SPSO Individual Decisions

Mr C, who is a prisoner, complained about the care and treatment provided to him by the prison doctor. The prison doctor had diagnosed Mr C as having external piles (small lumps that develop on the outside edge of the anus), but Mr C disagreed with this diagnosis. We took independent advice on this complaint from one of our medical advisers, who considered Mr C's medical records. The adviser told us that the symptoms reported by Mr C did indicate that he had external piles and because of that, the prison doctor's diagnosis and treatment were reasonable and appropriate. Related reading View Decision Report 201303379 as a PDF (10.84 KB) Updated: March 13, 2018

Mr C, who is a prisoner, complained that it took five months for him to see a dentist. He was dissatisfied with the board's response to his complaint, in that they did not tell him what had gone wrong or what they would do to ensure this did not happen again. After Mr C asked to see the dentist, the healthcare team gave him an acknowledgement slip advising that he would be placed on the waiting list. However, a member of staff lost Mr C's paperwork and he was not listed to see the dentist. When the health care team became aware of the problem, they placed Mr C on the waiting list and he was later seen by the dentist. We were concerned that during our investigation the board sent us conflicting responses about the guidance they were using as a standard for treating prisoners. This showed that there was confusion for their staff in relation to the standards they applied. We noted, however, that since taking over responsibility for NHS care in prisons, the board aim to have routine patients seen by a dentist within ten weeks. They also apologised to Mr C for the delay in his case, and told us that they would introduce a new appointments system to reduce the likelihood of this happening again. We were aware that at the time of the complaint the Scottish Government had developed draft guidance for a robust framework for oral health improvement and dental services in Scottish prisons. This says that prisoners will have access to a dentist within ten weeks (the current target timescale). Whilst the board had apologised for the delay, we concluded that it was unreasonable for Mr C to wait 22 weeks to see a dentist and we upheld his complaint. We were satisfied that the board were introducing a new system but considered that they should have explained to Mr C what had gone wrong and the improvements they were making, in order to reassure him.

Miss C, who is a prisoner, complained that there was an unreasonable delay in her receiving dental treatment. She also complained because the prison doctor refused to review her pain medication. The board told us that Miss C saw the dentist for treatment but she was missed for a follow-up appointment. They told us that this probably happened because the way the waiting list system operated had changed. Miss C saw the dentist again a little over five months after her initial appointment. We agreed this delay was unreasonable and we upheld Miss C's complaint. In addition, Miss C said in her complaint to the board that her pain medication was not helping. The board told her that the doctor had said it was not appropriate to review her medication before she had been seen by physiotherapy, and had advised that if she responded poorly to physiotherapy then her medication would be reviewed. We took independent advice on this from one of our medical advisers, who said that it was not acceptable for the prison doctor to refuse to review Miss C's pain medication only after she had been to physiotherapy, as she had indicated she was in pain and her medication was not helping. In light of that, we upheld the complaint.

Mr C, who is a prisoner, complained that he was not seen by the prison dental hygienist after being advised that he would be seen again in three months. He was also unhappy that it took nearly four months for him to see the dentist after he reported that a tooth had broken, causing him pain and increasing difficulty in eating and sleeping. The board told us that when they took over responsibility for providing NHS care for prisons in their area in April 2012, there were no guidelines in place aimed specifically at the treatment of prisoners but this was now underway. They also said that since Mr C complained, the prison had audited its practice against the board's new dental services standard statement. Although we recognised that the prison's dental resources were going through a transitional period, we were unable to clearly identify why Mr C's hygienist appointment did not go ahead until 11 months after it was recommended he be seen again. We took independent advice from our dental adviser, who said that from the evidence in the dental records it would have been reasonable for Mr C to see the hygienist around every three months. We, therefore, took the view that the delay was likely to have affected the progression of Mr C's gum disease, which the records show got worse during the months he was waiting to be seen. In addition, we found that the time it took before Mr C saw the dentist was unreasonable and not in accordance with the guidance in place at the time, or the draft guidance due to be published. We were concerned that the board did not identify this while investigating his complaint. We found that the delay was likely to have contributed to his tooth decay and the possibility that he may lose a tooth.

