SPSO Individual Decisions

Mrs C's father (Mr A) was diagnosed with cancer, and underwent surgery followed by a course of chemotherapy. About six months later, Mr A began experiencing new symptoms, and a scan was arranged. Mr A was told that the scan showed 'no evidence of recurrence', and he was discharged (with a follow-up planned for four to six weeks). However, Mr A's symptoms continued and he was admitted as an emergency a few days later, and underwent further surgery. While Mr A thought the surgery was to address symptoms resulting from his previous surgery, the surgery found that Mr A's cancer had returned and he was given a purely palliative procedure. Mr A passed away a few months later. Mrs C was concerned that her father was told he was 'all clear' after the chemotherapy, only to find out his cancer had returned six months after this. Mrs C was also concerned that her father was not given regular scans, and she queried how the scan he was given could show no return of the cancer, when Mr A was found to have cancer just a few days later. After taking independent medical advice, we upheld Mrs C's complaints. While we found no evidence Mr A was given incorrect information about being 'all clear' from cancer following chemotherapy, there was also no evidence that he was offered information about his prognosis and the high possibility of recurrence at this time. In relation to Mrs C's concerns about scans, we found that the board had undertaken reasonable follow-up of Mr A, consistent with national guidance (which did not require regular scanning). However, we found that, although the scan showed a possibility that the cancer had returned, the consultant surgeon did not share this with Mr A, which was unreasonable.

Mrs C complained that the board had neither diagnosed nor treated her eye condition reasonably. She also felt they had not given her sufficient information about medication she was prescribed previously (Mrs C felt she should have been made aware of the possible visual side effect, as her medication was ultimately thought to have contributed to her subsequent eye condition). She was also unhappy with the board's response to her complaint. Mrs C's complaint made it clear how strongly she felt about this matter and how much her condition had affected her. Although we recognised that and took it into account, our role was to consider whether the board's steps were reasonable in the circumstances at the time. We took independent medical advice from three advisers – a GP, an ophthalmologist (a doctor who examines, diagnoses and treats diseases and injuries in and around the eye) and a rheumatologist. They all thought that medical staff had, overall, taken reasonable steps to diagnose and treat Mrs C's condition. This included the steps taken at her medical practice and also at Raigmore Hospital. In terms of Mrs C's historic medication, our medical advice was that the side effect she highlighted and appeared to have suffered was very rare and, in addition, it was associated with a pre-existing medical condition Mrs C had. The evidence indicated that she was given the standard information leaflet at the time she was prescribed her medication. Although we recognised that this leaflet may not have been as detailed as Mrs C may have liked, we did not consider this meant that clinical staff had acted unreasonably. In terms of the board's response to Mrs C's complaint, we had to consider whether any inaccuracies, viewed as a whole and within context, were enough to make it unreasonable. Our medical advice was clear that Mrs C had suffered from a rare and complicated condition and this was reflected in the detailed correspondence. Although we recognised that any discr

Ms C complained about the care and treatment her late father (Mr A) received at the Royal Northern Infirmary. She said the board failed to provide adequate nursing care for her father and unreasonably failed to diagnose his broken collarbone and stroke. We obtained independent advice on the case from a nurse adviser and a GP adviser. Our nursing adviser said Mr A's fluid balance and food intake, repeat fall assessments and care planning fell short of what should have been in place. However, she said that even if these areas of Mr A's care had been up to standard, the outcome may not have changed. Our adviser said the board's response to Ms C's complaint was poor and she would have expected the board to have recognised their shortcomings, and to have apologised and ensured lessons had been learned. Our GP adviser said there was documented evidence in Mr A's medical records of a review of his condition after each of his falls by a clinical member of staff. She noted that the documentation of the examination and assessment was thorough and of a reasonable standard. She said the doctor who attended to Mr A noted his on-going confusion, poor mobility and number of recent falls. The doctor identified that Mr A's condition had deteriorated and arranged transfer to Raigmore Hospital for further investigation. The doctor also identified that Mr A may have had a stroke and correctly referred him to Raigmore Hospital for a scan. Our adviser said this was reasonable management and was in accordance with relevant guidelines.

