Upheld, recommendations

Summary

A consultant psychologist working for the board diagnosed Ms C with a histrionic personality disorder (a condition in which people act in a very emotional and dramatic way that draws attention to them). Ms C was known to frequently appear at the local accident and emergency (A&E) department and at her medical practice, and the consultant wrote to those services advising that they should manage her behaviour carefully and that they should not entertain threats of self-harm or suicide.

In his letters, the consultant noted that Ms C might become aggressive toward staff and suggested that the police could be called should this happen. Ms C complained that the consultant's advice to these services meant that she was prevented from receiving treatment for other conditions, in particular, for nerve pain in her legs. She also complained that the consultant did not make her aware of her diagnosis or of the fact that he had written to other healthcare services about her behaviour.

We found that it was reasonable for the consultant to send letters to the medical practice and A&E, as both services had an ongoing involvement with Ms C. Generally we were satisfied that the content of his letters was appropriate and represented advice rather than instruction. However, in one of his letters to Ms C's GP, the consultant made what we felt was a clear instruction that threats of suicide should not be tolerated. As good practice guidance says that all threats of suicide should be taken seriously and investigated, we did not find this instruction to be appropriate. Comments from the board and our mental health adviser suggested that it was likely that Ms C would have been told her diagnosis. However, there was no written record of such a discussion and nothing to suggest that she was made aware of the letters that were being sent to other healthcare services. It is an underpinning principle of mental health care that patients are involved in decisions about their care and treatment. We considered that the board had failed to involve Ms C in her care or to record her involvement, and upheld her complaints.

Recommendations

We recommended that the board:

• apologise to Ms C for the issues highlighted; and
• draw the consultant's attention to our adviser's comments about the letter.

Summary

Mr C, who is a prisoner, complained to the prison that the lunchtime meal had been adulterated (made impure or inferior by adding foreign substances) and was excessively salty. In taking his complaint to the prison's internal complaints committee (ICC), Mr C requested to call the catering manager as a witness. This request was refused, but the ICC chair then proceeded to speak to the requested witness about the complaint. The ICC concluded that food provision was of a good standard and that there were robust procedures in place to minimise the risk of adulteration.

Mr C complained to us that his witness request was improperly refused as he had relevant and potentially important evidence. He also complained that the prison had failed to explain the measures that were in place to minimise the risk of food adulteration.

We observed that the prison rules allow the ICC chair to refuse witness requests only where they are satisfied that the evidence the witness is likely to give would be of no relevance or value in considering the complaint. In this instance, as the ICC had later discussed the complaint with the requested witness, we could not agree that they were of no relevance or value. We, therefore, concluded that the refusal of the request was inappropriate. We also considered that it would have been appropriate for the prison to have explained the precautionary procedures referred to in their response. In the circumstances, we upheld the complaint.

Recommendations

We recommended that Scottish Prison Service:

• remind staff acting as ICC chairpersons of their duties under Rule 123(7) to refuse witness requests only where they are satisfied that the witness will be of no relevance or value to the consideration of the complaint;
• advise staff acting as ICC chairpersons that, where relevant, it would be good practice for them to record their reasons for refusing requests to call witnesses;
• issue a fuller response to Mr C's complaint, ensuring that they explain the procedures in place to minimise the risk of food adulteration; and
• apologise to Mr C for the inappropriate handling of his complaint.

Summary

Mr C, who is a prisoner, complained to the prison after his study application was refused. In taking his complaint to the internal complaints committee (ICC), he asked to call the chair of the Higher Education Access Board (HEAB) as a witness. The ICC chair refused this request but later appeared to have discussed the complaint with the requested witness.

Mr C complained to us that there was no proper basis for refusing his witness request. He also complained that the reason for doing so was not explained to him. We noted that the prison rules allow the ICC chair to refuse witness requests only where they are satisfied that the evidence the witness is likely to give would be of no relevance or value in considering the complaint. In this instance, as the ICC had later discussed the complaint with the requested witness, we could not agree that they were of no relevance or value. We, therefore, concluded that the refusal of the request was inappropriate. We also considered that it would have been good practice for the ICC chair to have recorded the reason for refusal on the complaint form. In the circumstances, we upheld the complaint.

