explanation for that. When he escalated his complaint, it was agreed that the meeting would be rescheduled. However, that meeting also did not go ahead because the officer was not available but the prison informed Mr C that it had been rearranged for a later date.

In line with good complaints handling, we felt it would have been appropriate for the manager to follow up with Mr C to find out whether he was satisfied following the outcome of the meeting. If that had happened, the manager would have identified at an earlier stage that the meeting had not taken place and steps could have been taken to reschedule it without Mr C having to escalate his complaint. Therefore, we upheld the complaint.

Recommendations

We recommended that Scottish Prison Service:

• apologise to Mr C for the failures we found with the handling of his complaint; and
• offer Mr C the opportunity to meet with the officer to discuss his concerns as outlined in his initial complaint.

Summary

Mr C complained to us about the council’s handling of his tenant’s application for Local Housing Allowance (LHA). There were significant delays in the processing of the application, and Mr C completed a form to ensure that the first payment was made directly to him. However, a computer system fault meant that the first payment went directly to the tenant’s bank account, instead of to Mr C. When Mr C asked the council about what was happening, the system fault was identified. It also appeared that the council had inappropriately made a second payment to the tenant.

While the council were responding to Mr C’s complaint, they provided varying explanations about the second payment, but eventually provided payment of this smaller sum to Mr C. However, they said that they were unable to pay Mr C the first payment, as this payment had already been made to the tenant, and it was Mr C's responsibility to seek payment from his tenant.

We found that the council delayed in processing the application, and there were then faults with the payment system. We found that it would have been reasonable for the council to make the first payment directly to Mr C, but they should have confirmed with the tenant that he had not already paid any rent for this period.

We were also critical of the council's handling of Mr C’s complaint. They did not identify the complaint appropriately, or respond within their stated timescales. They also did not tell Mr C why the investigation was taking longer or when he could expect a response. We also identified failures with the way the council responded to the complaint, giving Mr C inconsistent information.

Recommendations

We recommended that the council:

• pay the cost of the first payment which was sent in error to the tenant;
• apologise to Mr C for the errors in handling the tenant’s LHA application, and for the time and effort involved in this complaint; and
• review the need for the staff involved in processing LHA applications to receive training in complaints handling.

Summary

Mr C complained to us that the council had failed to take action on his request for remedial gardening works. He said that he told the council that an area close to his home was in need of works. He said that the council agreed, and advised him that works would take place. He said that he noticed this had not happened and approached the council for an explanation. Mr C said the council responded to say that weeding would only be done once a year and referred him to the complaints section of their website. Mr C added that when he tried to query this with the council they terminated his phone call saying they had no further comment.

We found that the council had advised Mr C that a few areas of improvement would be carried out over the coming weeks but that when Mr C queried this they then said this work is only done once a year. The council were unable to provide us with any evidence that the works had been carried out. We also found their refusal to comment on Mr C's questions to be unreasonable, so we upheld Mr C's complaints.

Recommendations

We recommended that the council:

• issue a letter of apology to Mr C for failing to carry out the promised remedial work;
• issue a letter of apology to Mr C for failing to deal appropriately with his enquiry/complaint about remedial work;
• share the outcome of this letter with the relevant complaints handling staff; and
• take steps to ensure that maintenance work that is agreed to is recorded appropriately and that once the work is complete, this too is recorded and dated on worksheets as appropriate.

Summary

Ms C damaged central heating pipework under her floor. She did not dispute the fact that the cost of the repair should be recharged to her. Her concern was about the amount she was being charged and that it had not been properly explained to her. We found that Ms C had been charged for three hours of work. One hour was for the Friday night out-of-hours call when a contractor attended to make the leak and boiler safe. A further two hours were charged for the replacement of a small section of pipework the following day and for making sure the boiler was working as it should be after the repair was finished.

We upheld Ms C's complaints. The association had not asked the contractor about his arrival or departure times from Ms C's property and so were not in a position to say whether the amount charged was reasonable or not. The repair works order which should have contained this information was incomplete. We asked the association to reduce the rechargeable amount by one hour. We also asked them to apologise to Ms C and asked them to carry out a review to ensure invoices and repair orders are appropriately filled in.

Recommendations

We recommended that the association:

• reduce the amount to be recharged by the agreed amount;
• review the process to ensure that invoices and repair orders, particularly those which will be recharged to tenants, are appropriately filled in; and
• offer Ms C an apology for the shortcomings identified.