After her appendix was removed, Ms C suffered a number of complications which meant that her recovery was prolonged. She also developed a hernia (an area of weakness in the abdominal wall muscles), and an operation to repair this was carried out. Ms C was in hospital for nearly a month because the operation was prolonged and difficult, and there were concerns about reduced blood flow to the skin edges at the operation site. She was discharged home, and was to have her wound managed by district nurses. Five days later, she was readmitted to hospital and underwent another operation to remove dead skin. Ms C complained that she had not been not fit to be discharged and that hospital staff failed to ensure that her wound was healing appropriately. She also complained that district nurses were shocked at the condition of the wound and after several days made arrangements for her to return to the hospital for the further operation. After taking independent advice from two of our health advisers, a surgeon and a nurse, we did not uphold the complaint. We found that nursing and psychiatric staff had tried to alleviate Ms C's concerns about discharge, and that it was reasonable to discharge her in the absence of any specific reason to stay in hospital such as signs of infection or concerns about the wound. Furthermore, there was evidence that the wound was inspected on the day of discharge, there were no concerns about it and it had previously been dry and clean. We also found it was appropriate to discharge Ms C to the care of district nurses for wound management. Related reading View Decision Report 201205065 as a PDF (11.36 KB) Updated: March 13, 2018

Mr C, who is a MSP, complained on behalf of Mrs A's family. Mrs A, who was 94, was admitted to hospital with shortness of breath, and chest and back pain. Her family were told that she would be examined for a possible chest infection or a clot on her lung. Mrs A was found to have a chest infection and pneumonia. The family were reassured that she would be discharged home within a few days. During her admission, however, Mrs A had a fall and a number of seizures. She also developed confusion. Her breathing difficulties persisted and she died nine days after admission. Mr C raised a number of concerns about the treatment and nursing care provided during Mrs A's admission. He also complained about the level of communication with the family. We took independent advice from two of our advisers, one a specialist in the care of older people, and the other an experienced nurse. Our investigation found that, although Mrs A was initially assessed as being at a low risk of falling, she was not reassessed in line with the board's policy after she fell, and so we upheld the complaint about this. That said, we were satisfied with the level and type of investigations that the board carried out to assess whether she had incurred any injuries or whether her condition had changed. We did not uphold the other complaints, as generally we found the nursing care to be adequate, although we highlighted some issues that could have made Mrs A's stay in hospital more comfortable. Mrs A's family had found the communication from staff to be poor and the information contradictory on some occasions. Based on the clinical records, however, we were satisfied that the family were given full details of the nature and severity of Mrs A's condition. We recognised that there may have been additional conversations not documented in the notes, but felt that, overall, the communication was sufficiently frequent and detailed.

Mrs C complained about the care and treatment the board provided to her son (Master C) after he was admitted to hospital with a perforated appendix. His appendix was removed but he later had to be re-admitted to hospital because of infections, and twice had further unplanned abdominal surgery to release fluid. It was almost a month before he recovered. Mrs C complained that the board failed to diagnose and correct her son's problem; failed to identify a leakage from the stump of the appendix which she felt suggested that the initial surgery had failed; denied her request for the attendance of a surgeon; and failed to provide appropriate nursing care for her son when his condition deteriorated. She also complained that the board did not respond to her complaint appropriately, by failing to answer her question about her son being transferred to a major paediatric surgical centre for treatment. We took independent advice on this case from one of our medical advisers, who is a paediatric surgeon, and a nursing adviser. Our medical adviser said that the protracted course of events was more likely to be related to the advanced stage of the appendicitis when Master C reached hospital, rather than the care he received there. He explained that the leak was unlikely to have been caused by the initial surgery, but more likely to be associated with the severity of the underlying diagnosis. He was of the view that the board did not unreasonably deny Mrs C's request for a surgeon, that the timing of surgical review was reasonable and the review itself appeared to have been appropriate. Our nursing adviser indicated that staff took appropriate action in response to Mrs C's concerns about her son's deteriorating health and that they requested review as appropriate. We accepted the views of both our advisers. Although we deemed the board's care and treatment of Master C to be reasonable we did, however, draw their attention to our medical adviser's view that that, given Mas

