SPSO Individual Decisions

C complained about the Crown Office and Procurator Fiscal Service (COPFS), regarding interactions they had before, during and after a homicide prosecution following the death of their adult child (A). C did not consider that COPFS had adopted a reasonable approach to victim support in their case. They expressed a number of concerns about the support that they had initially been provided. They told us that this led them to request no further contact with the officer initially allocated to provide support, but when they changed their mind and asked for contact to resume, COPFS had refused to allocate another officer to support their family. They also raised concerns about COPFS communication with them and their family, both in terms of the tone, and failures to respond to specific points raised by them. In addition, they told us they did not consider COPFS had reasonably handled their resulting complaints about these matters. On investigation, we found that COPFS had failed to provide C and their family with appropriate support in a number of ways. We found that COPFS had internally recorded a number of concerns about C’s attitude and behaviour, suggesting that they were acting in a way that was difficult or unreasonable, without recording what behaviours they considered were unreasonable or why, or raising these concerns with C to allow them the opportunity to amend any behaviours COPFS considered unreasonable. This was despite the difficult circumstances C’s family were facing, and nothing within the records evidenced that COPFS had considered the additional pressures facing C and their family. We considered that COPFS had effectively refused to provide normal victim support to C and their family, by failing to honour clear requests by C for support to resume. We also found that COPFS had failed to follow their normal protocols when the case had been handed over from the Police, which negatively impacted C’s family’s experience of that process. Overall, we

C complained about the way that the Crown Office and Procurator Fiscal Service (COPFS) dealt with their communications with them following their adult child (A)'s death by suicide. C said that the COPFS failed to deal with C's request for the return of A's property appropriately; failed to provide C with the final post-mortem report on A's death within a reasonable time; and failed to investigate C's complaint about these two matters appropriately. It is not for this office to question decisions by the COPFS regarding the release of A's belongings, as the COPFS's decisions regarding prosecutions/whether or not to investigate Fatal Accident Inquiries are outwith the remit of this office. We therefore considered whether or not the COPFS did what they advised C that they would do in relation to the release of A's belongings and whether they acted in line with their guidance. The records showed that the COPFS considered C's request for the return of A's property, made during a telephone call, and authorised release of some of A's belongings and that this was then communicated to the police and the belongings were released. It would appear that after receipt of an email from C in which they complained and requested the release of the remainder of A's belongings, the COPFS then authorised their release. The COPFS acknowledged that they should have responded to C's email, advised that they fed back this failing to staff and provided documentary evidence to verify that this took place at the time. We considered the remedial action by the COPFS to be reasonable and did not uphold this part of the complaint. On the matter of the provision of the final post-mortem on A's death, the COPFS explained the difficulties they experienced with their toxicology report service provider and how this in turn impacted on the timescale for receipt of post-mortem reports by the COPFS and notification of the outcome to the next of kin. In this case, notification of the outcome of the po

Mrs C complained about the care of her late father (Mr A) at University Hospital Ayr. Mr A underwent surgery to remove bowel cancer and required further surgery due to a complication. He remained unwell thereafter and, due to his poor nutrition and weight loss, a decision was made to start nasogastric (NG) tube feeding (where a tube is placed through the nose into the stomach). However, the NG tube was mistakenly inserted into Mr A’s lungs instead of his stomach and this was not recognised prior to commencement of NG feeding. This error caused a severe deterioration in Mr A’s condition and he died just over a week later. The board carried out a Significant Adverse Event Review (SAER) and the Crown Office and Procurator Fiscal Service (COPFS) also looked into the circumstances of the death. As Mrs C was unhappy with the outcome of the board’s SAER and response to her subsequent complaint, she contacted the SPSO. We took independent advice from a consultant gastroenterologist (a physician who specialises inthe diagnosis and treatment of disorders of the stomach and intestines)(a physician who specialises inthe diagnosis and treatment of disorders of the stomach and intestines). We considered that the board’s SAER process was reasonable and recommended appropriate policy changes to prevent a similar future recurrence. It was identified that there were some departures from existing policy but these did not contribute to Mr A’s death. These included record-keeping deficiencies and a failure to take all advised steps to obtain an aspirate (where a small amount of stomach content is sucked through the tube and the acidity checked to confirm correct placement of the tube). As the tube was incorrectly placed in this case, the further advised steps would have been unsuccessful anyway and an x-ray would still have been required. The significant failing was a consultant surgeon’s incorrect interpretation of the x-ray and consequent failure to identify the misplacemen

