Annual Report 2007-08 - the Parliamentary and Health Service ...

We have had continuing contact withthe Department of Health, the NationalOffender Management Service, thePrisons and Probation Ombudsman andthe Healthcare Commission to sharelearning about prison complaints. Inparticular, we have provided theDepartment of Health and the NationalOffender Management Service withrelevant background informationto assist them in updating instructionsto Prison Service staff on dealing withcomplaints about healthcare.We have also liaised with the UK BorderAgency about the complaints proceduresapplying to immigration removal centres– some of which are operated by thePrison Service, while others are privatelyrun on behalf of the Agency. This contactwith the Agency has been useful inproducing a redraft of their guidance tostaff, which will correctly reflect the roleof the NHS, the Prisons and ProbationOmbudsman and the Parliamentary andHealth Service Ombudsman in dealingwith complaints about healthcare forpeople in detention or custody.The case of Mr W illustrates how jointinvestigation of a complaint may be thebest way to reach a suitable remedy.Mr W, a prisoner in Swansea Prison,was dissatisfied with the handling of hiscomplaint about his psychiatric careand complained to the ParliamentaryOmbudsman and the Public ServicesOmbudsman for Wales. His complaintwas about events spanning the time whenthe responsibility for commissioningprimary healthcare services at SwanseaPrison transferred from the Prison Serviceto the NHS in April 2006. The remit forinvestigating complaints about theprovision of primary healthcare servicesin prisons before that date falls to theParliamentary Ombudsman, and after thatdate to the Public Services Ombudsmanfor Wales. Using the provisions in theirrespective statutes, both Ombudsmenagreed that Mr W’s complaint was bestanswered by a joint investigation anda single, joint report.23Case StudyDelay in psychiatric assessmentadded to prisoner’s concern anddistressMr W was imprisoned in Swansea Prison in November 2005. Hewas subsequently assessed by the Prison Service GP who referredhim to the Prison Psychiatrist for a psychiatric review whichtook place on 28 November 2005. During this review, the PrisonPsychiatrist recommended that Mr W should be assessed byone of the prison’s visiting forensic psychiatrists. There is noevidence that such a referral took place at the time and in 2006Mr W complained to the Prison Service about the lack ofpsychiatric provision.Dissatisfied with the outcome of his complaints, Mr W complainedto the Parliamentary Ombudsman and the Public ServicesOmbudsman for Wales, who agreed to conduct a joint investigation.The Ombudsmen upheld Mr W’s complaint of delay in providinghim with a psychiatric appointment. The recommendation ofthe Prison Psychiatrist in November 2005 was not implementedfor some months. The Ombudsmen’s view was that it was notfor the other healthcare staff at the prison to decide that thepsychiatrist’s recommendation could be overlooked or deferredand that this was a potentially serious shortcoming. In the absenceof any reasonable explanation for the failure to promptlyimplement the recommendation, the Ombudsmen foundmaladministration by Prison Service staff.When Mr W was eventually seen by two separate forensicpsychiatrists in July and August 2006 it was decided that therewas no need to change the arrangements for providing him withpsychiatric oversight. Therefore the maladministration did notresult in Mr W being without appropriate treatment whilst heawaited his forensic assessment. However, it did add to theinjustice that Mr W felt, in terms of his real concern and distressat the time.The Ombudsmen recommended that the Prison Service provideMr W with an apology and an explanation of its actions. They alsorecommended that the prison’s Healthcare Service staff shouldbe reminded of the need to ensure that recommendations madeby clinicians are properly considered and acted upon promptly.54