Summary

Mrs C complained about her treatment at A&E at Ninewells Hospital. She told us that when she attended with a broken foot she was fitted with a moon boot (a removable cast) and told, since it was the weekend, she was to return home and wait for a phone call on Monday. Mrs C said that she was in extreme pain at home and she said she noted trauma blisters on her foot. She said she phoned the hospital for some advice. She said that the staff member that answered the phone did not give any guidance and said that it was Mrs C's choice as to whether she went back to the hospital or not. Mrs C received a call from an orthopaedic consultant the following day who told Mrs C that she should not have been sent home and asked her go to hospital immediately. Mrs C believed that the delay in treatment had contributed to having to spend more time in hospital and having to have two operations.

As part of our investigation we took independent advice from one of our medical advisers, who said that the doctor reviewing the initial x-ray failed to correctly act on the information that identified that Mrs C’s foot was indeed broken. In relation to Mrs C’s complaint about the phone advice she was given following her discharge from A&E, our adviser also said was also of the opinion that all requests for clinical advice should be recorded and that when Mrs C reported on-going symptoms, clear advice about returning for further review should have been given. The board apologised and described the action they would take to avoid a re-occurrence of this situation, although our adviser expressed disappointment that it had taken a formal complaint to identify a training need.

Recommendations

We recommended that the board:

• remind staff about the procedure to be followed when a patient phones for medical advice.

Summary

Mr C phoned the Scottish Ambulance Service (the service) for an emergency ambulance as he was suffering from severe abdominal pains. He described his symptoms to one of the service's clinical advisors who told him to attend his local out-of-hours centre. He attended the centre and was examined by a doctor who immediately phoned for an ambulance and Mr C was taken to hospital where it was diagnosed that he had perforated ulcers. Mr C complained that the service should have sent an ambulance when he originally reported his symptoms.

We took independent advice from an adviser, who is a paramedic, and they explained that, although Mr C's condition was not immediately life threatening, the service's clinical advisor failed to ask sufficiently detailed questions about the character of the pain or associated symptoms. As a result, the service's clinical advisor failed to put himself in a position to safely judge whether or not to despatch an ambulance.

Although there was not a need to send an immediate ambulance, we upheld the complaint because there was a failure to assess Mr C's symptoms appropriately.

Recommendations

We recommended that the service:

• apologise to Mr C for the failure to ask appropriate and relevant questions regarding his abdominal pain; and
• share our decision with the clinical advisor involved and consider whether a training need has been identified.

Summary

Mrs A had fallen at home and sustained a head injury and suspected fractured hip. She had contacted the medical practice and a GP attended and decided that she required to be taken to hospital. The GP arranged that an ambulance should attend within an hour and left Mrs A with a neighbour to wait for the ambulance. Mrs A's daughter (Mrs C) complained that the GP should have arranged an emergency ambulance and should have waited with Mrs A, who is elderly, until its arrival. The practice maintained that Mrs A was stable and the situation was not life-threatening and the GP was satisfied that she did not need to wait for the arrival of the ambulance.

We took independent medical advice from one of our GP advisers, who said that given the situation, Mrs A required an immediate ambulance and the GP should have remained with her in case she deteriorated. The adviser noted that Mrs A was immobile; had symptoms of a hip fracture; had a significant head injury which was bleeding; was unable to recall how the fall occurred; and had a complex medical history. Our adviser was also concerned that the GP had noted the possibility that Mrs A may have required a brain scan to rule out any possible bleed to the brain. In light of this advice, we upheld Mrs C's complaint that the GP failed to provide Mrs A with appropriate medical treatment when she attended the home visit.

Recommendations

We recommended that the practice:

• apologise to Mrs A for the failure to arrange an emergency ambulance; and
• ensure the GP reflects on the comments made by our adviser and discusses the matter at their annual appraisal.

Summary

Ms C complained about the care provided to her when she was admitted to the Western General Hospital (the hospital). Ms C, who lives within another board area, was visiting Edinburgh when she became ill with abdominal pain, severe constipation, and vomiting. She attended the A&E department of another hospital in the board's area and was transferred to the hospital. Ms C was seen by one consultant on admission who said that he planned to do a sigmoidoscopy (an investigation of her intestines by way of a flexible camera) the following day.