Mrs C's father (Mr A) visited the practice on several occasions with stomach problems. Although an endoscopy (an investigation of the stomach using a camera) was considered early on, Mr A was instead treated for stress and anxiety for about six months, before an endoscopy was arranged. The endoscopy led to a diagnosis of stomach cancer. Mrs C raised concerns that Mr A was not referred for an endoscopy sooner, and referred to an online article that recommended urgent referral for patients over 55 with unexplained and persistent dyspepsia (indigestion). After taking independent medical advice from a GP adviser, we did not uphold Mrs C's complaints. Our adviser considered the GP's actions were consistent with the national guidance on dyspepsia, and reasonable in light of the information known at the time. Our adviser said that Mr A's dyspepsia was not unexplained, as he had been diagnosed with stress (and there were several factors that supported this diagnosis, including that Mr A's symptoms seemed to respond to medication for this). Our adviser also noted that the GP had appropriately checked for any 'alarm features' and regularly checked Mr A's blood tests. When Mr A's blood test showed an abnormality, he was appropriately referred for an endoscopy. Related reading View Decision Report 201406016 as a PDF (11.24 KB) Updated: March 13, 2018

After Ms C was diagnosed with Lyme Disease (an infection transmitted by the bite of ticks) in 2014, she complained that her GP practice had failed to identify the symptoms of the condition at a consultation a year earlier. Ms C said that in 2013 she presented with a tick bite and large surrounding rash on her arm but the doctor she saw on that occasion did not offer her blood tests or antibiotics. Ms C was concerned that an electronic record of the consultation differed to the hand written entry by that doctor in her medical records and that a second doctor did not put accurate information in a referral letter to an infectious diseases specialist. Ms C also complained that a health care assistant was unprofessional with matters related to her blood test in 2014. We took independent advice from one of our medical advisers who is a GP, and found that there was no evidence to indicate that Ms C had a bite mark on her arm or that the rash was typical of that associated with Lyme Disease. We considered, on balance, that the first doctor's assessment, diagnosis and suggested treatment were reasonable at the time. We also found that the electronic medical record did not differ materially from the handwritten record. Furthermore, the referral letter to the infectious disease specialist was consistent with the recorded entries in the medical records and were not inaccurate or misleading. We concluded that it was good practice that the health care assistant had sought advice from a senior colleague regarding the blood test and took steps to appraise himself of the laboratory guidance. Whilst it was difficult for us to comment on the discussions between Ms C and the health care assistant, we obtained electronic records which provided an audit of the likely advice that Ms C was given by him during a phone conversation about the blood results. We, therefore, did not uphold the complaints. Related reading View Decision Report 201405101 as a PDF (11.53 KB) Updated: March 13

Miss C complained that the board had unreasonably removed her pet from her property and had also failed to gain her consent to search her property. We took independent advice from one of our mental health advisers. Our investigation found that, in the circumstances, the action taken to arrange for Miss C's pet to go into foster care was reasonable, but that it had not been reasonable to ask her to make a decision about the long-term future of her pet without allowing sufficient time to consider this and give her informed consent. Our investigation also found that, given the concern about Miss C's welfare and safety at that time, it had been reasonable to search Miss C's home and remove medication. However, the record-keeping was unreasonable.

Mrs C complained about the mental health care and treatment provided to her late son, as well as the lack of support for her and her family, the lack of family involvement in the critical incident review (CIR) following her son's death, and the delay in providing her with a copy of the CIR report. Mrs C also complained to the General Medical Council (GMC) about the psychiatrist involved in her son's care. The GMC investigated, and decided to take no action. We decided not to re-investigate those matters which had already been considered by the GMC. However, we agreed to investigate some issues which had not been looked at by the GMC, including the conduct of a mental health assessment, the support provided to the family, and the complaints about the CIR. After taking independent mental health advice, we upheld three of Mrs C's complaints. We found that the board unreasonably failed to include Mrs C in the CIR process and that the delay of over six months in providing Mrs C with a copy of the CIR report was unreasonable. However, we accepted that the board had apologised for this delay and taken appropriate steps to improve their CIR process. We also found the board had not provided reasonable support for Mrs C and her family as carers. While the board had since amended their paperwork to improve involvement of carers at the assessment stage, we did not consider this was sufficient to prevent a recurrence, as the meaningful involvement of a person's relatives should be on-going, rather than completed as a one-off exercise. In relation to the mental health assessment of April 2011, we found this had been conducted reasonably, and we did not uphold this complaint. However, we were concerned that there had been a delay in arranging a referral to a psychiatrist following this assessment, and we raised our concerns about this with the board.

