SPSO Individual Decisions

Mrs C brought a complaint to us on behalf of her late husband (Mr C), in relation to the care and treatment he received over a five week period shortly before his death. She was concerned that the medical practice had not acted with enough urgency when she felt Mr C's condition was deteriorating. He had three consultations with a GP over a four week period. At the final consultation the GP had concerns about his breathing and referred him for an x-ray, which took place the next day. The results of the x-ray indicated that Mr C had pleural effusion (a build-up of excess fluid around the lungs). The results arrived in the practice the following day, and the GP referred Mr C back to hospital when he viewed the results on his return to work the day after. Mr C was treated in hospital, and was discharged home, to await further treatment. He died before this further treatment could take place. We sought independent advice from a GP adviser. The adviser reviewed all three consultations, and was satisfied that the GP had taken appropriate action, on the basis of the symptoms which Mr C presented with. They noted that there was no indication of pleural effusion until the third consultation. The adviser also reviewed the practice's response to the x-ray results, and noted that the results did not indicate a need for urgent action. They considered the practice's response to the x-ray results to have been reasonable. We noted concerns that Mrs C had raised which were beyond the scope of this investigation, in relation to conversations which could not be corroborated. We noted the adviser's comments in relation to the GP's actions, and we did not uphold Mrs C's complaint. Related reading View Decision Report 201405422 as a PDF (11.43 KB) Updated: March 13, 2018

Ms C made a complaint about health care she received whilst in prison. During our investigation, Ms C was released. We made attempts to trace Ms C but were unable to establish contact with her. As such, we did not issue a decision on Ms C's case. Related reading View Decision Report 201503391 as a PDF (10.69 KB) Updated: March 13, 2018

Mr C complained that the board failed to provide him with the necessary preparation in advance of a procedure to examine his bowel (colonoscopy). The board acknowledged that Mr C was not given the necessary preparation, which he should have received three days in advance of the procedure, and they apologised to him. We took independent medical advice from a GP. They noted that the hospital had sent clear instructions to the prison health centre regarding the preparation for the procedure and the adviser therefore considered it unreasonable that this was not carried out. The hospital subsequently recorded that Mr C had refused to attend his appointment and he complained about this as he did not consider that the fault for this lay with him. The board apologised to Mr C for inaccurately recording that he had refused to attend. The GP adviser considered that this incorrect recording was unreasonable as it could have resulted in Mr C not receiving a follow-up appointment when the investigation was important to rule out a potential underlying cancer diagnosis. As it happened, the prison doctor re-referred Mr C for a colonoscopy but this was vetted by the hospital and the procedure was changed to an examination of only the lower part of his bowel (flexible sigmoidoscopy). Mr C complained that this change of procedure was not explained to him. We were advised that it would have been reasonable for the sigmoidoscopy procedure to be explained to Mr C on the day of the procedure and the records indicated that this happened. However, we could not see any evidence of the reasons for the change in procedure being explained to him. Mr C also complained about the time the board took to respond to his complaint and for their failure to answer his questions. The board acknowledged that there were inconsistencies in their responses and that they had not answered all of Mr C's specific questions. They also acknowledged that they had taken too long to respond to Mr C's final

Mr A was admitted to Forth Valley Royal Hospital after taking an overdose of drugs. His sister (Ms C) said that it was considered that he had suffered an organically induced psychotic state and a few days later, after his blood pressure and temperature returned to normal, he was discharged. Ms C, however, remained concerned about Mr A's state of mind and wrote to his psychiatrist but her contact was rebuffed. Mr A took his life five months after the overdose. Ms C complained that the board had failed to contribute positively to Mr A's care and perhaps change his outcome. She also complained about the psychiatrist's attitude to the family and that he had focussed incorrectly on Mr A's physical, rather than his mental health. We took independent advice from a consultant psychiatrist and we found that, initially, it had been reasonable to conclude that Mr A's behaviour was due to a transient illness caused by an organically induced psychotic state, and to treat him for this. However, Mr A's psychiatrist later declined important information from Ms C which should have been included in decision-making and clinical management (although it could not be concluded that this would have changed the outcome for Mr A). Subsequently, when Ms C complained, it took too long to provide her with an explanation. We upheld the complaint.

