SPSO Individual Decisions

Mr C complained about being detained by the partnership under the Mental Health (Care and Treatment) (Scotland) Act 2003. We took independent advice from a consultant psychiatrist. We found that the emergency detention carried out by the partnership complied with the Act on both clinical grounds and in terms of procedure. We did not uphold this complaint. Mr C also complained that the partnership unreasonably arranged an appointment to see him at home some time after his detention. We found that there were unreasonable shortcomings in the communication from the partnership. We noted that the partnership had acknowledged this and apologised to Mr C. We upheld this complaint but took no further action. Mr C also complained that the partnership invoked their unacceptable behaviour policy. We found that Mr C had been provided with some incorrect information by the partnership about access to information held about his detention. However, the actions displayed by Mr C met at least two of the criteria required for this policy to be invoked. He had also been advised of the reasons why it was being invoked. We considered that the partnership had appropriately followed their policy on unacceptable behaviour. We did not uphold this complaint. Related reading View Decision Report 201810212 as a PDF (24.3 KB) Updated: August 19, 2020

C's late parent (A) had dementia and received care services in their home from a care provider managed by the partnership. A had increasing difficulties with mobility. C complained about delays in the care provider putting appropriate measures in place to assist A to mobilise. A remained in bed while suitable equipment was being sourced. C complained that delays in putting measures in place to assist A in mobilising resulted in A's health declining. C's complaint was responded to by the partnership. The partnership said that relevant measures were implemented at each stage of the process following a necessary assessment with relevant specialist professional input. They said it was evident that A's general health and mobility were in a downward decline during this period of time. From the available evidence, we noted that although the care providers were liaising with appropriate professionals to put measures in place they were responsible for a number of delays which impeded this process. We took advice from a suitably qualified adviser. We recognised that A's health and mobility were declining and variable during this period and there were clear practical difficulties in maintaining their mobility. However, we considered that there were some unreasonable and avoidable delays in putting measures in place to assist with mobilisation. We therefore upheld this complaint.

C, a support and advocacy worker, complained on behalf of their client (A). A received psychiatric and social work support for a number of years. A obtained copies of letters written by their psychiatrist to other clinicians. C complained to the partnership about the actions of the psychiatrist and social workers. There were issues with the investigation of the complaint and a response was ultimately provided a number of months later. The response included the partnership's views on the actions of the psychiatrist but not of the social workers. The response also included acknowledgement that there had been delays in the handling of A's complaints. A was dissatisfied with the response and C brought their complaint to us. During our investigation of these complaints it became clear that A was not a client of the partnership in respect of social work matters. We found that the delays had been caused by confusion over which of the bodies within the partnership were responsible for the matters complained of, the partnership's inability to quickly and accurately determine the whereabouts of a complaints co-ordinator, the failure to alter voicemail messages or monitor voicemails received and confusion over management responsibility. We found that the partnership had opportunities to pro-actively advise C of these delays but had not done so. We also found that the partnership had unreasonably failed to advise C that A had not been a client of theirs in respect of social work. We upheld the complaint.

C complained to us that the partnership had failed to provide reasonable psychiatric care and treatment to their parent (A) before they completed suicide. We took independent advice from a psychiatric adviser. We found that there had been a number of failings in A's care: There was no specific action taken to either address or mitigate the risks identified on A's care plan beyond continuation of the current treatment plan and referral to psychotherapy. It was not clear from the record to what extent there was direct communication between the psychiatrist and the community psychiatric nurse (CPN), specifically with respect to A's management following an overdose. The fact that A was neither reviewed medically or from a nursing perspective over a six-week period in the aftermath of their overdose was a significant shortcoming. The lack of development of shared risk management plans within the community mental health team (CMHT) was not reasonable. The fact that there was not a scheduled regular meeting to discuss complex cases was not reasonable. There was neither a clearly understood protocol within the CMHT to annually review longer-term cases or a robust facility to provide the psychiatrist with regular consultant supervision for cases under their care. It was not apparent from the case record exactly which consultant was responsible for A. A did not receive appropriate annual review from the CMHT and that this was not reasonable. In view of these failings, we upheld C's complaint. However, we considered that the action the partnership had decided to take in response to these failings had been reasonable, but asked for evidence that this had been completed. There was also no clear evidence that A's death could have been prevented. C also complained that an officer from the partnership had failed to meet them in response to their complaint as previously agreed. Whilst it was not entirely clear if the officer had offered to meet C, overall, the handling of the m

