Upheld, recommendations

Summary

Mr C, who is a prisoner, progressed to the national top end (NTE) in January 2012. This is a less secure prison facility, to which prisoners can progress before moving to open prison conditions. The risk management team (RMT) there were concerned that Mr C had not been assessed for offence-related programme work prior to his progression. They decided he should be assessed before they made any decisions about his progression. The assessment identified that he should participate in outstanding programme work and because of this, he was returned to a secure prison to complete it. Mr C complained about being returned to a secure prison because he said the RMT there had approved his progression. He could not understand why he was now being asked to participate in further programme work when he had been told that he had completed everything he was required to. Mr C complained to us that the Scottish Prison Service (SPS) failed to manage his progression to the NTE appropriately. He also said the SPS’ handling of his complaints was unreasonable.

The SPS introduced their generic assessment process at the end of March 2011. Prisons across Scotland were told they should use that process to assess individual prisoners’ needs for suitable programmes. We asked the SPS whether Mr C was assessed by the secure prison before he progressed to the NTE. They said he was not, because the process was not in place there. The evidence we saw confirmed that Mr C should have been assessed and given the opportunity to complete identified programmes before he was progressed to less secure conditions. Because of that, we upheld his complaint.

We also upheld Mr C’s complaint about the SPS’ handling of his complaints. He submitted a number of complaints to the secure prison, raising the same concerns about his progression and asking for explanations about what had happened. The evidence we saw suggested that the prison only responded to a couple of Mr C’s complaints, and did not adequately address the issues he raised. They should have carefully investigated these issues and provided a full and detailed response. Had they done so, this might have prevented Mr C from having to refer his complaint to us.

Recommendations

We recommended that the SPS:

• apologise to Mr C for the failings identified with the prison's handling of his sentence management; and
• apologise to Mr C for failing to adequately address the complaints he raised about his progression.

Summary

Ms C complained that in documents held by the Scottish Children's Reporter Administration (SCRA) she was referred to as male, after they had agreed to refer to her as female. She described this reference as a hate incident. Ms C also complained that the SCRA failed to follow their procedures in dealing with her complaint about this.

We looked at the documents that Ms C and the SCRA provided, and found that male pronouns had been used in a note on the file. The SCRA had agreed to refer to Miss C as female and, in our view, once that agreement was made all subsequent references to her should have been female.

We also found that the SCRA investigating officer did not contact Ms C to agree her complaint and what she was looking for as a result of it, and did not keep a record of the investigation, as required by their complaints handling procedure. Neither was it clear, from their responses to Ms C'’s complaint and to our enquiry, how they had learned from her complaint and how SCRA staff would benefit from that learning. These are also requirements of their complaints handling procedure. We upheld Ms C's complaints.

Recommendations

We recommended that the SCRA:

• ensure SCRA staff are made aware of the need to refer to transgender customers appropriately and consistently;
• remind SCRA staff of the need to follow the complaints handling procedure in dealing with complainants;
• remind SCRA staff to keep records of complaint investigations; and
• inform the Ombudsman of what learning was taken from the investigation into this complaint, and how it has been or will be incorporated into training and guidance for staff.

Summary

When Mr C was sent to prison, he terminated his council tenancy and gave the council a mandate to dispose of his personal property to reduce an amount of money that he owed them. The council put a number of items up for sale in a local auction house, and put the net proceeds towards Mr C’s rent arrears, but he still owed council tax. After Mr C was released from prison, he returned to the area and shortly afterwards the council sent him a statement of his council tax arrears. Mr C then made an information request about the disposal of his property. He had compiled an inventory from memory and believed that his property had been sold for an eighth of its value. After the council responded to his information request he complained to them, then to us, that the process used in disposing of his property was inappropriate.

We found that the council had disposed of Mr C’s property before the Housing (Scotland) Act 2001 and related regulations came into effect. As he terminated the tenancy and did not abandon it, the council had not needed to compile an inventory of his belongings. Our investigation also found that the terms of Mr C’s mandate to the council were wide ranging and unequivocal. However, we upheld his complaint, as we took the view that they should have written to him in prison to account for the discharge of his mandate, advised him of the proceeds of the sale and told him that these had not been enough to clear his debts.