Mrs C complained about the care her relative (Mrs A) received at Forth Valley Royal Hospital. Mrs A was admitted with severe abdominal pain but on her first night in hospital, she suffered a fall. An x-ray was taken but clinicians caring for Mrs A did not identify any fracture after reviewing the image. The x-ray was subsequently reviewed by a radiologist (a doctor specialising in medical imaging) who reported that there was a suspicion of fracture to the pelvis. This report was not acted on for over a week, during which time staff continued to try to mobilise Mrs A. A subsequent scan showed that Mrs A had sustained multiple fractures. When Mrs C complained to the board, the first response she received included a number of factual inaccuracies including that Mrs A had been admitted to hospital following a fall at home. A later response apologised for these errors. Mrs C remained dissatisfied and asked that we consider her complaints that there was an unreasonable delay in identifying Mrs A's fracture and that she had been unreasonably mobilised. After taking independent advice from a consultant geriatrician, we upheld Mrs C's complaints about the medical care Mrs A received. The adviser considered it unreasonable that the x-ray report indicating that there was a suspicion of fracture had not been acted on and said it appeared staff caring for Mrs A had wrongly assumed the initial opinion that there was no fracture was correct. We found no evidence that Mrs A had been inappropriately mobilised after her fractures were identified but, in light of the fact that attempts were made to do so prior to this, we upheld Mrs C's complaint on this issue. We also upheld Mrs C's concerns about complaints handling as it is vital that complaint responses are factually accurate. While the board have already apologised for this matter, we found that they had not referred to the delay in acting on the x-ray report in their response, which we did not consider to be reasonabl

Mr C complained to us that staff at Forth Valley Royal Hospital had removed a cannula (a small tube inserted into the body that can be used to drain fluid or to give medication) against his will when he was being discharged from hospital. We took independent advice on the complaint from a medical adviser. We found that it had been reasonable for staff to remove the cannula, as there was a risk of infection. We did not uphold this aspect of Mr C's complaint. Mr C also complained that the board failed to deal with his complaints about this appropriately. He had complained to a prison health centre and they sent the complaint to the board's complaints handling team to respond. However, the complaints handling team did not receive the complaint and, as a result, Mr C did not receive an acknowledgement or a response to his complaint at that time. He had to write to the board again and faced a significant delay before receiving a response to the complaint. Some of the information in the board's response was also factually inaccurate. In view of this, we upheld this aspect of Mr C's complaint.

Mr C complained to us about the care and treatment he had received from the board at a prison health centre in relation to his stomach pains. We took independent advice from a medical adviser. We found that the care provided to Mr C in relation to his stomach pains had been of a reasonable standard and we did not uphold the complaint. Mr C also complained that the board failed to provide a reasonable response to his complaints about this. We were satisfied that the board had acted in line with their complaints procedure and that they had issued a reasonable response to Mr C's concerns. In view of this, we did not uphold this aspect of Mr C's complaint. Related reading View Decision Report 201500983 as a PDF (10.85 KB) Updated: March 13, 2018

Mrs C complained on behalf of her son (Mr A) who had been admitted to Forth Valley Royal Hospital with chronic liver disease. Mrs C said she believed the care and treatment provided to her son had been inadequate, highlighting poor dietary input as a particular concern. Mrs C also said the decision to discharge him had been inappropriate, as he had refused all treatment at home and died a few days later. We took independent medical advice on Mr A's treatment and discharge. The adviser said that Mr A had been provided with all treatments short of a liver transplant. The advice noted that Mr A had been adamant that he wished to be discharged and that he was prepared to refuse to eat or drink in order to achieve this. Although it was arguable Mr A should have been made to discharge himself, he had been provided with follow-up care as an out-patient. Mr A had refused to engage with this treatment. We found Mr A's care and treatment had been reasonable and that the decision to discharge him was also, on balance, reasonable. Related reading View Decision Report 201501358 as a PDF (11.07 KB) Updated: March 13, 2018

Mr C complained that the decision to stop his prescription for co-codamol was unreasonable. He said he had been prescribed the medication for around two years for arthritis but the doctor stopped it without explaining why. We reviewed Mr C's medical records and we took independent advice from a medical adviser who is a GP. We found that the prison health centre doctor took the decision to stop Mr C's prescription for co-codamol because there was no medical evidence available to indicate that he had arthritis. The adviser told us that the doctor's decision was reasonable. They also confirmed that the doctor prescribed another suitable medication for Mr C's muscular and bone pain. In light of this information, we did not uphold Mr C's complaint. Related reading View Decision Report 201501739 as a PDF (10.92 KB) Updated: March 13, 2018