Mr C complained about the care and treatment he was given for addiction issues while in prison. We took independent advice from a mental health nurse with experience in addictions. We found that the treatment and support offered to Mr C was reasonable. In particular, the decision not to offer Mr C alternative medications to methadone was reasonable given that he admitted to the ongoing use of heroin and other illicit medications in prison, and would therefore have been at risk of an overdose. We also noted that with alternative medications to methadone there is a risk of them being covertly diverted in the prison environment. We did not uphold Mr C's complaint. Related reading View Decision Report 201809475 as a PDF (23.65 KB) Updated: October 23, 2019

Mr C, an advocate, complained on behalf of his client (Mrs B) about the care and treatment provided to Mrs B's daughter (Ms A) by the partnership. Ms A was referred to the partnership after she was considered to have experienced an episode of psychosis (a mental health problem that causes people to perceive or interpret things differently from those around them). Mr C complained that the mental health team had failed to provide Ms A with reasonable care and treatment in response to physical symptoms she was experiencing. He complained that there was a failure to communicate appropriately with Ms A's GP and with her parents. Mr C also complained that the mental health team inappropriately had meetings with Ms A in public settings. We took independent advice from a consultant psychiatrist and from a mental health nurse. We found that Ms A's care and treatment was reasonable in relation to her physical symptoms and we did not uphold this aspect of the complaint. We found that there was an unreasonable gap in updating Ms A's GP, which the partnership had already acknowledged and apologised for. We upheld this aspect of the complaint and we asked for evidence of the actions carried out by the partnership in response to this. We found that the communication with Ms A's parents was reasonable. We found that there were occasions where meetings were offered to Ms A's parents, which were not arranged. However, we did not find evidence that this affected Ms A's care and treatment so we did not uphold this aspect of the complaint. We found that it was reasonable that the mental health team had meetings with Ms A in public settings as this was at her request and consideration was given to maintaining her confidentiality. We did not uphold this aspect of the complaint. Related reading View Decision Report 201803099 as a PDF (24.11 KB) Updated: September 18, 2019

Mr C complained about the way the partnership had handled his request to be assessed for suitability for a single cell in prison. Mr C had approached the prison health centre about this matter, and was told that this was an issue for the Scottish Prison Service (SPS). He complained to the partnership about the prison health centre's refusal to support his request for a single cell. Mr C wrote a letter to the health care team, saying that SPS staff had explained to him it was up to the mental health team to indicate whether he should be assigned a single cell. We made enquiries with both SPS and the partnership. SPS confirmed that they are responsible for carrying out cell sharing risk assessments. If a prisoner believes they should be allocated a single cell, then SPS would expect a recommendation from the health centre to support that requirement. The partnership said that decisions on single cell allocation were a matter for the SPS. They said it was not the role of healthcare staff to carry out an assessment for allocation of a single cell. They said there were limited situations in which NHS staff might be involved in requesting such an allocation, and these did not apply to Mr C. While we accepted that it was the overall responsibility of SPS to allocate single cells, on the basis of the evidence put forward by SPS and the information they shared in support of their position, we concluded that when a prisoner asks to be allocated a single cell on medical grounds, such a request should be appropriately considered by the prison healthcare team. It is for healthcare staff to assess whether a single cell is required on health grounds and to determine whether those grounds exist or not. Therefore, we found that the health centre's handling of Mr C's request was unreasonable and we upheld this complaint.

Ms C, an advocate, complained on behalf of her client (Ms A). Ms A contacted the partnership to request a self-directed support assessment. A number of efforts were made to arrange a meeting to complete the assessment, however, after a number of months the partnership expressed concerns about the difficulty in progressing the assessment. They advised Ms A that her case would be suspended until a later date so that the case worker could progress other work. Ms A complained that the partnership failed to make reasonable adjustments in light of her communication needs. Ms A said that she wanted the partnership to fund her preferred interpreter service. We took independent equalities advice. We found that the partnership made an interpreter available for meetings and made reasonable efforts to accommodate all those that Ms A wished to have in attendance at meetings. We also found that the partnership permitted Ms A to use her own preferred interpreter, however, we did not consider they were required to fund that service as they had already made a service available. We did not uphold the complaint. Related reading View Decision Report 201805785 as a PDF (23.87 KB) Updated: August 21, 2019