Recommendations

We recommended that the council:

• apologise to Mr C for their failure to write to him after the disposal of his property and inform him of the consequences for his indebtedness.

Summary

Mr C complained to the council about actions of the social work department in relation to his son. He was dissatisfied with the council's responses and raised his complaints with us.

We decided that the council's responses to his complaints was not reasonable, as their letters were unclear on how appeal requests would be dealt with and did not respond to a specific enquiry that he made. We upheld the complaint.

Recommendations

We recommended that the council:

• apologise to Mr C that they did not respond reasonably to his complaints correspondence; and
• ensure that information in complaints responses about appeals is clear.

Summary

Mr C complained that the council had failed to acknowledge and respond to his online complaints about water drainage in his street.

During our investigation, we looked at information provided by Mr C, and at the council’s records. We found that the council took practical steps to resolve the issue underlying the complaints, in terms of trying to deal with the drainage problem. However, their records, to some extent, gave a confusing picture of how Mr C’s complaints were handled. We upheld his complaint, as we took the view that the council should have been aware that Mr C’s complaints required a formal answer, which they failed to provide.

Recommendations

We recommended that the council:

• apologise to Mr C for failing to respond formally to his resubmitted complaints; and
• review how this matter has been dealt with, in order to learn lessons.

Summary

Mr C was unhappy when, after he exchanged tenancies with his father, he could not exercise his entitlement to buy his home through the modernised right to buy scheme. He complained that, as a result of the information the housing association gave him, he was unaware before he exchanged tenancies that the scheme had been suspended. He also said that he did not know that this suspension was extended for another ten years after he and his father completed the exchange. This meant that Mr C could not purchase the property as he had hoped to do.

During our investigation, the association could not demonstrate that they had advised Mr C about the suspension at the time of the exchange. They showed us evidence that the extension of the suspension of the scheme was not confirmed until after the tenancies were swapped, but the leaflet provided to Mr C at the time of the exchange did not mention the suspension at all. It said that a preserved right to buy would be lost when the properties were exchanged, but that someone in Mr C’s position would qualify for the modernised right to buy scheme.

We upheld Mr C’s complaint because the scheme was in fact suspended at the time of the exchange, and the association could not show that they had made Mr C aware of this. This meant that their administrative procedure fell below a reasonable standard. Although we recognised that the association could not give assurances to tenants over what would happen in the future, as there was already a suspension in place we took the view that they could have alerted Mr C to the possibility of this being extended.

Recommendations

We recommended that the association:

• apologise to Mr C for their handling of the matter;
• update all relevant staff and paperwork to reflect the existing suspension of modernised right to buy and the potential for it to be extended; and
• consider making an appropriate ex-gratia payment to Mr C in light of their administrative shortcoming in this matter.

Summary

Mr C hurt his head when his vehicle overturned. He said that when he arrived at hospital he walked in without a wheelchair or a neck brace. He was examined by a doctor, who instructed a nurse to dress Mr C's head wound and advised him to take painkillers. After this, Mr C attended two GP appointments, but went to hospital again about two weeks later feeling faint and woozy. He said he was left unattended for an hour until seen by a doctor, who did not examine him and advised him to buy painkillers from a shop. A few days later, Mr C saw a consultant who told him that there was nothing wrong and to continue with the painkillers. Mr C complained to us that the board failed to provide a neck collar, and did not properly clean the wound and investigate his injury. Finally, he said that they did not take him seriously when he attended hospital several weeks later.

We took independent advice on this case from one of our medical advisers, who specialises in emergency medicine. The adviser said that there were failings in the care and treatment provided immediately after Mr C's accident. When he was taken to the emergency department, he was not immobilised as he should have been. Given the nature of his injury, it was possible that he might have had a neck fracture, which should have been ruled out through careful examination before he was mobilised. A more thorough investigation might also have highlighted the need for an x-ray. However, there was evidence in the medical records that his wound was treated appropriately. Furthermore, after Mr C's initial attendance at hospital, the adviser said that management of the injury and subsequent symptoms was reasonable. We accepted that advice, but upheld the complaint as we were concerned about the management of his injury immediately after the accident.

Recommendations

We recommended that the board:

• ensure that the failures identified are raised as part of the annual appraisal process of relevant staff; and
• apologise to Mr C for the failures identified during our investigation.