Mrs C complained about the care given to her late husband (Mr C) while he was in hospital. She said that he was moved three times but only on the last occasion was it suitable for his condition. She alleged that he was not comfortable or properly looked after and that his clinical care was poor. In particular, she said that he endured terrible pain when his chest drains were being replaced. Overall, Mrs C believed that the lack of proper care hastened Mr C's death. She further complained that she was not kept informed by staff about his condition. In investigating this complaint, we obtained independent advice from medical and nursing advisers. We also took into account all the information provided by Mrs C and by the board (including the relevant correspondence and clinical records). The board had said that the clinical care and treatment given to Mr C were appropriate. However, our medical adviser said that Mr C should have been referred earlier to a thoracic surgeon and should not have undergone four attempts to insert chest drains, particularly without appropriate sedation. There were also failings in Mr C's nursing care, in that his dignity and privacy were not always protected. We, therefore, upheld Mrs C's complaints about her husband's care and treatment, although we did not uphold the complaint that she was not kept informed, as the evidence showed that good attempts were made to let her know what was happening.

Mrs C complained about an examination she was given by a doctor before undergoing an emergency caesarean section (c-section - an operation to deliver a baby). She felt the examination was unnecessary, that she was not given information on what it entailed and that the doctor had not obtained her consent for it. Mrs C was also unhappy with the length of time it took the board to reply to her complaint and said that some of the information in their letter was inconsistent with previous information she had been given. The hospital had identified two days before the c-section was carried out that Mrs C's baby was in the breech position (ie in a bottom down position instead of the more common head down position). We established that on the day of the c-section, it was necessary for the doctor to examine Mrs C to confirm whether her waters had broken and that she was in labour. After taking independent advice from one of our medial advisers, we found that the examination was carried out in accordance with both the board's local policy and guidance issued by the Royal College of Obstetricians and Gynaecologists. Without further independent evidence, we could not say for certain what the doctor discussed with Mrs C about the examination, as her recollection of events differed to those of the doctor. Our medical adviser said that it is good practice for oral consent to be documented, and that the General Medical Council recently issued guidance that a patient's consent to an intimate examination should be obtained and recorded. We noted that this guidance was not in place at the time of Mrs C's examination, however, so although we made a recommendation we did not uphold that complaint. Whilst we found that the board regularly updated Mrs C on the progress of her complaint, we found that there was a significant delay of three months in providing a full response and we upheld that element of her complaint. We concluded, however, that the response was not contradictory,

Mr C complained that staff failed to involve him and his brother in discussions about future care plans for their mother (Mrs A). He said that staff decided that their mother was to be moved to another hospital to be assessed for a nursing home without any consultation with the family. We found that this was a difficult situation where Mr C and his brother, along with the health care team, were trying to get the best outcome for Mrs A. It appears that Mrs A was not able to return home and staff did their best to involve Mr C and his brother in the discharge arrangements. There was clearly some confusion regarding Mrs A's transfer to another hospital. The records showed that Mr C was told that his mother would have a further assessment for a nursing home there. The doctor also tried to contact Mr C again to discuss this before Mrs A was transferred, but there was no answer. We did not uphold Mr C's complaint about this, as we found that the records provided evidence that staff spoke to Mr C and his brother very frequently throughout their mother's stay in hospital. There was no evidence of shortcomings in relation to communication and we were satisfied that staff took on Mr C's concerns about Mrs A's future care plans when he later complained about this. Mr C also complained that staff inappropriately assessed Mrs A without ensuring that her hearing aid was in place. Although Mrs A lost her hearing aid on several occasions, we were satisfied that staff took reasonable steps to obtain replacements. Ideally, a patient should be wearing a hearing aid when being assessed. However, where this is not possible, as in Mrs A's case, it is reasonable for staff to carry out an assessment without the hearing aid in place, providing that they speak clearly and loudly during the assessment. Finally, Mr C complained that staff failed to adequately investigate his concerns that some of Mrs A’s clothing had been lost. We were satisfied that staff adequately dealt with his