Mrs C complained that her brother (Mr A), who has mental health problems, was able to access alcohol and/or illicit drugs while he was a patient in the Forth Valley Royal Hospital. Mr A did not give his consent for Mrs C to pursue her complaint on his behalf with the board or us, so we were unable to investigate her specific concerns. However, we did investigate the matter in general terms to ensure that the board had sufficiently robust policies and procedures in place to address the types of concerns Mrs C was raising. We took independent advice from a mental health nursing adviser. We reviewed the relevant national legislation, the Mental Health (Care and Treatment)(Scotland) Act 2003 and the Mental Health (Safety and Security)(Scotland) Regulations 2005. The adviser was satisfied that the board's policies and procedures complied with the legislation and were practical, clear and reasonable. In these specific circumstances, we were unable to determine if the policies and procedures had been followed in Mr A's case. However, we were satisfied that the policies and procedures were sufficiently robust to ensure patient safety if used appropriately. Related reading View Decision Report 201502348 as a PDF (11.15 KB) Updated: March 13, 2018

Mr C complained about the physiotherapy and orthopaedic care he received from Forth Valley Royal Hospital after dislocating his knee-cap. He said that staff ignored his on-going symptoms and that he should have had a scan of his knee to identify what was causing him persistent pain. He was concerned that a locum orthopaedic specialist had wrongly diagnosed a meniscal tear (damage to cartilage in the knee) rather than a loose fragment under the knee-cap. We took independent advice on this case from two of our advisers, one of whom is a physiotherapist and the other a consultant orthopaedic surgeon. We found that the physiotherapy management of Mr C's injury was in accordance with guidance on managing patients who have dislocated their knee-cap for the first time. Whilst the board said that it would have been appropriate for Mr C to have had a scan prior to surgery, we did not consider that the diagnosis of a meniscal tear was unreasonable given that loose fragment can have similar symptoms. Furthermore, both meniscal tears and loose fragments can be treated by the surgery that Mr C underwent. We also considered that it was reasonable to proceed to surgery without a scan given that Mr C's symptoms were not resolving and were affecting his ability to work. Related reading View Decision Report 201405274 as a PDF (11.22 KB) Updated: March 13, 2018

Mr C complained about the care and treatment provided to his wife (Mrs C) by her GP practice in relation to her stomach problems. The practice investigated her stomach problems by carrying out blood tests and arranging for further investigations in hospital. When she was admitted to hospital, it was subsequently established that she had a mass on her liver, and it was confirmed that she had secondary cancer of the liver. Mr C complained of a lack of treatment and investigations into Mrs C's symptoms by the practice, and said that if they had taken her abdominal problems more seriously, then the cancer would have been diagnosed sooner. We took independent advice from one of our medical advisers, who specialises in general practice. We found that the practice properly investigated Mrs C's symptoms, including making referrals to secondary care within a reasonable time, and that, overall, the treatment provided was reasonable. Related reading View Decision Report 201501912 as a PDF (11.05 KB) Updated: March 13, 2018

Ms C attended her GP with swelling and hardening tissues between her vagina and rectum. The GP prescribed antibiotics to be taken for seven days. She was told to return in one week, or sooner if her symptoms became worse. Three days later, she returned to the practice and saw a different GP as the pain was worse. The medical notes also state that she was experiencing diarrhoea and vomiting. She was examined and the medical records indicate that her vaginal symptoms were no worse, and that the GP considered the diarrhoea and vomiting to be side effects of the antibiotics. On Ms C's request the GP prescribed anti-sickness medication. The GP told her to take the antibiotics for only five days, recorded that there was no sign of infection and gave her a one-week sick note. Six days later, Ms C attended the first GP again, who diagnosed a perianal (situated in or affecting the area around the anus) abscess. Ms C was admitted to hospital. Ms C complained that, at her second appointment, the GP had failed to provide adequate medical advice, care and treatment. We obtained independent advice from one of our GP advisers. We concluded that, while the care and treatment provided to Ms C was reasonable, it was unreasonable that Ms C was not given any specific instructions by the GP at the second appointment about what to do if her vaginal symptoms did not improve or got worse. As this particular failure was significant, we upheld Ms C's complaint. During our investigation, the practice apologised to Ms C and the GP reflected on her practice. The GP explained that, in future, she would try to give more specific instructions for patients so they are sure they can come back if they need to. Therefore, we did not consider that we needed to make any specific recommendations. Related reading View Decision Report 201502335 as a PDF (11.48 KB) Updated: March 13, 2018