Mrs C, who is an advice worker, complained on behalf of Mrs A about the care and treatment she received at Caithness General Hospital in 2004/05 for a lump in her breast. In August 2013, Mrs A had a routine mammogram and was referred for further tests, after which she was diagnosed with breast cancer in the area that had been examined in 2004/05. Mrs A was concerned about the lack of communication by the surgeon in 2004/05 in relation to some test results which indicated an abnormality. She also complained that a procedure for exploring whether there was any sign of malignancy (cancer cells) was not properly performed; that she was wrongly advised that the lump would never be cancerous; and that she should have been kept under continual review. The board found no failings in the treatment given in 2004/05. However, they acknowledged that there were failings by the surgeon in the record-keeping of one of her procedures, and that there was a lack of evidence that the results of a test which indicated an abnormality (but not malignancy) had been explained to her. We took independent advice on this case from one of our medical advisers. We found that Mrs A was given appropriate investigations in accordance with national guidance in place at the time. However, we were critical of the poor record-keeping by the surgeon and the failure to explain all of Mrs A's test results. Therefore, we upheld this aspect. We did not identify evidence to support that Mrs A was given misleading information about the lump and, even though there was an abnormality in one of the tests, this was not a reason to keep her under continual review.

Mrs C complained about the care her late daughter (Miss C) received from her former GP practice between January and August 2011 after Miss C was diagnosed with a brain tumour in July 2012. Mrs C was concerned that Miss C was misdiagnosed with depression and, given that her symptoms (headaches, dizziness, tiredness and dilating pupils) were getting progressively worse, she should have been referred for a brain scan. Mrs C also provided evidence to show that Miss C had been unwell at college and had attended another medical facility. We took independent advice from one of our medical advisers who is a GP. Based on their advice, we found that the initial diagnosis of vertigo was reasonable based on the symptoms of dizziness and abnormal eye movements. It was also noted that Miss C had described symptoms of anxiety which were explored by the practice, and the reasons for this were plausible. We did not find evidence in any of the records made of the eleven GP consultations, the records made by the college, or medical facility, that Miss C had reported suffering from headaches or that her condition was getting progressively worse. We found that Miss C's symptoms were not consistent with the symptoms of brain tumour set out in the relevant Scottish guidelines for referring patients for urgent assessment (such as for a brain scan). We concluded that this was a tragic case where Miss C's symptoms were not clearly typical of a brain tumour. Related reading View Decision Report 201403274 as a PDF (11.32 KB) Updated: March 13, 2018

Mr C complained on behalf of his father (Mr A) who had suffered a stroke following a bleed in his brain which required specialist surgery. He was left with dense weakness in his left side with no active movement. Mr A was an in-patient at Raigmore Hospital for a number of months while he underwent rehabilitation in their stroke unit. When he was discharged, Mr A received physiotherapy at York Day Hospital. He was later seen by a consultant in stroke rehabilitation medicine and a specialist physiotherapist. Mr A also received other physiotherapy in the community. Mr C was unhappy with the range, intensity and frequency of the physiotherapy that Mr A received and complained that the board had failed to provide appropriate rehabilitation following his stroke. The board considered that the rehabilitation they provided was reasonable. After taking independent advice from a medical adviser who is a consultant in stroke medicine and rehabilitation, we found that the clinical rehabilitation treatment that Mr A had received was appropriate. The advice highlighted an area where communication with the family could have been better but, overall, we considered this element of Mr A's care to be reasonable. We also took independent advice from a physiotherapist specialising in neurological rehabilitation and acute neurology (the science of the nerves and the nervous system, especially of the diseases affecting them). Overall, the range, intensity and frequency of Mr A's physiotherapy was found to be reasonable and the adviser considered that a holistic approach had been taken in relation to his treatment. The physiotherapy advice highlighted a single area of concern where there was no record that an issue identified during an assessment at York Day Hospital was monitored. After taking all the information about Mr A's rehabilitation care and treatment into account, we did not uphold Mr C's complaint but made a recommendation to the board to ensure that lessons are learn