Ms C has multiple allergies. In September 2011, she was admitted to hospital with severe abdominal pain and vomiting. She was diagnosed with appendicitis and had an operation later that day. The surgeons found that the appendix had ruptured and she had peritonitis (inflammation of the tissue lining the abdomen). The consultant anaesthetist noted that she had at least one anaphylactic shock (a severe, potentially life-threatening allergic reaction) the day after the operation. A week later, her condition deteriorated and she needed another operation. Several days after being discharged, Ms C was re-admitted to hospital with abdominal pain. She was discharged the next day and staff arranged for her to be seen as an out-patient. In December 2011 she was admitted again with abdominal pain and vomiting. She was prescribed two forms of pain relief and an antibiotic and considers that she had an anaphylactic shock as a result. Ms C was discharged just over a week later to attend the pain and surgical clinic as an out-patient. She was admitted to the intensive care unit at the hospital at the end of February 2012 following an anaphylactic reaction to a barium solution (a liquid used when carrying out scans and x-rays) in the x-ray department. She told us that she also had further reactions to medical wipes. Ms C complained that as a result of the board’s failures, she endured a second avoidable operation, and developed hernias, constant abdominal pain and abnormal bowel movements. She said she had a number of anaphylactic attacks, which were avoidable had staff taken reasonable steps to prevent them. She also complained that while she signed consent forms, she was not physically or mentally capable of giving consent to treatment, and raised concerns about the way the board handled her complaint and the delay in responding. After taking independent advice from two of our medical advisers, a surgeon and a nurse, we did not uphold Ms C's complaints about her care

Mr C complained that his medical practice refused to update him on changes in his son (Master A)’s medical file, about which his estranged wife had not told him. Mr C also complained that the practice had prevented him from transferring his son to an alternative practice in the area. We looked at the information provided by Mr C and obtained information from the practice. We also took independent advice from our GP adviser. Our investigation found that the practice were not required to keep Mr C informed, and that it was a matter for him and his estranged wife to resolve. We also found that the practice had acted correctly dealing with Mr C's request to transfer Master A, as it was not reasonable for one parent to try to re-register a child without the other parent's knowledge. Related reading View Decision Report 201204853 as a PDF (10.99 KB) Updated: March 13, 2018

Mr C, who is a prisoner, was told by a prison officer that he was to attend an appointment at the prison health centre. The doctor wanted to review Mr C's 'medically unfit' status. Mr C said that he was not well enough to go to the appointment and asked the prison officer to tell the health centre. After this, Mr C complained that he had to pass information about his health to the prison officer, which he felt was inappropriate. During our investigation, the health board explained to us that prison staff are responsible for the movement of prisoners around the different areas of the prison. That includes taking prisoners to the health centre for appointments. In addition, the board confirmed that prisoners are required to let prison staff know when they feel unwell. They advised that prisoners do not need to explain to staff why they are unwell. In light of the information provided, we were satisfied that what happened in Mr C's case was appropriate and we did not uphold his complaint. Related reading View Decision Report 201205355 as a PDF (11.13 KB) Updated: March 13, 2018