Mr C complained about the care and treatment provided to his daughter (Miss A) at Forth Valley Royal Hospital. He was dissatisfied that she was not reviewed by a cardiologist (doctor specialising in disorders of the heart) when she reached the age of two, despite concerns about her heart when she was born. He complained that he was not informed about the change of plan about reviewing her. Mr C was also unhappy that the board's complaints team had access to Miss A's clinical records without his consent, that they took an unreasonable length of time to respond to his complaint, and that they did not respond reasonably to his questions. We took independent advice on this case from one of our medical advisers who is a consultant paediatric cardiologist. We did not identify clear evidence that Mr C had been told Miss A would be reviewed at the age of two. We considered that the care given to Miss A was in accordance with established good practice, and there was no evidence of a heart defect requiring further review. It would have been difficult for the board's complaints team to respond fully to Mr C's concerns without access to Miss A's clinical records. However, there was no evidence that Mr C was clearly informed of the possibility that relevant health records would be handled by a member of the complaints team (in accordance with national complaints handling guidance and the board's procedures). Therefore, we upheld this part of the complaint. We considered, on balance, that the board's responses were reasonable and were issued to Mr C without undue delay.

Mr C complained that the prison health centre's handling of his pain medication was unreasonable. He had been prescribed a medicated patch for nerve pain for a trial period of one month. Mr C said that the doctor did not review his treatment throughout the trial period or when the prescription ended. Because of that, he said he was left in pain. The information available confirmed that Mr C did not raise any concerns with healthcare staff about pain whilst receiving the treatment or after the treatment ended. We took independent advice from one of our GP advisers who noted that Mr C's mental health at the time the medication was being trialled was unstable and he did have episodes of self harm which involved him creating more damage to his wound. Because of that, our adviser considered that a routine review of Mr C's treatment for pain was not feasible at that time, and management of his acute and unpredictable mental health was the priority. In addition, our adviser noted that it was not practicable or common practice for doctors to contact patients routinely to enquire whether their prescribed medication was sufficient. Therefore, we did not uphold Mr C's complaint. Mr C also complained that the board failed to respond appropriately to his complaint but we did not agree. Related reading View Decision Report 201500933 as a PDF (11.22 KB) Updated: March 13, 2018

Mrs C, who is an advocacy worker, complained to the board on behalf of her client (Mrs B). Mrs B's mother (Mrs A) had been admitted to Forth Valley Royal Hospital with swallowing difficulties, and there was a problem when a nurse was performing an endoscopy (a procedure where a tube-like instrument is put into the body to look inside). A consultant gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas) was called to continue the procedure and Mrs A's oesophagus was perforated, which meant the procedure had to be cancelled. Mrs A was transferred to the intensive care unit (ICU) and Mrs B complained that Mrs A suffered problems with her catheter, blockages of her NJ tube (nasojejunal tube - a small tube that is passed through the nose and into the small intestine), inappropriate management of her chest drain, and poor communication from staff. The board maintained that the perforation of the oesophagus was a rare but recognised complication of an endoscopy procedure and that Mrs A was transferred to ICU for close monitoring. They said Mrs A had received appropriate care and treatment, and that it was appropriate for the catheter to have been fitted. They said the blockages in the NJ tube were addressed in a timely manner, and explained that staff dealt appropriately with problems of fluid build-up by managing chest drains correctly. After taking independent advice from a gastroenterologist adviser and a nursing adviser, we did not uphold the complaint about the care and treatment which Mrs A received. We found that Mrs A had suffered a recognised complication of an endoscopy procedure which was not caused by failings by the staff involved. We were also satisfied that the staff provided Mrs A with appropriate care and treatment in relation to the problems with her catheter, NJ tube and chest drain management. However, we did find that, although communication from the staff to the family was generall

Mr C complained to us on behalf of his daughter (Mrs A) in relation to two assessments she had at Forth Valley Royal Hospital’s psychiatric services. Mrs A’s mental health was deteriorating, and her family initially sought help for her from a GP, who referred her for a psychiatric assessment. She was subsequently sent home, so her family sought GP assistance again. Following a home visit, Mrs A was again referred for a psychiatric assessment, with a very similar outcome. Mr C complained that the family were only given the opportunity to explain why they were so concerned about Mrs A after her second psychiatric assessment, when they insisted on speaking to the doctor. We took independent advice on this complaint from one of our advisers in psychiatry. The adviser was critical that Mrs A’s family were not expressly involved in either of the assessments. He said that this should be a standard part of such assessments. He also noted that insufficient weight was given to the GP’s concerns and findings. He noted that the first GP had done a detailed assessment and history, and this was not fully considered during either of Mrs A’s psychiatric assessments. The adviser noted that both doctors who assessed Mrs A were trainees, and expressed concern that there was insufficient documentation as to why Mrs A did not meet the criteria for detention at hospital. He also found that the plan for future follow-up was not practical and did not sufficiently involve her carers. We considered the advice we received, and found that the psychiatric assessments had not been sufficiently robust. We therefore concluded that she was not given a reasonable standard of treatment. We also noted that the failings in this case potentially put Mrs A at significant risk, as her family no longer felt able to keep her safe.