The next day Ms C was reviewed by a different consultant who said that the sigmoidoscopy was not necessary and that it would be better for her treatment to be undertaken at her home hospital, where she had previously been treated for a condition involving her intestines. No treatment was provided for Ms C's constipation; her pain was not sufficiently addressed; and when she was discharged on the Saturday, she was told to self-refer to the hospital nearer her home (in another board area) for treatment on the following Monday.

We took independent advice from one of the our medical advisers and a nursing adviser who were of the view that Ms C's condition could and should have been investigated and treated at the hopsital. The medical adviser was of the view that if the team at the hospital felt specialist input was needed from a hospital in another board, Ms C should have been transferred there in a formal process rather than told to self-refer. The result was that Ms C's condition went untreated from Thursday to the next Tuesday as Ms C was admitted to the hospital in another board area on the Monday but there was then a delay in sending the result of a scan done in the hospital to another hospital nearer Ms C’s home.

Ms C also complained that some of the responses from the board to her complaint were inaccurate and this was upheld as some of the matters referred to were not documented in the clinical notes.

Recommendations

We recommended that the board:

• take action to remind all staff involved in this complaint of the importance of effectively monitoring, recording and addressing patients' pain;
• ensure all the staff involved are made aware of the findings in this case;
• give consideration to formulating guidelines on adequate arrangements for patients being discharged for on-going care which is expected to take place at a different institution;
• remind all staff involved in this complaint of the importance of effectively monitoring, investigating, recording and addressing patients' care and treatment;
• remind all staff involved in this complaint of the importance of accurately responding to complaints, based on the clinical records and other evidence available; and
• issue an additional written apology for the failings identified during this investigation.

Summary

Mr C complained that the prison health centre failed to provide appropriate treatment for the injury to his knee. After injuring his knee, Mr C attended the health centre and was prescribed pain medication. Mr C saw the doctor again a few days later because of the pain in his knee and also because the pain medication had given him a rash. The doctor prescribed a different pain medication and referred Mr C for physiotherapy and an x-ray. Mr C said his pain medication was not working but was advised that the doctor would review his medication after the x-ray results were received. The result confirmed Mr C had fluid and a loose fragment in his knee and the health centre referred him to an orthopaedic consultant.

NHS Scotland’s national guidelines for the management of knee pain indicates that if a patient presents with a significant knee injury then they should be referred to A&E, a minor injuries unit or to an orthopaedic specialist which would allow for imaging of the knee to be carried out by x-ray or MRI scan. We took independent advice from one of our GP advisers about the treatment Mr C received and they confirmed that the correct referral protocol – as outlined in the guidelines – was not followed by the health centre when Mr C presented with his knee injury.

In light of the evidence available, and given our adviser’s view which we accepted, we concluded that the health centre failed to provide appropriate treatment for the injury to Mr C’s knee because they did not refer him to A&E for further assessment when he first presented with the injury. Therefore, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the failures we found with the treatment he received;
• ensure relevant health centre staff familiarise themselves with the NHS Scotland guidelines; and
• reflect on Mr C's case and feed back any learning to us.

Summary

Mr C complained that the board required him to post a complaint to their patient relations team, rather than allowing him to submit a complaint to his prison health centre. Mr C felt this was unfair as he only had access to one second class stamp each week.

The board explained that in order to meet the national 20 working day target for dealing with complaints, they had asked prisoners to post their complaints directly to the patient relations team. In the board's view, this helped to remove any unnecessary delays in complaints being passed from the prison health centre to the patient relations team. The board also felt this approach was in line with the national complaints guidance 'Can I Help You' (CIHY).

We decided that the board's approach was not in line with CIHY, as the guidance does not specify to whom complaints should be made, only that the board must accept written or verbal complaints. This means complaints can be made to any member of board staff, including prison health centre staff. It is for the board to resolve any internal problems that might delay complaints being passed from the prison health centre to the patient relations team, and we would expect the board to deal with this without requiring prisoners to post a written complaint to the patient relations team. We upheld Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for requiring him to post his complaint;
• reimburse Mr C for the cost of a second class stamp;
• revise their process so that prisoners can submit complaints to their prison health centre; and
• put in place internal arrangements to expedite the transfer of complaints from prison health centres to the patient relations team.