Mrs C's late father (Mr A) was admitted to hospital in late 2011 with recurrent abscesses. In October 2011, he was transferred to another hospital for audiology (hearing) tests. He was transferred without an escort and wearing only pyjamas and a cardigan. Mr A was doubly incontinent during the journey and also suffered a fall. In November 2011, Mr A was referred to a specialist colorectal (bowel) surgeon and a loop colostomy (a procedure whereby the loop of the bowel is pulled through the thickness of the abdomen wall) was planned. Mr A had bowel surgery several days later. During the operation, Mr A’s bowel suffered a trauma, which the board said the surgical team did not know about at the time. He returned to the ward with a temperature which was treated by antibiotics (drugs to treat bacterial infection). His condition deteriorated and he started to show signs of sepsis (blood infection). Further investigations (chest x-ray, ECG, blood tests and blood cultures) were carried out and he was prescribed a strong antibiotic intravenously. Just over an hour later, staff noted that Mr A might be showing signs of sepsis, and an abdominal examination showed tenderness. An anaesthetic review noted that surgical emphysema (formation of bubbles of air in the soft tissues) was present. He was taken back to the operating theatre, where the surgeon discovered that Mr A’s bowel had been perforated and this had caused peritonitis (inflammation of the tissue lining the abdomen). Mr A needed further operations, and was transferred to intensive care, but his condition deteriorated and he passed away several weeks later. The cause of his death was recorded as acute peritonitis and perforation of colon (bowel) during colostomy operation. Mrs C complained about Mr A’s care and treatment at the hospital including aspects of his transfer to the other hospital. In particular, she complained about the surgeon's failure to detect that Mr A’s bowel had perforated during the ori

Mr C, who is a prisoner, complained that the board had refused his requests to see the prison doctor. Mr C had attended the prison's health centre regularly with approximately two to three consultations every month over a six-year period. He made several requests to see a doctor in 2012. However, he received reply slips either asking for more information or advising that his current medication was sufficient and that a consultation with the doctor was not required. Mr C said that because of this his condition had gone undiagnosed and was effectively untreated. In their response to our enquiries, the board said that requests to see the doctor are through a nurse referral. They said that in Mr C's case, his requests and care were discussed with the doctor. The doctor decided that he did not need to see Mr C and asked that advice was given to him instead. Our investigation found no evidence in the medical records that Mr C's condition had gone undiagnosed or that the treatment provided to him was inappropriate. However, we noted that although Mr C was eventually given an appointment with a doctor, this was nearly five months after he first asked for one. We found it is reasonable for a nurse to triage (assess) the need for an appointment with the doctor. However, if a patient insists on seeing the doctor and considers that there has been a change in their condition or requirements, it would not be reasonable to repeatedly block access. We took the view that it would be more productive for the doctor to discuss with the patient the most appropriate way to access health care services in the future; why they had been triaged; how the triage system works; and why the doctor was satisfied that the current arrangements were appropriate. We considered that when Mr C continued to request an appointment with the doctor, he should have been given this earlier so that such a discussion could take place.

Mrs C complained about the care and treatment that her father (Mr A) received from the board during the four months it took to provide a definitive diagnosis of pancreatic cancer (cancer of the pancreas - a gland in the digestive system). Mr A had been attending his medical practice, and they referred him to hospital for a range of tests. When the test results indicated the possibility of pancreatic cancer, Mr A was referred on an urgent suspected cancer pathway (a route into further treatments which are not available to GPs directly) for a scan. Following this, his case was discussed at a team meeting, and he was referred on for another specialist scan. The results of this test were reviewed at further team meetings, which identified a need for a specialist form of endoscopy (a medical procedure where a tube-like instrument is put into the body to look inside). Mr A had to wait four weeks for this test, and was given a final diagnosis of pancreatic cancer four months after he first attended his GP. During his hospital visits, he was seen by a clinical nurse specialist three times, but never had a clinic appointment with a consultant. We obtained independent advice on this complaint from two medical advisers. Their advice indicated that pancreatic cancer is difficult to diagnose, so it took several tests to get a diagnosis. In Mr A's case, there were no significant delays in delivering the tests or results. However, we upheld Mrs C's complaint as our investigation found that the lack of contact with a consultant indicated a lack of good patient care. Mr A's needs and concerns were not kept at the heart of the process, and this made it more difficult for him and his family to accept the apparently slow progress in reaching a diagnosis.