Mrs C complained that the Crown Office and Procurator Fiscal Service (COPFS) unreasonably delayed in investigating the death of her daughter (Miss A) and that their communication with her had been unreasonable. We found that COPFS have no fixed timescales within which investigations should take place; the reasons for this are clear given the range of complexities of investigations and the involvement of various external authorities. We accepted their position that they have no power to compel individuals and authorities to respond to them, but we considered that they must be proactive in driving investigations forward. We considered it would be reasonable for this to include giving timescales within which a response is expected, and escalation where deadlines are not met. We saw no consistent evidence of timescales being given, and we noted that often it took communication from Mrs C before authority responses were chased up. We therefore upheld this complaint. In relation to unreasonable communication, COPFS acknowledged failings in the period leading up to Mrs C's complaint. We upheld this complaint.

Ms C complained about the service provided by the Crown Office and Procurator Service (COPFS) when they were dealing with the investigation into the circumstances around her relative's death and the Victims Right of Review of that investigation. Ms C considered there was a lack of compassion when dealing with her family and that they were always having to chase for information and updates. Ms C also complained about the response she received to her complaint. Ms C considered it was not clear which part of the organisation was dealing with it. She also felt that no specific improvements were addressed as a result of her feedback about her experience. We upheld all aspects of Ms C's complaint. We found that there was a failure to instigate communication with the family and provide updates, even if the details of those investigations could not be disclosed. There was also a failure to take reasonable care when deciding the route to a meeting room where discussions were held with the family. We considered that the organisation failed to confirm which part of the organisation was dealing with the Victims Right to Review or which part of the organisation was dealing with Ms C's complaint . We also found that when responding to Ms C's complaint there was a failure to clarify what specific steps would be taken to ensure communication with other families would be improved in the future.

Mrs C was required to attend court on two occasions as a witness, and a victim, of charges relating to assault and threatening behaviour. Mrs C was identified as a vulnerable witness, and arrangements were made for statutory special measures to support her in giving evidence, namely witness screens and a witness supporter. However, outside the courtroom the accused was able to move freely throughout the courthouse, except for the witness waiting room. Mrs C said that she tried to stay in the witness room for her own safety, but that she had to leave at some points as there were no toilets in the room, and she was also required to leave at lunchtime, when the court building closed. Mrs C said the accused waited outside the court building on one occasion, and also approached her and intimidated her within the court building. Mrs C first complained about her experience to the Crown Office and Procurator Fiscal Service (COPFS), who told her that security within the court building was the responsibility of the Scottish Court and Tribunal Service (SCTS). She then complained to the SCTS. While the SCTS said they were restricted by the physical layout of the building, they also said that they could have made other arrangements, in addition to the statutory special measures. SCTS said these arrangements could have included: providing a separate access route, or working with police colleagues to stagger departure times; providing access to a different toilet; and arranging for Mrs C to remain within the building during lunchtime. SCTS said these arrangements were not provided because they were not made aware by COPFS, or Witness Support, of any particular issues of intimidation or harassment. After investigating this matter we found that COPFS and SCTS each gave different versions of the process that should be followed for notifying SCTS of the need for additional arrangements, aside from statutory special measures. Neither organisation gave evidence that their version of the

Mrs C complained about the Crown Office and Procurator Fiscal Service (COPFS). Mrs C was required to attend court on two occasions as a witness and victim of charges relating to assault and threatening behaviour. She was identified as a vulnerable witness and arrangements were made for statutory special measures to support her in giving evidence, namely witness screens and a witness supporter. However, outside the courtroom the accused was able to move freely throughout the courthouse (except for the witness waiting room). Mrs C said she tried to stay in the witness room for her own safety, but had to leave at some point as there were no toilets in the room. She was also required to leave at lunchtime when the court building closed. Mrs C said the accused waited outside the court building on one occasion, and also approached her and intimidated her within the court building. Mrs C complained about her experience to COPFS, who told her that security within the court building was the responsibility of the Scottish Court and Tribunal Service (SCTS). She then complained to the SCTS. The SCTS said they were restricted by the physical layout of the building, but they also said that they could have made additional arrangements (in addition to the statutory special measures). They said that this could have included: providing a separate access route, or working with police colleagues to stagger departure times; providing access to a different toilet; and arranging for her to remain within the building during lunchtime. SCTS said these arrangements were not provided because they were not made aware by COPFS or Witness Support (a voluntary organisation) of any particular need. In response to our enquiries, COPFS said they had identified Mrs C’s concerns on the Vulnerable Witness Application, so the SCTS would have been aware of these. However, the SCTS said that this application only related to the statutory special measures and they were not made aware of any particular issu