Recommendations

We recommended that Scottish Prison Service:

• remind staff acting as ICC chairpersons of their duties under Rule 123(7) to refuse witness requests only where they are satisfied that the witness will be of no relevance or value to the consideration of the complaint;
• advise staff acting as ICC chairpersons that, where relevant, it would be good practice for them to record their reasons for refusing requests to call witnesses; and
• apologise to Mr C for the inappropriate handling of his complaint.

Summary

Mr C, who is a prisoner, complained that an officer delivered an item of his mail to another prisoner's cell. In taking his complaint to the prison's internal complaints committee (ICC), Mr C requested to call the prison's data controller as a witness. This request was refused, but the ICC chair then proceeded to speak to the requested witness about the complaint.

Mr C complained to us that his witness request was improperly refused as the data controller had an input into the resolution of the underlying problem. He also complained that, despite the prison having acknowledged the misdelivery of his mail, he had not received an apology.

We found that the prison rules allow the ICC chair to refuse witness requests only where they are satisfied that the evidence the witness is likely to give would be of no relevance or value in considering the complaint. In this instance, as the ICC had later discussed the complaint with the requested witness, we could not agree that they were of no relevance or value. We, therefore, concluded that the refusal of the request was inappropriate. We also considered that the prison should have apologised to Mr C for misdelivering his mail. In the circumstances, we upheld the complaint.

Recommendations

We recommended that Scottish Prison Service:

• remind staff acting as ICC chairpersons of their duties under Rule 123(7) to refuse witness requests only where they are satisfied that the witness will be of no relevance or value to the consideration of the complaint;
• advise staff acting as ICC chairpersons that, where relevant, it would be good practice for them to record their reasons for refusing requests to call witnesses;
• apologise to Mr C for the inappropriate handling of his complaint; and
• apologise to Mr C for delivering his mail to the wrong cell.

Summary

Mr C, who is a prisoner, complained to the prison that they unnecessarily delayed in processing his request for additional phone credits. He took his complaint to the prison's internal complaints committee (ICC), and requested to call as a witness the manager who had been responsible for handling his request. The ICC chair refused this witness request but then proceeded to speak to the manager about the complaint.

Mr C complained to us that his witness request was improperly refused as the manager was relevant to his complaint. In addition, as the ICC's response merely noted that the manager had by then responded to the complaint, Mr C complained that they failed to address his complaint of delay.

We upheld Mr C's complaint. Our investigation found that the prison rules allow the ICC chair to refuse witness requests only where they are satisfied that the evidence the witness is likely to give would be of no relevance or value in considering the complaint. In this instance, as the ICC had subsequently discussed the complaint with the requested witness, we could not agree that they were of no relevance or value. We, therefore, concluded that the refusal of the request was inappropriate. We also noted that the complaint concerned an alleged delay but the ICC response made no reference to timescales. As such, we considered that the complaint response was inadequate.

Recommendations

We recommended that Scottish Prison Service:

• remind staff acting as ICC chairpersons of their duties under Rule 123(7) to refuse witness requests only where they are satisfied that the witness will be of no relevance or value to the consideration of the complaint;
• advise staff acting as ICC chairpersons that, where relevant, it would be good practice for them to record their reasons for refusing requests to call witnesses;
• issue a fuller response to Mr C's complaint, ensuring that they address his complaint of delay; and
• apologise to Mr C for the inappropriate handling of his complaint.

Summary

Mrs C complained on behalf of a company that Business Stream incorrectly calculated their water charges between December 2009 and April 2012. She said that while she was in dispute with Business Stream about the matter, the company was pursued by debt collectors, although she had been told that the account was on hold.