Mr C complained on behalf of his mother (Ms A) about the partnership's decision to discharge Ms A from hospital based care and into a care home. We took independent medical advice. We found that the partnership had followed Scottish Government guidance in both reaching their decision, and in processing Mr C's appeal of that decision. We did not uphold the complaint. Related reading View Decision Report 201707564 as a PDF (23.49 KB) Updated: April 17, 2019

Mr C complained about the care and treatment he received at the prison health centre. Mr C attended a number of appointments regarding a pain in his hand and wrist and said that he had severed a nerve a number of years ago. At each appointment, Mr C was assessed and prescribed different medications for pain relief, including ibuprofen gel. Mr C said that the medication was not working and pointed out that ibuprofen gel is used to treat muscle pain and not nerve pain. The prison health centre said they could not find any evidence that Mr C had damaged the nerve, despite enquiring with the relevant hospital, and they referred Mr C to the plastic surgery out-patient service for further investigation. We took independent advice from a GP. We found evidence that Mr C had surgery to his hand and wrist a number of years ago. However, we considered that the centre carried out appropriate clinical assessments of Mr C's reported pain and the treatment prescribed based on their findings was reasonable. We did not uphold Mr C's complaint. Related reading View Decision Report 201706415 as a PDF (23.84 KB) Updated: February 20, 2019

Mr C complained that his prison health centre failed to provide medication when requested. He also complained about the responses to his complaints. During our investigation Mr C was liberated from prison. Mr C did not provide us with his post-liberation contact details. As we could not contact Mr C, we closed the file on his complaint. Related reading View Decision Report 201705851 as a PDF (10.75 KB) Updated: December 2, 2018

Mr C complained that the partnership were incorrectly managing his son's direct payment account, as it had fallen into financial deficit. We found that it was clear from the financial information that Mr C had taken on additional care services, and that this had led to the deficit in the account. However, Mr C had written to the partnership at the time he took on the additional services, and he had continued to provide the necessary financial information to the partnership. Had this information been acted on, the issue would have been identified. We upheld the complaint.

Ms C, an advocacy worker, made a complaint to the partnership on behalf of Mrs B, regarding the care and treatment provided to Mrs B's mother (Mrs A). Mrs A suffers from dementia and was an in-patient at Stobhill Hospital. Mrs B was concerned about the nursing care provided to Mrs A, in particular with regards to management of Mrs A's incontinence, use of restraint, and an incident which resulted in Mrs A breaking her hip. Mrs B also raised concerns that when Mrs A was moved to Glasgow Royal Infirmary for treatment of her broken hip, there were failings in nursing care. In particular Mrs B was concerned that Mrs A was not receiving her medication due to staff failing to administer it covertly (mixed in food). We took independent advice from a mental health nurse and a general nurse. We found that the management of Mrs A's incontinence had been reasonable, and that there was no evidence to suggest that the incident in which Mrs A broke her hip could have been avoided or that this was due to an unreasonable level of care. However, we found that the relevant policy in relation to restraint was out of date. Therefore, we considered the nursing care at Stobhill Hospital to be unreasonable and upheld this aspect of Ms C's complaint. In relation to nursing care in Glasgow Royal Infirmary, we found that there was a failure to follow the covert medication guidance, which was, in any case, out of date. We also found that there was a lack of adequate care planning taking Mrs A's dementia into account, and in particular a lack of multi-disciplinary planning involving Mrs B and an appropriate level of specialist input, which may have resulted in poor and inconsistent care. We also found that there was a lack of pressure ulcer care planning. Therefore, we upheld this aspect of Ms C's complaint. Ms C also complained about the level of communication from the partnership with Mrs B in regards to Mrs A's care and treatment. We found that whilst there was communication from staff at b

Ms C has an adult son with autism and she is his main carer and financial welfare guardian. Ms C complained that the partnership did not respond reasonably to a complaint she made about various elements of her son's care and her position as carer and guardian. We found that the partnership had issued a lengthy stage two complaints response. Whilst we noted that this response was quite strongly worded and that this tone may have been upsetting to Ms C, we found that the content of the response was reasonable. We considered that it adequately answered all of the issues Ms C had raised, including evidence of the efforts that had been made to work with Ms C regarding various elements of her son's care. We did not consider the partnership's position on any of these issues to be unreasonable. We did not uphold Ms C's complaint. Related reading View Decision Report 201706687 as a PDF (11 KB) Updated: December 2, 2018