Mr and Mrs C complained about how the Crown Office and Procurator Fiscal Service (COPFS) responded to their enquiries. Mrs C contacted COPFS a number of times over the space of two months. After receiving some initial advice from them, including information that her enquiry had been passed on to another member of staff, she found it difficult to contact them. COPFS said Mrs C had been incorrectly advised that her enquiry was being dealt with by another member of staff. They said they had given Mrs C advice, that they could not help her with her enquiry, and when she contacted them subsequently they had ignored her calls and emails. When Mr and Mrs C complained to COPFS, they were told they could not be helped with their enquiry and that, under the unacceptable actions part of their complaints policy, COPFS would no longer respond to contact from Mr and Mrs C about the same issue. We found that COPFS should have had a dedicated unacceptable actions policy. We also found that their complaints policy was not compliant with the SPSO model Complaints Handling Procedure. We upheld Mr and Mrs C's complaint as COPFS had unreasonably advised them that their enquiry was being dealt with and then failed to rectify their error. It was not acceptable to ignore Mr and Mrs C's calls and emails and we therefore upheld their complaint.

Ms C was involved with a court case that was not continued by the Crown Office and Procurator Fiscal Service (COPFS), and complained about this to them. Ms C then complained to us that COPFS ignored her phone calls and that their communication with her was unreasonable, specifically that two letters from COPFS were contradictory. We found that Ms C had not complained to COPFS about all of the matters she brought to us. We also found that COPFS no longer had recordings of phone calls as they were kept for a limited time. In addition, it was not within our jurisdiction to determine whether COPFS' letters were or were not accurate as a matter of law and, therefore, we could not determine whether they were contradictory in that respect. In the circumstances, we could not reach findings on Ms C's complaints and we could not uphold them. Related reading View Decision Report 201507816 as a PDF (11.01 KB) Updated: March 13, 2018

Mr C complained about a number of actions of the Crown Office and Procurator Fiscal Service (COPFS). Most were beyond our jurisdiction but Mr C also complained about how COPFS had responded to his complaint. We considered that, in their response, COPFS had addressed the issues Mr C complained of, gave him accurate information and reached views that, though Mr C disagreed with, they had discretion to reach. Consequently, we did not uphold his complaint about COPFS' complaints handling. Related reading View Decision Report 201506127 as a PDF (10.8 KB) Updated: March 13, 2018

Mrs C complained about the care of her daughter (Miss A) who committed suicide while she was an in-patient at Hairmyres Hospital. Mrs C raised concerns that staff did not appropriately supervise Miss A in view of her condition, and that the family were not told about a suicide attempt the day before Miss A’s death. When we reviewed Mrs C’s complaint we found that the Crown Office and Procurator Fiscal Service was currently investigating the circumstances of Miss A’s death. Additionally, the Child Protection Committee was also conducting a significant case review in consultation with the Mental Welfare Commission. In view of these on-going investigations by other independent organisations, we decided not to investigate Mrs C’s complaints further at this stage. We invited Mrs C to contact us again if any issues raised in her complaint were not investigated as part of these processes. Related reading View Decision Report 201407901 as a PDF (11.05 KB) Updated: March 13, 2018

Mr C complained that during an interview with the Crown Office and Procurator Fiscal Service (COPFS), an officer made inappropriate remarks. He also complained that the time taken to investigate his allegations against a number of police officers was unreasonably protracted, and that he was not kept up to date on progress. Our investigation was unable to establish whether the remarks Mr C complained about had been made by the officer in question. Regarding communication during the investigation of Mr C's allegations, we found that there were failings by the COPFS over several months. However, the COPFS had apologised to Mr C for this and undertaken to update him regularly. After that point, communication between the COPFS and Mr C was regular. We did not uphold the complaints. Related reading View Decision Report 201502846 as a PDF (10.99 KB) Updated: March 13, 2018

