Decision Report 201507626

Summary

Mr C complained about a nurse in the substance misuse clinic within the prison. Specifically, that when he self-referred, the nurse did not provide him with adequate advice, care and treatment for his reported addiction and self-harm issues. Mr C had particular concerns that he had explained to the nurse that he did not wish to be prescribed methadone (a drug used medically as a heroin substitute) as he had had problems with taking it in the past, and that instead he needed a prescription for a different medication used to treat addiction. He said that the nurse had not passed this information to his psychiatrist. Mr C also said that the nurse had not passed on information about his self-harming to the psychiatrist.

During our investigation, we took independent advice from a mental health nurse. We found that there was no evidence that the information Mr C said that the nurse had failed to pass on to the psychiatrist had ever been disclosed to the nurse. However, we found that no proper assessment and care plan had been completed by the nurse when Mr C attended the substance misuse clinic and considered this unreasonable. We also considered that the nurse's record-keeping was insufficient. In view of these failings, we upheld this aspect Mr C's complaint.

Mr C also complained that the board's handling of his complaint had been unreasonable. We identified that, whilst the board's initial complaint response had been sufficient, they did not investigate Mr C's subsequent complaints. We found that this was unreasonable and not in accordance with national complaints handling guidance. Therefore we also upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• apologise for the failings identified in relation to record-keeping and lack of evidence regarding proper assessment;
• review their process when a prisoner self-refers to the addictions team to ensure adequate assessment and care planning is carried out where appropriate;
• draw the findings to the attention of the nurse;
• apologise to Mr C for not responding to his additional complaints; and
• draw these findings to the staff involved in the local investigation of Mr C's complaint in order to highlight the importance of investigating and responding to all issues complained about in accordance with national complaints handling guidance.