Summary

Mrs C, who has power of attorney for her father (Mr A), complained that she had not been involved in assessments to establish whether he met the criteria for NHS continuing care funding (funding provided by the NHS for specialist clinical or nursing treatment).

We found that, although the assessment is essentially a clinical one, the input of the patient or carers is crucial in the overall process. When Mrs C told the staff about her concerns they assumed this to be an appeal request on their decision, and they instructed an independent clinician to assess Mr A. We found that, from a clinical perspective, the staff acted in an appropriate manner. However, national guidance is quite clear that the views of the patient or their carers are an important part of the process and so we upheld the complaint. We were pleased to note that the board are now involving Mrs C in discussions about Mr A's care and treatment.

Recommendations

We recommended that the board:

• formally apologise to Mrs C for the failings identified in our investigation; and
• remind staff who deal with NHS continuing healthcare applications of the requirement to involve patients and their carers in the process.

Summary

Following a severe stroke a number of years ago, Mr C's wife (Mrs C) has had a number of ongoing health issues, including being unable to speak. Her shoulder (on the side affected by her stroke) has been dislocated several times. On one occasion, Mrs C attended the accident and emergency department of a hospital because her shoulder was painful. An x-ray was taken and an emergency doctor attempted to manipulate her shoulder back into position while she was sedated, fracturing one of the shoulder bones in the process. This was treated conservatively (with medical treatment that avoids radical therapeutic measures or operations) but Mrs C required hospital admission and her arm was immobilised.

Mr C complained that as a result of the fracture and bruising, Mrs C suffered a lot of pain. She also had to wear a sling and shoulder brace which made her life more difficult. Mr C said that the manipulation carried out was unreasonable and that Mrs C should not have had to cope with its consequences, particularly given the aftermath of the stroke.

During our investigation we took independent advice from one of our medical advisers, who examined Mrs C's medical records. Their advice, which we accepted, was that it was not reasonable to carry out the manipulation, because the shoulder was effectively not dislocated and there was a very high risk of a fracture occurring. These were significant failures. Furthermore, we were not satisfied from the medical records that Mrs C was fully informed of the risks of the procedure, or that the doctor properly obtained consent.

Recommendations

We recommended that the board:

• put in place a clear protocol for the treatment of chronic dislocation and subluxation (partial dislocation of a bone in a joint) of the shoulder particularly for patients with neurological abnormalities;
• ensure that written consent is obtained for invasive procedures, including the complications, which should be obtained prior to such procedures being undertaken and clearly recorded in the notes;
• ensure these issues are raised with the emergency department doctor as part of his annual appraisal; and
• apologise to Mr C for the failures identified in this investigation.

Summary

Ms C complained about the care and treatment provided to her son (Master A) after a circumcision operation. She said that hospital staff inappropriately discharged her son after the operation; failed to provide the family with information leaflets or advice about what aftercare was required and failed to provide appropriate follow-up treatment when it was evident that the wound was not healing.

After we took independent advice on this case from one of our medical advisers, a paediatric surgeon, we upheld all of Ms C's complaints. The adviser said that, given Master A’s level of discomfort and his difficulty in passing urine, he should not have been discharged from hospital when he was. The adviser also said that the board should have provided Ms C with a discharge summary, including plans for follow-up, when Master A was discharged. We found that the board failed to carry out an investigation into their discharge arrangements, information and documentation, as they had said they would, and to promptly convey the results to Ms C.

The adviser also said that a routine follow-up appointment should have been made for Master A, and that the board should have brought forward that appointment after his emergency reassessment, without any intervention from Ms C. Master A was later prepared for theatre without any explanation to his family, but a surgical registrar then decided not to operate and discharged him home. We found that the junior surgeon who initially saw Master A should have made Ms C aware that the final decision about surgery would be made by the surgical registrar.

Recommendations

We recommended that the board:

• ensure that this complaint is used as a learning tool for all staff responsible for the discharge arrangements for patients undergoing this type of procedure;
• ensure that patients undergoing this procedure are appropriately followed up, including ensuring any necessary follow-up appointments are made prior to discharge;
• ensure that a full review of their discharge policy is carried out for patients undergoing this type of procedure and provide the Ombudsman with evidence of the review; and
• provide both Ms C and Master A with a full apology for the failings identified.