Ms C complained about the length of time that it took to provide a diagnosis for her father (Mr A), who was eventually diagnosed with pancreatic cancer. Mr A initially attended his medical practice complaining of abdominal pain, weight loss and vomiting. He was prescribed medication, blood samples were taken, and he was referred for an endoscopy (a medical procedure where a tube-like instrument is put into the body to look inside). This found a hiatus hernia (where part of the stomach pushes up into the lower chest) and gastritis (inflammation of the lining of the stomach), for which Mr A had already been given medication. The blood tests, however, showed abnormalities, and Mr A's GP remained concerned. She referred Mr A for an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body). This came back normal, but the head of Mr A's pancreas was not visible. The GP remained concerned, so she referred Mr A for an urgent CT scan (a special scan using a computer to produce an image of the body) through an urgent suspected upper gastro-intestinal cancer pathway (a route into further treatments not available to GPs directly). We took independent advice from our medical adviser, which indicated that the steps taken by the GP in reaching a diagnosis were appropriate. The adviser noted that pancreatic cancer is difficult to diagnose. The diagnostic path required several tests, but there was no evidence of any delays within the practice in either making referrals or passing on test results. Our investigation also found no evidence of delays in providing test results. Related reading View Decision Report 201202678 as a PDF (11.53 KB) Updated: March 13, 2018

Ms C complained about the treatment her daughter (Miss A) had received from the Child and Adolescent Mental Health Service (CAMHS). She said that they had not responded soon enough when she and her daughter had expressed concerns about Miss A. Miss A experienced a significant deterioration in her eating behaviour, which coincided with a planned break from treatment, and a change in treatment staff. Ms C told us that she was concerned about her daughter's behaviour and weight loss, and while the staff did respond, by the time Miss A was referred to a specialist unit, she had to be hospitalised for re-feeding before she could receive treatment for her eating disorder. She felt that this significant deterioration in her daughter's health could have been avoided. As part of our investigation, we sought independent advice from one of our medical advisers. Having taken this advice, we upheld Ms C's complaint on the basis that, while community-based approaches to eating disorders can be effective, they require a strong working relationship between family and staff. This should be in place before the situation becomes critical. Given the absence of such a relationship, the community-based approach was unlikely to be effective in Miss A's case. The absence of a risk assessment also meant that there was less scope for staff to correctly assess the situation when it became critical, and act accordingly. The family had to wait for over a month before Miss A was referred to a specialist unit, and during this time her weight loss continued and her condition deteriorated. We agreed that this could have been avoided if an eating disorder risk assessment had been in place.

Mr C, who is a prisoner, suffers from irritable bowel syndrome (IBS) - a condition that can cause stomach cramps, bloating, diarrhoea and constipation. He told us that he spent a short period of time in one prison, where he received a gluten free diet to help his symptoms. However, when he transferred to the prison where he was to spend the majority of his sentence, he only received a gluten free diet for around three weeks. It was then stopped while the board awaited the results of blood tests. When the results came back, they showed that Mr C was not gluten intolerant, and he was told he would not receive a gluten free diet in future. We did not uphold Mr C's complaint as we found that the decision not to provide him with a gluten free diet was clinically appropriate. However, we were critical of the board for the apparent inconsistency in approach, as Mr C apparently initially received a gluten free diet, which raised his expectations about what he should receive. We drew this to the board's attention. Related reading View Decision Report 201201762 as a PDF (11.16 KB) Updated: March 13, 2018