We looked at the correspondence, statements of account and invoices, and printouts from Business Stream's billing system. Our investigation found that when Business Stream issued the company with an invoice in February 2011, they did so on the basis of information provided to them by Scottish Water. In March 2011, Business Stream learned that this information was wrong, and so were the bills they had issued. However, it took until September 2011 for the company's accounts to be closed and for a new bill to be issued. Business Stream were unable to provide us with any reasons for this. We found this to be maladministration and upheld the complaint.

Business Stream also provided dates of when the company's account was on hold but we found that a demand for payment was sent to them during this time. This should not have happened because Mrs C had been told the account would be suspended until the matter was resolved.

Recommendations

We recommended that Business Stream:

• apologise for the delay in regularising the situation with regard to the meter, Mrs C's water bills and address. The apology should also take into account the fact that a demand for payment was made when Mrs C's account was on hold, and should be enhanced by a payment of £200 in recognition of the inconvenience suffered as a consequence of Business Stream's actions;
• satisfy themselves that there is a process to ensure that holds on accounts are notified to companies seeking payment on their behalf; and
• advise staff concerned of the necessity of keeping correct records, particularly as failure to do so can lead to incorrect invoices.

Summary

Mr C had a long-standing problem with alleged antisocial behaviour from his neighbour, which he had reported to the council. He met with investigators from the council's antisocial investigating team twice to discuss his ongoing concerns. He complained to the council about the way in which the investigators acted towards him during those meetings. He later complained to us about the council's investigation of his complaints.

Mr C's complaint concerned members of the council's staff and, as such, the council did not disclose to him details of the findings of their investigation. They considered this to be an employment relations issue and said that the outcome of their investigation was protected by data protection legislation. We were not critical of the council's position on this, which was reasonable, and we were generally satisfied that steps were taken to investigate the issues and action was taken as a result of that investigation. That said, we found that there were significant delays throughout the investigation, Mr C was not kept informed about the reasons for these delays as we would expect and the council failed to advise Mr C of the final outcome of his complaint. We upheld Mr C's complaints and made a recommendation.

Recommendations

We recommended that the council:

• apologise for their failure to conclude their investigation within a reasonable time period and for their failure to keep in contact with Mr C during the investigation.

Summary
Mrs C complained that she received poor care in hospital after undergoing a procedure to remove a gallstone from her bile duct, which resulted in her bowel being perforated. Mrs C also raised specific concerns that the risk of perforation was not explained to her; there was a lack of information given to her about what happened during the procedure, and she had not been aware of a tube having being inserted during the procedure.

The board said that the procedure was appropriate as not removing the gallstone could have led to recurrent inflammation of the pancreas (pancreatitis), inflammation of the bile ducts and jaundice (yellowing of the skin or eyes). In addition, the procedure carried a lower risk than open surgery. We considered this response reasonable as earlier investigations had showed a small stone blocking the bile duct.

However, we upheld Mrs C's complaint. Our medical adviser said that, while junior medical staff did consider at an early stage the possibility that there had been a perforation, aspects of Mrs C's after-care fell below a reasonable standard. This was because there was no senior doctor accountable for Mrs C's care after the procedure, and no clear supervision of the junior medical staff who were reviewing her. Our adviser considered that there should have been a clear and consistent action plan from the time the perforation was identified to the time Mrs C was transferred to another hospital (five days later) for surgical review. In addition, there did not appear to be any clear instructions by medical staff about feeding or fluids. Therefore, five days were lost in getting the perforation effectively healed, due to poor nutrition and the likelihood that Mrs C's immune system was weakened.

The board said that Mrs C had been sent a leaflet on the procedure which included information on the risk of perforation. Our investigation, however, identified that Mrs C was given a different leaflet that did not explain any of the specific risks. General Medical Council (GMC) guidance says that doctors must tell patients if an investigation or procedure might result in a serious adverse outcome, even if the likelihood of it happening is very small.

In addition, although the consent form Mrs C signed included information on the risks of bleeding, infection and pancreatitis, it did not include information on perforation. GMC guidance on the recording of informed consent says that the patient's medical records or consent form must record the key elements of the discussion that has taken place.

