Upheld, recommendations

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.

Summary

Ms C complained to the council about the actions of council planning officers during consideration of an application she had submitted for permission in principle to build a new dwelling house on her property. She complained that an officer had invented a requirement about the distance the proposed development required to be from her neighbour's boundary, that the reasons given for refusal had not been mentioned in pre-application advice that she had received and that the reasons were not relevant to an application for 'in principle' planning permission.

She was dissatisfied with the responses she received and complained to us. Our investigation found that some of the issues she raised were not addressed. We took the view that the council had not provided full responses to her concerns, and upheld the complaint.

Recommendations

We recommended that the council:

• apologise to Ms C that their responses to her complaints were not as full as they could be; and
• provide Ms C with full responses to her concerns.

Summary

In 2012, the council sent Mr C a cheque with a refund of overpaid council tax. In 2013 he asked them to issue a new cheque, saying that the original was out-of-date and the bank would not accept it. Mr C said his local office advised him to send this back to a named officer in the council's Revenues and Benefits Division, which he said he did. The council investigated what had happened, but told Mr C they would not issue a new cheque because the original had already been paid into his bank. He disputed this and complained to us that the council had failed to investigate his complaint about it.

Our investigation found evidence confirming that the cheque had been deposited in Mr C's account. We also noted that they said he had not sent them back a cheque but a remittance advice slip. However, we upheld his complaint because we found that the council did not deal with it well, and that he had been put to unnecessary time and trouble in pursuing it. His complaint was subject to delay, confusion, poor record-keeping, and a failure to recognise that his correspondence was a complaint and to deal with it in good time.

Recommendations

We recommended that the council:

• issue an apology, in recognition of the fact that Mr C's complaint was not dealt with correctly;
• make a goodwill payment to Mr C, in recognition of the unnecessary time and trouble he was put to in pursuing his complaint;
• issue advice to staff in the Revenues and Benefits Division that all replies to customers' communications should identify when the customer made contact, how contact was made and what the contact was about; and
• ensure that the learning from this complaint is shared with relevant staff.

Summary

Mr C complained that the council failed to deal with his housing application appropriately, and that their response to his complaint was unreasonable. Mr C was formerly in the armed forces, and was of the view that the council's poor handling of his application showed they were prejudiced against former military personnel.

Mr C had a waiting time ('credit' that decides where the person will be on the housing list) of just over 30 years, in relation to his application for a council house. This was because housing applicants who have left the armed forces within three years of making an application may have their application backdated to the date they entered the armed forces. However, even with 30 years waiting time, Mr C's application was ranked below those with priority status. Priority status can only be awarded after an assessment, and is normally based on factors such as preventing long term hospital and care home admissions, the need for adaptations to a property, homelessness, or overcrowding. The council's policy, based on an agreement with the armed forces, did not provide former armed forces personnel with enhanced eligibility for housing; it simply provided additional waiting time.

We found that the council had wrongly cancelled Mr C's housing account for 16 months. During that time, Mr C kept bidding for houses on the council's website, but he was unaware that these were not being considered as he did not receive an error message. The council had acknowledged that his account was cancelled but said that this did not disadvantage him in any way. We could not, however, see how they reached this conclusion.

We found that the council dealt reasonably with some aspects of Mr C's complaint,but did not respond to others. They also provided us with information that they should have given Mr C when they were dealing with it. We could not see any evidence of prejudice against Mr C because he was formerly in the armed forces. However, we upheld his complaints, as we had found administrative failing in the cancellation of his housing account, and in how they dealt with his complaint.

Recommendations

We recommended that the council:

• provide us with evidence to support the assertion that the cancellation of Mr C's housing account meant that he was in no way disadvantaged;
• provide us with evidence to show that the failing that led to the cancellation of Mr C's housing account has been corrected;
• provide Mr C, copied to us, with a clear statement of his current status as a housing applicant;
• apologise to Mr C for failing to deal with all aspects of his complaint reasonably; and
• remind housing staff of the Employee's Guide to the Complaints Handling Procedure, as issued by our Complaints Standards Authority.