Upheld, recommendations

Summary

Mr C, who was a prisoner, complained that the board unreasonably delayed in arranging for him to see an optician over a period of time while he was in prison. We considered Mr C's relevant medical records and the complaints correspondence, and obtained independent advice on his care and treatment from one of our medical advisers. The adviser said that Mr C did not need an urgent appointment, and that delay would not have caused him a permanent eyesight problem. However, as the board said that the average time to wait to see an optician is two to four weeks we were concerned that, during two periods of his time in prison, Mr C waited more than four weeks to be seen, and we upheld his complaint.

Recommendations

We recommended that the board:

• apologise for the delay in Mr C being seen by the optician; and
• review their process to ensure that when a prisoner is listed to see an optician, an appointment is scheduled and appropriate checks are carried out if the prisoner does not attend the appointment.

Summary

A clinician at the prison health centre told Mr C, who is a prisoner, that he appeared to have a toenail infection and that she would let the health centre GP know, who might prescribe treatment. However, despite Mr C sending a number of written reminders on complaint forms, nothing happened. Mr C also complained that, despite his reminders, the health centre did not deal with his complaint. Our investigation showed that the complaint had not been answered appropriately, and when Mr C complained to the board, they replied to an earlier complaint that he had made on an unrelated matter.

When we became involved, this error came to light. Even then, the board did not say that they intended to put matters right, for example by arranging for Mr C to be re-examined and for any appropriate treatment to be given. Nor did they give any indication that they would be taking action in relation to the health centre's replies to the complaint. We upheld all Mr C's complaints, as we considered what had happened to be unreasonable.

Recommendations

We recommended that the board:

• apologise to Mr C for the clinical shortcoming our investigation identified;
• apologise to Mr C for the shortcomings we identified in the way in which the prison health centre and board's complaints staff handled his complaint;
• tell us what action they will take to help prevent a recurrence of the situation; and
• provide us with evidence that they have reviewed the complaints handling shortcomings we identified, and have taken action to help prevent a recurrence.

Summary

Ms C complained about the treatment that her late partner (Mr A), received after he was diagnosed with rectal cancer (cancer of the lower part of the large bowel). He had chemotherapy, and radiotherapy to try to shrink the tumour to the point where it could be operated on. Mr A needed three admissions to the Victoria Hospital to manage the pain caused by his condition. During the second admission, his recent CT scan (computerised tomography - a scan that uses a computer to produce an image of the body) was reviewed, and the clinical team thought that the tumour might be operable if Mr A was referred to a surgeon who had the expertise to provide a non-standard form of surgery. Mr A was referred to such a surgeon, but the cancer was advanced and an operation could not be carried out. Mr A died some 20 months after his diagnosis.

Ms C complained that she and Mr A had been led to believe that his tumour was operable and that his prognosis (forecast of the likely outcome of his condition) was good. She said that, because of this, Mr A's decline and death were unexpected and, had he known his true prognosis, he would have lived the final months of his life differently. She considered that there were avoidable delays in treatment and said that she and Mr A were cut off at home without support from the board. She was particularly concerned about the apparent lack of effective management of Mr A's pain outside hospital.

The evidence we saw indicated that Mr A's tumour was advanced by the time his cancer was diagnosed. We took independent advice from one of our medical advisers, who is a consultant clinical oncologist (cancer specialist). Our adviser confirmed that the course of treatment proposed was appropriate and that the timescales involved were reasonable. However, it was clear that clinical staff considered Mr A's prognosis to be poor from an early stage. Our investigation found that the board had not fully explained Mr A's condition and prognosis to him and Ms C. We also found that his pain was inadequately managed during two of his hospital admissions and when he was at home. We considered that there was a breakdown in communication between the hospital, his GP and the family and considered that the board's community palliative care (care provided solely to prevent or relieve suffering) team could have been used to coordinate his pain management.

Recommendations

We recommended that the board:

• apologise to Ms C for the issues highlighted in our decision letter;
• review Mr A's case with a view to identifying ways of improving communication with patients and their families and ensuring that patients' potential and likely prognoses are explained clearly where applicable;
• conduct an audit of staff compliance with their responsibilities for monitoring patients' pain levels and reviewing pain medication; and
• review Mr A's case and give consideration to how best to involve the community palliative care team in such cases.