Mr C complained that the board failed to prescribe him specific medication for his drug addiction, and that his drug worker did not listen to his concerns. We looked at Mr C’s medical records, and we took independent advice from one of our medical advisers. We found that the prison health centre kept detailed records of consultations with Mr C, and that they took his state of health into account when deciding not to prescribe him the specific medication he wanted. The records confirmed that assessments carried out by Mr C’s drug worker were appropriate. We concluded that the prison health centre’s actions were reasonable in the circumstances, and that the care provided by them was of a reasonable standard. We did not uphold Mr C’s complaint. Related reading View Decision Report 201402462 as a PDF (10.93 KB) Updated: March 13, 2018

Mr A was referred by his GP to the ear, nose and throat clinic at Forth Valley Royal Hospital with a swelling below his left ear. This was found to be cancerous and Mr A was referred to another health board for surgery. This surgery resulted in extensive facial disfigurement and Mr A's daughter (Mrs C) complained that the board failed to explain the extent of Mr A's cancer and the impact the surgery would have on him. Mrs C also complained about delays following surgery in arranging onward referrals for Mr A to various specialists. The board apologised that Mr A and his family were not adequately prepared for the life-changing results of the surgery, and they developed an improvement plan to address the concerns raised. They noted that their consultations with Mr A occurred at a very early stage in the process of preparing him for major surgery. They indicated that their role was to provide an overview and the intention was for a more detailed explanation to be provided by the board who were carrying out the surgery. We took independent medical advice from a consultant maxillofacial surgeon (doctor specialising in the treatment of diseases affecting the mouth, jaws, face and neck). The adviser confirmed that the board carrying out the surgery were responsible for explaining the procedure and obtaining informed consent. He considered that the board had appropriately carried out their duties in this case. However, he noted that the communication between the two boards appeared to be lacking. He found no evidence of a formal referral to the other board having been made and he considered there was a lack of clarity regarding the respective role of each board. This also applied to the handover between the cancer nurse specialists at each board, which meant that relevant patient information literature was not given to Mr A. The absence of clear lines of responsibility also resulted in a delay in arranging relevant onward referrals following surgery. We accepte

Mrs C complained about the care and treatment her late mother (Mrs A) received at Forth Valley Royal Hospital. Mrs A was admitted with kidney failure and, further to treatment, was discharged eight days later. However, she became ill again the following day and required re-admission. She responded well to treatment, this time for heart failure, but subsequently suffered a sudden heart attack and died. Mrs C raised concerns that the board did not take reasonable account of Mrs A's pre-existing heart problems when treating her kidney failure during her first admission. She felt that this led to them overloading her with fluids, thus contributing to her subsequent heart failure and eventual death. She also questioned the appropriateness of the discharge following Mrs A's first admission, raising concerns that her heart failure should have been detected prior to this and noting that Mrs A had been vomiting on the day of discharge. We took independent advice from one of our medical advisers, with experience in the acute hospital care of elderly patients with multiple illnesses. He explained that the treatment of kidney failure involves fluids being provided, whereas the treatment of heart failure requires fluid restriction. He advised that a careful balancing act was required where a patient has both kidney and heart problems. He considered that the doctors caring for Mrs A were mindful of this and said the treatment provided to her during both admissions was reasonable. He also considered the interim discharge to have been clinically appropriate at the time. He said Mrs A's sudden heart attack could not have been predicted and was not connected to her treatment. We accepted this advice and did not uphold the complaints. Related reading View Decision Report 201403540 as a PDF (11.43 KB) Updated: March 13, 2018