Mr C’s wife (Mrs C) died in April 2011, and the Procurator Fiscal (PF) investigated her death. They decided that they needed to retain some of Mrs C's organs for tests to establish the cause of her death, and told Mr C this by letter. Mr C did not wish to finalise his wife's funeral arrangements until he knew that her organs had been returned. When the funeral directors contacted the mortuary they found that the organs had been returned – they told Mr C this and the funeral then took place. Between 2011 and 2013 the PF instructed a number of medical experts to confirm the cause of Mrs C's death, during which time her death certificate was amended in light of clinical opinion. A final conclusion was reached in early 2013, and the family met with the PF and a medical expert in June 2013 to discuss his conclusions. The family were told the death certificate had to be amended again and that the PF would arrange this. By December 2013 the family had heard nothing, and Mr C complained to the Crown Office and Procurator Fiscal Service (COPFS). The death certificate was amended in January 2014, but Mr C did not receive a response to his complaint until he followed it up a few weeks later. Meanwhile, he received information from National Records of Scotland that indicated COPFS had supplied them with incorrect information. Mr C raised this with COPFS, who apologised immediately. We investigated Mr C's complaints and found that COPFS had not told him that Mrs C's organs had been returned; the time taken to decide the cause of Mrs C's death and to arrange for her death certificate to be altered was unreasonable; COPFS sent an incorrect document to Mr C's solicitor and referred incorrectly to Mrs C in correspondence, so we upheld Mr C’s complaints about all of these matters. Although we did not uphold some of Mr C’s complaints relating to a specific meeting with COPFS, we did make some recommendations about how such sensitive meetings should be recorded in future. We al

Mr C was a witness in a court case, but the case did not proceed on the day he attended court. Mr C said the Crown Office and Procurator Fiscal Service (COPFS) told him that one of the reasons for the case not taking place was because of a procurator fiscal's understanding that witnesses were not present. Mr C complained about this to COPFS but was not satisfied with their response, so he complained to us that COPFS failed to adequately investigate his complaint and respond to it. We found that, as COPFS had told Mr C, the procurator fiscal who dealt with the court case was not at work when COPFS responded to Mr C's complaint. COPFS told us that they could not give Mr C details about the procurator fiscal's absence, as it was confidential personal information. The evidence showed that, in the absence of the procurator fiscal, COPFS had looked at the notes from the relevant day in court, and had contacted court staff. We were satisfied that, in the circumstances, COPFS had adequately investigated Mr C's complaint and responded to him. We did not uphold Mr C's complaint. Related reading View Decision Report 201405577 as a PDF (11.09 KB) Updated: March 13, 2018

Miss C was the victim of a road accident in 2009. Charges were brought in relation to the accident and Miss C was cited to appear in court. Due to an error by the Procurator Fiscal in court in August 2010 the case was not called, and proceedings could not be re-raised because of the time that had elapsed. Miss C made enquiries about the progress of the case and, for the next five months, was advised that it was being rescheduled. At the end of January 2011, however, she was advised that the case had ended the previous August. Miss C complained to COPFS about this and received a final response in April 2013. She was dissatisfied with the response and raised her complaints with us. We did not uphold Miss C's complaint that COPFS had not reasonably advised her of the progress of the case as there is no requirement for them to do this, and she was advised that she did not need to attend court in August 2010, although she was given incorrect information about the reason for this. We did, however, uphold her complaints that COPFS did not reasonably advise her of the conclusion of the case, provided inaccurate information to her between August 2010 and January 2011 and did not respond reasonably to her enquiries and complaints from January 2011 onwards.

Miss C complained about the way COPFS handled her complaint, which concerned the death of a relative. Miss C said the handling of her complaint was very poor and took an unreasonably long time, and there was a lack of respect and compassion towards her as a bereaved relative in the written response to her complaint by COPFS. Our jurisdiction in complaints about COPFS is very limited, and we could look only at whether they acted in line with their complaints procedure. We found that Miss C raised a number of issues in her complaint to COPFS and, in their letter, COPFS provided a response to those issues. From an administrative point of view this showed there was a reasonable level of investigation into, and response to, Miss C's complaint. We were in no doubt that their response would have been difficult to read, given the distressing subject matter dealt with in the letter. However, we concluded that the letter was not lacking in respect or compassion; rather, it was empathetic and tried to deal with a difficult subject sensitively. In terms of the time taken to deal with Miss C's complaint, it took considerably longer than the 20 working days allowed for in the COPFS complaints procedure; it was in the region of 85 working days. COPFS explained why it took this length of time, and the explanation appeared to be reasonable. However, COPFS failed to update Miss C every 20 working days, as required by their complaints procedure. Miss C should have had at least three, if not four updates. This was particularly important given the impact on Miss C of her relative's death and subsequent events. Therefore, on this specific point, we upheld Miss C's complaint.