When Mrs C 's mother (Mrs A) became unwell, Mrs A's carer contacted Mrs C, who went to her mother's house, and a doctor from NHS 24 (the out-of-hours service) visited. He examined Mrs A and wanted to admit her to hospital but his notes recorded that she strongly refused. He prescribed an antibiotic (a drug used to treat bacterial infection) after asking Mrs C if she knew if her mother had any drug allergies. He also advised Mrs C to get in touch again if her mother's condition deteriorated. He later discovered that she was allergic to the drug he had prescribed, and contacted Mrs C to arrange an alternative. Mrs A, however, died during the night. Mrs C disagreed that her mother had refused hospital admission and felt that the doctor should have known of Mrs A's previous experience of the drug. Our investigation found that the doctor could not have known of Mrs A's allergy as he did not have access to her emergency care summary. This consists of basic information about a patient (including allergic reactions) and is available in the out-of-hours centre but not in the out-of-hours doctors' vehicles. The doctor was in his vehicle when asked to attend Mrs A. It was clear he took prompt and appropriate action to check her summary when he reached the out-of-hours centre, and to then arrange alternative medication. We took independent medical advice from one of our advisers, who said that the doctor's other actions, such as his examination of Mrs A, were also appropriate. We could not say for sure whether Mrs A had refused to go to hospital, as the accounts were so different. However, we did not uphold the complaint, as we found no grounds to suggest that the doctor's care and treatment (including his decision not to admit Mrs A to hospital) were unreasonable. Related reading View Decision Report 201203004 as a PDF (11.54 KB) Updated: March 13, 2018

Miss C complained that GPs failed to carry out appropriate investigations into the symptoms her late mother (Mrs A) was presenting with from November 2010. Mrs A was diagnosed with lung cancer in May 2011 and died in August 2011. Before she was diagnosed, Mrs A had been treated and monitored for breathlessness which was not resolving with the treatment provided. The family told us that they felt that the GPs were treating Mrs A as if her symptoms were psychological and that as a result there was a delay in diagnosing the cancer. When Mrs A (who was a smoker) first complained of breathlessness, various tests were carried out. Her chest x-ray and blood tests were reported as being normal. Mrs A continued to suffer breathlessness, however, and was reviewed regularly in the practice by the nurse. She was also seen by GPs and the out-of-hours service. In March 2011 Mrs A was diagnosed with a chest infection and prescribed antibiotics (drugs to treat bacterial infection). When the condition persisted, she was referred for a further chest x-ray. This x-ray was reported as abnormal and Mrs A was referred urgently for a CT scan (a special scan which uses a computer to produce an image of the body), after which she was diagnosed with lung cancer. Our investigation, which included taking independent advice from a medical adviser, found that the care and treatment provided to Mrs A was reasonable, and in line with the national and local guidance on investigating, managing and treating lung cancer. Although Mrs A had been referred for counselling from the community psychiatric nurse, we found no evidence that the GPs considered Mrs A's symptoms were psychological. The adviser said that the GPs clearly took note of Mrs A's physical symptoms and investigated them in a reasonable and timely manner, and in line with national guidance. Related reading View Decision Report 201200987 as a PDF (11.58 KB) Updated: March 13, 2018

Mr C complained about a wide range of issues concerning aspects of his mental health care by the board over a number of years. However, on investigation, we considered that the board had done all they could reasonably have been expected to do in respect of his mental health. For example, he had been seen by a number of appropriate clinicians, there had been very thorough assessments, and he had had appropriate treatment. We acknowledged that Mr C wanted more from the board but were satisfied that the board could not reasonably have been expected to have provided more. Related reading View Decision Report 201103221 as a PDF (10.91 KB) Updated: March 13, 2018