Mrs C complained about the pregnancy care she received from Raigmore Hospital. She said that the hospital failed to perform basic medical tests and that there was an inappropriate evaluation of her health which resulted in her pregnancy loss. Mrs C had a past history of thyroid problems and she complained that the management of this problem had been unreasonable. Mrs C also complained that no examination was carried out after her pregnancy loss to make sure everything was all right. We took independent advice from a consultant obstetrician and gynaecologist. Our investigation found that overall the care and treatment given to Mrs C was reasonable, including the care and treatment Mrs C received when she attended the hospital with bleeding. The advice we received was that the hospital had also reasonably managed Mrs C's thyroid levels and there was no evidence that the loss of her pregnancy was caused by her thyroid condition or its treatment. We were also satisfied that, as Mrs C's pregnancy loss had occurred abroad, the hospital had not been aware of the situation until they contacted Mrs C when she missed a number of appointments. When responding to Mrs C's complaint, the board offered a further appointment to discuss what further investigations were appropriate at that time. In light of our findings, we did not uphold Mrs C’s complaint. Related reading View Decision Report 201401161 as a PDF (11.24 KB) Updated: March 13, 2018

Mrs C complained on behalf of her sister (Ms A) about the continence nursing care she had received during a stay in Campbeltown Hospital. During the first few months at the hospital, a catheter was used to manage Ms A's continence. Mrs C complained to the board about urinary care issues that arose during this period including urinary tract infections. Following their investigation of Mrs C's complaint, the board apologised for the lack of involvement of a specialist continence care nurse and, more generally, for the wider record-keeping for Ms A. After taking independent advice from a nursing adviser, we upheld Mrs C's complaint. We found that, while many aspects of Ms A's urinary nursing care were appropriate, the lack of involvement of a specialist continence nurse and record-keeping matters (such as a lack of evidence that the continuing need for a catheter was reviewed) meant that, overall, the care could not be considered as reasonable.

Ms C, an advocacy worker, complained about Mr A's care and treatment at Caithness General Hospital, where he underwent keyhole surgery to remove his gallbladder. She noted that Mr A was led to believe the surgery would be routine, but complications were encountered, requiring corrective surgery at Raigmore Hospital and an extended hospital stay. She complained that the risks of the surgery were not adequately explained and that reasonable steps were not taken to avoid the complications encountered, such as infection. She also complained that the surgery resulted in Mr A developing a foot drop (a condition which impairs the ability to lift the front part of the foot). We took independent advice from one of our medical advisers who noted that consent forms were completed both prior to Mr A's admission and on the day of the surgery. However, our adviser observed that the forms did not document the potential risks of the surgery. Our adviser stated that it was good practice to list common complications, or those which are rare but severe. In the absence of this, we could not find evidence that the risks were adequately discussed with Mr A and so we upheld this aspect of the complaint. Our adviser confirmed that the complications encountered were recognised complications of this type of surgery, and did not consider that anything could reasonably have been done to prevent them in Mr A's case. In addition, our adviser considered it unlikely that Mr A's foot drop was related to the surgery. We accepted this advice and did not uphold the remaining aspects of the complaint.

Ms C complained that the board had not managed her Individual Patient Treatment Request (IPTR) panel appropriately. She had been obliged to make an IPTR in order to obtain a drug which helped control the symptoms of her multiple sclerosis (MS) as the drug was not licensed for prescription in Scotland. Ms C had been prescribed a free trial of the drug and said her neurologist supported the prescription of it once the trial had finished. She said there had been undue delay in arranging her hearings and that the board had not provided her with information about the panel's decisions appropriately. Ms C also complained that the panel had failed to consider the evidence she had presented appropriately. Ms C said this had caused her considerable distress and worsened her MS. We took independent advice from one of our medical advisers who said he believed the panel had been conducted appropriately. He noted there were delays in the submission of the original IPTR request, and further delays caused by the departure from the board of Ms C's original neurologist. The board had acted to mitigate these delays, but were not responsible for them. Our investigation found the board had arranged the IPTR process appropriately. Although Ms C had been successful on appeal, this was due to a change in Scottish Government guidance, rather than a reassessment or reinterpretation of the evidence by the IPTR Panel. The substantial delays in the IPTR process were due to the actions of Ms C's neurologists and the delays in submitting documents. We did not find the board failed to provide Ms C with information about the panel's decisions. Related reading View Decision Report 201401952 as a PDF (11.38 KB) Updated: March 13, 2018