Mr C complained that COPFS failed to send a production release note to the police. This would allow Mr C to collect his property, which was used as evidence in a court case, from the police. Our jurisdiction is very limited in complaints about COPFS. In this case, we looked at whether or not COPFS followed the proper procedure, or considered relevant information in dealing with the administrative process of returning property to Mr C. We found there was a delay in this matter being resolved. COPFS explained how this happened, and the action they took to address this problem. They also apologised to Mr C. COPFS confirmed to Mr C, and to us, that a release note was sent to the police. We were satisfied that COPFS sent a release note to the police and, therefore, we did not uphold Mr C's complaint. Related reading View Decision Report 201400711 as a PDF (10.99 KB) Updated: March 13, 2018

Mr C complained about how the Crown Office and Procurator Fiscal (COPFS) dealt with his complaint. Our jurisdiction in complaints about COPFS is very limited, and we could look only at whether they acted in line with their complaints procedure. We found that Mr C raised a number of issues in his letters, and in their responses at each stage COPFS: explained how they had investigated, referred to and cited evidence in support of their responses; and provided responses to the points Mr C raised. This showed a reasonable level of investigation. At the time Mr C complained, however, COPFS had three formal stages in their complaints procedure. At stage one, they took longer than the 20 working days allowed for in their procedure to respond to Mr C's complaint. We found that this was reasonable in the circumstances, given the content of letters between Mr C and COPFS. At stage two, however, there were two periods longer than 20 working days when COPFS provided no updates. In addition, they did not explain to Mr C until the stage three response why the investigating officer changed during the stage two consideration of his complaint. In our view, it would have been reasonable to tell Mr C at the time the change was made, and we upheld his complaint due to the failings at stage two. We did not, however, make any recommendations because COPFS had already apologised for the lack of updates at stage two. COPFS also explained to us what they had done to improve complaints handling under their new complaints procedure. Related reading View Decision Report 201400081 as a PDF (11.34 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment that her son (Mr A) received when he was admitted to hospital as a voluntary psychiatric patient, after being taken there by the police. He was examined on admission and a care plan was completed. He was reviewed again the following morning by a doctor who had treated him when he had previously been admitted. The doctor gave him a pass to leave the hospital for two hours. Mr A did not return to the hospital and was found dead a number of days later. We were able to investigate only limited elements of Mrs C's complaint, because the main aspects of it had already been investigated by the Crown Office and Procurator Fiscal Service when deciding whether to hold a Fatal Accident Inquiry. We found that the care and treatment provided to Mr A during the short time he was in the hospital was reasonable and appropriate. Communication between the doctors who saw Mr A had also been satisfactory, and it was reasonable for a doctor to previously diagnose Mr A with schizophrenia. That said, we found that no one from the hospital had phoned Mrs C back after she contacted them the morning after Mr A was admitted, asking to speak to the doctor who had previously treated him. Our investigation found that they were not required to call her back immediately, but should have done so at some stage, as it is good practice to involve family and carers when assessing and managing patients. We, therefore, found that communication with Mr A's family during his short admission was not reasonable. However, in view of the fact that a doctor had written to Mrs C to apologise for this, we did not make any recommendations. Related reading View Decision Report 201000633 as a PDF (11.46 KB) Updated: March 13, 2018