Summary

Mrs C told us that her late mother (Mrs A) did not get the care she deserved during the last few hours of her life at Borders General Hospital. She said that at other times the standard of care provided during her mother's stay in hospital had been good or excellent. Mrs C and other family members were aware that Mrs A was in the final few days of her life, and had stayed with her throughout the night. She said that Mrs A suffered unnecessarily because staff failed to check or assess her condition despite family members reporting her distress to them.

The board told us that Mrs A was assessed every time family members asked staff for help, although they also noted that drugs that might have provided some relief for Mrs A could have been given earlier. We found, however, that Mrs A's medical records did not contain the necessary entries to support the statement about assessment, and that there were some gaps in these records. Based on the information available we could not, therefore, conclude that they properly assessed Mrs A's needs, and we upheld the complaint.

Recommendations

We recommended that the board:

• provide us with an update on the service manager for medicine's review of this complaint and any action plan arising from this;
• undertake a further review of this complaint in the light of our findings and provide us with an action plan arising from this;
• apologise that there was no assessment at an earlier point of whether pain and symptom relief should be provided; and
• provide us with evidence of their current plan for terminal and end of life care and of the staff training undertaken to support this.

Summary

Mr C complained that Business Stream had inaccurately measured his water consumption. He thought he had been overcharged because a neighbouring property's water supply had not been removed from his invoice. Business Stream visited the property and found that a submeter on his neighbour's ground had been bypassed. They fitted a new one, took a reading from it and deducted money from Mr C's bill. However, Mr C was not happy about how they calculated this.

After Mr C complained, Business Stream had reviewed the consumption and agreed to make a further credit to Mr C's account. They also provided evidence that the credits on his account were backdated to when the problem was first reported. They confirmed that the metering was now correct, and we were satisfied that they had sorted this out. After we became involved Business Stream said they would remove a recovery charge from Mr C's account and make him an ex-gratia payment, as they recognised they had not communicated with him well, and had taken too long to fix the problem. We were, however, concerned at the length of time this had taken and the efforts Mr C had to go to in pursuing the matter, and we upheld his complaint.

Recommendations

We recommended that Business Stream:

• apologise to Mr C for their handling of the matter.

Summary

Mr C, who is a prisoner, complained to the prison several times because he said they did not give him enough time to eat lunch before the exercise period. He said that because of new arrangements exercise was being called much earlier from Monday to Thursday, which meant prisoners were not being given enough time to eat.

In response to Mr C's complaints, the prison accepted that staff had, at times, called for the exercise period too early. They apologised to Mr C and issued a notice to staff confirming that the afternoon exercise period should not be called for before 13:00. They also confirmed that this would be monitored to ensure staff were complying with the instruction.

The evidence we saw confirmed the prison had provided several assurances to Mr C that they were taking a number of steps to prevent this exercise period from being called too early. However, we also found that Mr C had continued to submit complaints because the instruction was being ignored. We upheld his complaint, as it was clear that the prison had failed to effectively resolve the problem, which they themselves had accepted.

Recommendations

We recommended that the Scottish Prison Service:

• provide us with evidence of the monitoring they say has been carried out; and
• confirm what actions will be taken to effectively resolve Mr C's complaint.

Summary

Mr C, who is a prisoner, complained that the Scottish Prison Service (SPS) had decided that he no longer needed to be managed under their process for prisoners at risk of suicide or self-harm. Mr C had been managed under this process for a number of days, as he had carried out acts of self-harm. During that period, two medical reports had been obtained identifying that he was at risk of further self-harm, and successive case conferences had also reached the decision that he was at risk of this.

However, a fifth case conference decided that Mr C was not at risk. Despite this, the action plan that the SPS put in place after this decision outlined a number of potential risks and risk management interventions. Mr C carried out a further act of self-harm and was put back on the process. We considered that the SPS should have obtained a further medical report on Mr C before deciding that he no longer needed to be managed under the process. There was no evidence that they had done so and we upheld the complaint, as well as his complaint that they had not responded to some of the questions on his complaint form.

Recommendations

We recommended that the SPS:

• make the staff involved in the decision aware of our finding on the matter; and
• issue a written apology to Mr C.