Mr C complained that, due to a high staff turnover within the practice, he had been seen by a number of different dentists over the years. He said that each dentist changed his treatment plan and, as a result, his gum disease was never treated. In responding, the practice noted that the staff turnover was outwith their control. They confirmed that a treatment plan should continue from one dentist to the next unless there were clinical grounds for changing it. They did not comment specifically on Mr C's treatment plan as they did not have his records to hand. We took independent advice from one of our dental advisers. He said the treatment carried out by the various dentists appeared consistent in that the primary aim was to address Mr C's chronic gum disease. He explained that this was a longstanding condition which progressed to the position where loss of the teeth was inevitable, despite the treatment carried out. He concluded that the treatment provided by the practice was reasonable. We accepted this advice and did not uphold the complaint. We were concerned, however, that the practice had responded to Mr C's complaint about his dental treatment without specifically referring to his dental records. We also noted that their response had not told Mr C that he could complain to us in the event that he remained dissatisfied. In addition, we noted that the practice sent Mr C's original dental records to us and did not use a secure postal method. In light of these observations, we made some recommendations.

Miss C complained to us about the care and treatment she had received when she attended the A&E department at Forth Valley Royal Hospital. Miss C had gone to A&E after injuring her ankle. She said that she also told staff that she had sickness and diarrhoea, and that she had a rash on her forehead. Miss C returned to the A&E department two days later with shortness of breath, swelling in the right leg, bruising and a rash. She was assessed as requiring immediate attention and was then diagnosed as having myositis (inflammation of the muscles) caused by group A streptococcus (a bacterial infection). She required treatment in the intensive care unit and several emergency operations, including an above-the-knee amputation of her right leg. She also had surgery on her other limbs. Miss C said that she had not received reasonable care and treatment when she had first attended the A&E department, and had been seen by an emergency nurse practitioner. We took independent advice from one of our nursing advisers, who is an emergency nurse practitioner. The medical records that were completed when Miss C had initially attended the A&E department only referred to an injury to her left ankle. No other symptoms were documented. We found that it had been appropriate for the emergency nurse practitioner to diagnose and treat this minor injury, and that the care and treatment the nurse practitioner had provided had been reasonable and appropriate. As there was no evidence that Miss C had reported sickness, diarrhoea or a rash when she attended the hospital on the first occasion, we did not uphold the complaint. Related reading View Decision Report 201405247 as a PDF (11.35 KB) Updated: March 13, 2018

Mr C complained about the decision taken by the prison health centre to stop his medication for nerve pain. He said he was told that the medication had been stopped because he was on methadone. In response to his complaint, the board said the prison health centre decided to stop his prescription because they did not think he needed the medication. We sought independent medical advice from a GP adviser. She reviewed the evidence available and confirmed that Mr C had a history of past and current drug misuse including using a combination of drugs. She said the prison doctor had a responsibility to ensure they were prescribing medication to Mr C safely and responsibly. Our adviser considered that in view of Mr C's drug misuse (including misusing the medication for nerve pain) and the increased risk of addiction, it was appropriate for the prison doctor to try less harmful, alternative drugs for him. The adviser noted that Mr C had been started on an appropriate alternative medication. She said the actions taken by the prison health centre were consistent with General Medical Council guidance and, in her view, the care and treatment provided to Mr C was reasonable. In light of the evidence available, we did not uphold Mr C's complaint. Related reading View Decision Report 201406063 as a PDF (11.17 KB) Updated: March 13, 2018

Mr C complained that the board had contributed to the decision that he no longer needed to be managed under the Scottish Prison Service's process for prisoners at risk of suicide or self-harm (the ACT 2 Care process). 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 further case conference decided that Mr C was not at risk. A mental health nurse was a participant at this case conference and agreed with the decision reached. Mr C carried out a further act of self-harm and was put back on the process. We took independent medical advice from our mental health nurse adviser. Our adviser said that Mr C was removed from the process on the basis that he was not suicidal, however, as it is also a strategy for minimising the risk of self-harm this was not a reasonable decision. We found that the risk of life-threatening self-harm had not been sufficiently taken into account when the board contributed to the decision to remove Mr C from the process. The adviser also said that an entry that had been made in Mr C's healthcare record was unreasonable in both tone and clinical approach to self-harming behaviour. We also upheld a second complaint that Mr C made about the board's failure to provide him with a legible copy of his completed complaint form.

Mr C complained that a nurse at his prison health centre gave his medication to a prison officer to administer. We looked at Mr C's medical records and the board's file on Mr C's complaint, and we took independent advice from one of our nursing advisers. We found that the board took Mr C's complaint seriously, and the nurse was managed in line with the board's medication safety policy. We concluded this was appropriate action to take. However, this was a serious incident which the board should have acknowledged in their response to Mr C's complaint, and for which they should have offered him an apology. We upheld Mr C's complaint.