Mr C was cited as a witness in a trial. He attended court on that date, only to be told that his attendance was not necessary as the accused had pled guilty. Mr C complained to the Crown Office and Procurator Fiscal Service (COPFS) that, because he was not told that his attendance was no longer required, he had suffered financial loss and unnecessary upset, anxiety and inconvenience. COPFS explained that this had happened because there were administrative errors in their process for advising witnesses that they need not attend court. They apologised to Mr C for this and invited him to submit an expenses claim, which they paid as they would have, had the trial gone ahead. In relation to the upset and inconvenience caused, COPFS advised Mr C that such concerns are addressed through witness support services such as Victim Support Scotland and their witness service, but that they do not provide compensation for upset, anxiety or inconvenience. Given that COPFS accepted that administrative errors on their part had led to Mr C attending court unnecessarily we upheld his complaint, but as they had already taken action to address what had gone wrong, we did not find it necessary to make any recommendations. Related reading View Decision Report 201204430 as a PDF (11.26 KB) Updated: March 13, 2018

Mr C complained to the Crown Office and Procurator Fiscal Service (COPFS) on behalf of his parents (Mr and Mrs A) about a decision taken by a procurator fiscal. Mr and Mrs A had been victims of a crime involving damage to their property. A decision had been made to fine the individual responsible, using a process called Fiscal Fine, but this did not include any provision for the cost of the damage. After Mr C complained to COPFS they decided to make a goodwill payment to Mr and Mrs A for the cost of the damage. Mr C was dissatisfied with this, as he felt COPFS should have paid additional compensation. He felt that they should have ensured that the original fine included a requirement on the individual to pay compensation. He said that the time taken to deal with this, and failures in the handling of his complaints, had resulted in stress and distress for his parents beyond the physical damage to the property. Mr C's complaint about the fiscal's decision was not something that we could look at, as such decisions are for the body itself to make, provided they do so through the correct process. We did, however, investigate and uphold his complaint about COPFS' complaints handling. This was because they had not responded to specific issues he raised, because there was unreasonable delay in responding and because they dealt with his complaint twice at the same stage of their complaints procedure. We made recommendations, but none about further payment. (We cannot say whether compensation is due, which is a matter for the courts, but we may make recommendations for redress payments.) In this case, in line with our redress policy, we took the view that the failures were not serious enough for us to recommend financial redress.

Mr C complained that the Crown Office and Procurator Fiscal Service (COPFS) (including the Lord Advocate) had failed to adequately respond to correspondence from him. Having carefully reviewed the correspondence between Mr C and the COPFS, we were satisfied that the responses he received were adequate and in line with the COPFS customer feedback policy. Related reading View Decision Report 201002513 as a PDF (10.81 KB) Updated: March 13, 2018

Mrs C was a witness to an incident that was taken to trial by the Crown Office and Procurator Fiscal Service (COPFS). Mrs C was unhappy with how matters had been handled. When COPFS responded to her complaints, they accepted that telephone calls were not returned when they should have been and apologised for this. Mrs C remained dissatisfied and complained to us that COPFS had not returned her telephone calls. We upheld her complaint but as COPFS had taken appropriate steps to apologise to Mrs C and ensure that the issues she faced would not happen again, we did not make any recommendations. Related reading View Decision Report 201200770 as a PDF (10.95 KB) Updated: March 13, 2018

The Crown Office and Procurator Fiscal Service (COPFS) prosecuted Mrs C for breach of the peace. Mrs C's husband (Mr C) had questions about some of the witness statements that were provided as evidence. He had several email exchanges with COPFS and complained about the way they had responded. Mr and Mrs C said that some emails were not responded to, and that others were not provided within a reasonable time. We upheld the complaint because when we looked at the correspondence we found that there were instances when COPFS failed to respond, or did not respond in a reasonable way, to specific emails. We noted that there was an extensive amount of contact from Mr C which included long email chains and it was not always obvious what emails COPFS were acknowledging or responding to. Overall, we also found that they were inconsistent in dealing with Mr C's contact with them, because they continued to respond to him about issues that they had previously told him should be raised with them through Mrs C's solicitor.

Mr C complained to the Crown Office and Procurator Fiscal Service (COPFS) after a charge of assault against him was dropped during a trial. He was unhappy with COPFS's response, and made a complaint to us about the way his complaint was handled. We upheld one of Mr C's complaints relating to delay at Stage 3 of the complaints process. However, we took a number of matters into account – COPFS' explanation for this, the fact that Mr C had not written to the appropriate person identified in the complaints procedure nor requested escalation of his complaint and that COPFS had apologised to Mr C. We, therefore, made no recommendations. Related reading View Decision Report 201102675 as a PDF (13.69 KB) Updated: March 13, 2018