Summary

Mr C, who is a prisoner, complained that the Scottish Prison Service did not highlight on his computer records the names of prisoners who assaulted him in a particular prison. He said this was necessary so that staff would always be aware that he was to be kept separated from them. He was also unhappy that another prison did not fully respond to his complaint about this.

Our investigation found that the day after the assault Mr C was transferred to a second prison for his safety. Staff at the first prison had recorded the incident in his security file, to which only certain staff had access. We also found that it was normal practice after an assault for an entry to be made in a prisoner's computer records so that prison officers in any establishment would be aware of known enemies and whether they should be kept separated. Although Mr C was relocated the next day, the first prison had not made this link on Mr C's records. Staff there could not input this information because he had transferred, but they should have contacted staff at the second prison to have this done. We also identified that another prison took steps to have Mr C's computer records updated with his known enemies after he complained. However, there was insufficient evidence to show that this had been properly explained to him.

Recommendations

We recommended that the Scottish Prison Service:

• draw to the attention of relevant staff in the first prison the importance of ensuring that steps are taken to update a prisoner's computer records with information about known enemies and whether they have to be kept separated; and
• share our findings with staff at the prison who dealt with Mr C's complaint.

Summary

Mr C, who is a prisoner, said the Scottish Prison Service (SPS) did not provide relevant and accurate information in his parole dossier. He said they did not share with the parole board information about his disagreement with intelligence information held about him, and that inaccurate information about a staff assault was included in a report prepared by an officer. Mr C said that, in fact, he had prevented a staff member from being assaulted.

The SPS confirmed a note was added to Mr C's intelligence file noting that he disagreed with the information but they did not provide a copy of that note to the parole board. They also acknowledged that the reference to a staff assault in the report was inaccurate. We asked them if they had amended the information. They told us they did not, because the parole board accepted Mr C's explanation, and because the parole board did not refer to the alleged staff assault in their decision on his case.

We upheld Mr C's complaints. It was not clear to us why the SPS did not let the parole board know about Mr C's disagreement with the information held about him. Although a prisoner can submit self-representations to the parole board, we felt it was fair for the SPS to also provide that information, given it was available when they prepared Mr C's dossier. We were also disappointed that they did not take steps to correct the inaccuracy in the report about the alleged staff assault even though they agreed the information was wrong. The SPS have a responsibility to ensure that non-intelligence information held about a prisoner is up-to-date, relevant and accurate.

Recommendations

We recommended that the SPS:

• apologise to Mr C for the failings identified;
• advise staff responsible for preparing prisoners' parole dossiers to ensure that relevant, up-to-date and accurate information is contained in the file, including any record of a prisoner's disagreement with intelligence held about them;
• ensure both prisoners and staff are aware of the steps that should be taken by a prisoner if they have concerns about the information contained within their dossier; and
• review the information contained in Mr C's file relating to the alleged staff assault and take appropriate corrective action.

Summary

Mr C, who is a prisoner, was assaulted and injured on three separate occasions. As the third assault was serious, he was placed in a protected section of the prison. Mr C complained about being held in protected conditions over the period of a year. In response to the complaint, the Scottish Prison Service (SPS) advised Mr C that he was separated from his known enemies for his own safety. Mr C then complained to us because he had not agreed to be placed in protected conditions.

We acknowledged that the SPS had a duty of care to Mr C in terms of ensuring his safety from potential harm. Although they told us that Mr C had requested protection on a number of occasions after being assaulted, they were unable to provide documentary evidence to support this. Written guidance about the protection assessment process in place at the time said that a prisoner's written agreement should be obtained when placing them in protected conditions. We were critical of the fact that there was no evidence to show that Mr C went through the proper assessment process and his consent was obtained, either when he was placed in protected conditions after the assaults or when he remained in protected conditions at a later date. We also found no evidence to show that his protection status was regularly reviewed in line with the guidance. We upheld the complaint as we concluded that there was no evidence to support the SPS's account that Mr C had requested protection or that they had sought his agreement when placing him under protection.

Recommendations

We recommended that the SPS:

• conduct an audit of prisoners' files held in the prison to ensure that protection agreement forms have been completed and six monthly reviews conducted; and
• ensure that relevant prison staff are fully aware of the guidance about this that was issued to all prisons on 3 May 2012.