While the board explained to Mrs C the reasoning behind the medical staff's initial diagnosis of pancreatitis before the perforation was identified, there was no clear record made of any discussions the medical staff had with Mrs C either before or after the complication was identified. We noted that the board were correct in informing Mrs C that a tube had not been inserted at the time of the procedure.

Recommendations
We recommended that the board:

• apologise to Mrs C for the failings identified in our investigation;
• ensure there is clear guidance to consultants regarding the clinical oversight and management of a person's care and supervision of junior colleagues, including care arrangements to cover out of hours, weekend care and periods of leave;
• consider reviewing patient information leaflets on the procedure (ERCP) to ensure all possible risks and complications are clearly explained; and
• consider reviewing their consent policy to ensure that all common and serious risks are fully explained to patients when obtaining consent and that these are clearly recorded on the consent form. 

Summary

Mr C complained about the care and treatment that his mother (Mrs A) received from a hospital after she was admitted with a severe headache. Mrs A was diagnosed after about 13 hours with a subarachnoid haemorrhage (a type of stroke where there is a bleed from one of the blood vessels running over the brain). Mr C was concerned about the length of time it took for the hospital to carry out a scan and felt that the brain damage his mother suffered could have been less severe had the scan been done sooner. Mr C also complained about the time it took for the board to respond to his complaint and that the response did not answer all of his concerns.

The board accepted there had been an unacceptable delay of approximately four hours between the time it was decided the scan should be done until it was actually carried out. They were unable to provide a clear reason for the delay but outlined that there were communication problems between the junior doctor and the radiology department. As a result of their findings, the board said that they would rewrite their protocol in relation to scanning and out-of-hours care.

We found further communication problems that impacted on identifying the need for an urgent scan. The medical records show that the on-call medical consultant said that Mrs A was to be scanned immediately in the event of further deterioration. However, when her condition further deteriorated early that morning, before the scan was done, neither the on-call doctor nor the radiologist was informed.

We were unable to say whether earlier diagnosis would have influenced the final outcome in Mrs A's case. However, it would have at least provided the possibility of early transfer and intervention, along with reducing the overnight anxiety the family suffered. Overall, therefore, we considered the care to be below the standard that could reasonably be expected.

We also identified significant delays in the board's responses to Mr C's letters of complaint, which were not in line with the guidance issued by the Scottish Parliament at the time. Whilst we noted inconsistencies in the board's first response to Mr C, their second response was more accurate and in keeping with the information contained within Mrs A's medical records.

Recommendations

We recommended that the board:

• apologise to Mr C and Mrs A for the failings identified in our investigation;
• review the new protocol to ensure that there is appropriate involvement of the senior medical staff responsible for the care of the patient when reviewing patient care, and that appropriate clinical features are included in the protocol to aid diagnosis;
• review clinical communication at the time of handover between all clinical staff, including radiology, to ensure urgent scan requests are effectively communicated and expedited; and
• apologise to Mr C for the delay in responding to his complaint and for providing contradictory information.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mr A) who had a hernia repair operation. Several days after the operation, a district nurse suspected that Mr A had developed an infection. Mr A saw his GP who prescribed antibiotics. Five months later, Mr A experienced a swelling at the site of the operation, which then burst. Mr A went to the accident and emergency department of a hospital, and was seen as an out-patient on several occasions over the next eight months until he had further surgery. Mrs C complained to us that the board failed to provide a reasonable standard of treatment for post-operative complications following Mr A's hernia repair surgery.

We upheld Mrs C's complaint. We found from looking at the records and obtaining independent advice from our medical adviser, that Mr A had an infected mesh (used to repair the hernia) in his wound that needed to be removed. Hospital staff treated the problem with antibiotics, in an attempt to avoid further surgery on Mr C. However, our adviser said that as surgery was inevitable, the decision to remove the infected mesh could and should have been made sooner. In addition, once the decision had been made to remove the infected mesh, there was an unreasonable delay before the surgery was carried out. We also had concerns that the record-keeping in this case was poor.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified in our investigation; and
• reflect on the comments of our adviser in relation to record-keeping.