Mr and Mrs C complained that the medical practice inappropriately prescribed their father (Mr A) anti-inflammatory medication on a long-term basis, without also prescribing gastric protection medication. Mr A had sciatica (lower back pain caused by pressure on a nerve) and osteoarthritis (the most common form of arthritis, affecting the joints) in his knees. He had been on a non-steroidal anti-inflammatory drug (NSAID) for a number of years when he attended hospital several times complaining of abdominal (stomach) pain. He was eventually admitted to hospital, where he was found to have a massive gastro-intestinal haemorrhage (severe bleeding in the stomach/intestine) because of a bleeding ulcer. Doctors were unable to control this, and although Mr A had emergency surgery, he did not survive. Our investigation found that guidance in 2008 said that gastric protection medication should be prescribed with NSAIDs. We upheld the complaints, as we found that from 2008 onwards Mr A should not have been prescribed a NSAID without this protection. We noted that this was in fact picked up at a medication review that year, which noted that Mr A was over 65 and a smoker and was, therefore, at increased risk of stomach bleed. The review said that if the NSAID prescription was continued, gastric protection medication should be added. The NSAID was then removed from Mr A's repeat prescriptions. However, a year later, a NSAID was added to his repeat prescriptions without gastric protection medication. The practice apologised to Mr C for this after Mr A's death and carried out a significant event analysis. Mr C also complained that the practice failed to diagnose and treat Mr A's ulcer. Mr A had attended the hospital with abdominal pain several times, and they had told the practice about this. We found that the practice were not required to follow this up unless the hospital specifically asked them to do so, and there was no evidence that Mr A attended the practice with a

Mr C complained about the care and treatment given to his late wife (Mrs C). He said that Mrs C had initially been taken into hospital with a urinary tract infection. The following month, she was transferred to another hospital for rehabilitation and physiotherapy. Later that month she was noted to have red heels, with a blister on one of them. Mrs C was discharged home shortly afterwards and Mr C said that at that time she had pressure sores. Mrs C died some six months later. Mr C complained that his wife suffered from pressure sores while in the care of the board. He said that she was inadequately nursed and that this contributed to her death. In our investigation we took all the relevant information into account including the board's file of correspondence and Mrs C's clinical notes. We also obtained independent nursing advice about Mrs C's care and treatment. We upheld all Mr C's complaints. Our investigation found that there was no reason not to discharge Mrs C home with dressings on her feet. However, there was also no evidence to suggest that a wound chart was completed before discharge, which would have assisted community nurses to plan their care for Mrs C. Community nurses were also not told that Mrs C's heels needed dressing and we found that communication between the hospital and the community nurses was poor. Similarly, record-keeping was below a satisfactory standard.

Mrs C, complained to us about the care and treatment of her late mother (Mrs A) who had a complex medical history, including bowel cancer. After falling, Mrs A was admitted to a hospital high dependency unit. She was given a blood transfusion and antibiotics for a urinary tract infection. As doctors thought Mrs A had suffered a stroke she was moved to the stroke ward at 03:30. Shortly after admission to the stroke ward, Mrs A stopped eating, experienced constipation and complained to her daughter of knee pain. Six days after she was moved there, her condition deteriorated rapidly and Mrs C’s husband telephoned Mrs C saying that the hospital had called to say that Mrs A had taken a bad turn and Mrs C should go to the hospital. Mrs A passed away shortly afterwards. The death certificate noted Mrs A’s cause of death as toxins and a perforated bowel. Mrs C complained about these events, saying that staff should have dealt with Mrs A’s problems sooner and that her mother was transferred from one ward to another at an inappropriate time. She also said that she suspected that the suppositories or other medical interventions might have caused her mother’s deterioration and death, and was unhappy about the attitude of nursing staff. She said that they showed unprofessional attitudes to her and her mother and failed to properly contact her on the morning of Mrs A’s death. The board’s reply to Mrs C’s complaint recognised that there were some problems with communication between nurses and Mrs A’s family. They also recognised that the early morning transfer between the high dependency unit and the stroke ward was inappropriate as there was no clinical need for it to be done at this time. They agreed that staff should have known to contact Mrs C directly on the morning of her mother’s death. They apologised and ensured that the relevant managers were made aware of the issues. We did not uphold Mrs C's complaints. After reviewing the board’s file and Mrs A's medical records, and