Decision Report 201608798

Summary

Mr C complained that when he returned to prison having undergone surgery, he was not prescribed with appropriate pain relief.

While in hospital, Mr C had been prescribed dihydrocodeine and paracetamol (pain relief medications). However, on returning to the prison, clinicians prescribed Mr C with co-codamol (a mixture of codeine and paracetamol). The prescription was not issued until after the pharmacy cut-off time and so Mr C only received paracetamol until the following morning when he was given a one-off dose of dihydrocodeine.

We took independent medical advice. The adviser's view was that Mr C had not been provided with sufficient pain relief and that the delay was unreasonable. We accepted this advice and upheld the complaint.

We also found that the board's response to the complaint was contradictory. They had told Mr C at stage one of the complaints process that they would take action to ensure there was not a repeat of the situation. However, when we contacted the board to find out what action they had taken, they said there were no actions taken as the delay was unavoidable. We were critical of this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in prescribing appropriate pain relief and for the contradictory response to his complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Patients should receive appropriate medication when returning to prison after surgery.

In relation to complaints handling, we recommended:

• The board’s decision on a complaint should be clear and, if it differs to the view reached at stage one, this should be explained in the response.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.