Ms C complained about the care and treatment her late mother (Mrs A) had received from the board. Mrs A had taken lithium medication for many years for her bipolar disorder. This medication was changed in November 2012 and then changed back to lithium around six months later. Ms C was unhappy with these decisions as she felt they caused her mother to suffer from lithium poisoning, which caused Mrs A to attend Lorn and Islands Hospital. She was transferred to Argyll and Bute Hospital and then was moved between the hospitals again. Mrs A died within two months of her initial admission and Ms C was unhappy with the care her mother had received throughout this period. We considered whether Mrs A's treatment was reasonable in the circumstances at the time. We did not use the benefit of hindsight in making that decision and we took independent medical advice from a psychiatrist and a geriatrician (a doctor specialising in medical care for the elderly). Their advice confirmed that the original decision to change Mrs A's medication was reasonable in the circumstances, as was deciding to reintroduce lithium. In light of this clear advice, we did not uphold Ms C's first two complaints. Our medical advice was that Mrs A appeared to have been suffering from lithium toxicity when she first attended Lorn & Islands Hospital, and that it was unreasonable to have transferred her to Argyll and Bute Hospital at that time. Mrs A was then transferred back to Lorn and Islands Hospital for a time before returning to Argyll and Bute Hospital. Our medical advice was that the potential severity of Mrs A's lithium toxicity appeared not to have been recognised during this time and her condition was not investigated sufficiently. We upheld Ms C's complaints about these admissions. However, in terms of Mrs A's final admission to Lorn and Islands Hospital, our medical advice was that care and treatment was by that point reasonable, so we did not uphold Ms C's complaint about that.

Ms C complained that she had not been provided with pain relieving injections for her chronic back pain within the 18 week referral to treatment target. Ms C was initially offered injections to block the nerve with a combination of steroids and anaesthetic. A trial was carried out first, however, using just the anaesthetic, in order to ensure she would respond to these injections, as not all patients find them effective. The board did not accept her treatment had missed this target significantly, as Ms C had received the trial injection some 20 weeks after referral. Although Ms C did respond to the trial injections, she did not wish to continue with this treatment pathway as she said she wished to proceed with surgical denervation (the blocking of a nerve supply through surgical intervention), which she had discussed as an option at an earlier consultation. When she was told a referral would need to be made to another board area for this procedure, Ms C also complained to us that she had been unreasonably refused a denervation procedure locally. We took independent advice from a medical adviser, who is a specialist in pain medicine. The adviser said the board's definition of what constituted treatment was unreasonable and contradicted their own patient pathway information. Ms C's assessment of the delay she had experienced in receiving the injection was reasonable. We found that the board had already taken some action to address the delays experienced by Ms C, but that it was unreasonable for them not to accept that her delay had exceeded 30 weeks before she received the full injection treatment. We found the board had failed to write to Ms C as they were obliged to by NHS Scotland guidance when the 18 week target was breached, so we upheld Ms C's complaint about the unreasonable delay in treatment. However, our adviser said that it had not been unreasonable for the board not to provide a denervation service locally, as this was a specialised procedure, whi

Mrs C complained about the care and treatment she received for endometrial cancer (cancer in the lining of the womb) between April 2011 and March 2012 at Raigmore Hospital. Specifically, she was concerned that she was not given enough information about the cancer and her treatment options. She also raised concerns about the treatment she received in 2011 and about delays in surgery going ahead after evidence of cancer was identified in 2012. Mrs C also complained about inaccuracies in the board's response to her complaint. We found the record-keeping by the staff involved in Mrs C's care and treatment was of an appropriate standard and reflected reasonable attempts to help her understand the diagnosis and treatment plan. We considered that this was done within a reasonable timescale after she presented with abnormal symptoms in 2011. The board also ensured Mrs C had the opportunity to discuss her concerns about her care with relevant specialists. We took independent advice on her case from one of our medical advisers who found that the treatment given in 2011 was appropriate and in line with national guidance. Our adviser said that there were certain factors that had to be properly considered before decisions could be made regarding Mrs C's care, because of the risk to her life. Whilst we noted a slight delay in a second opinion being sought after it was indicated in 2012 that there was residual evidence of the cancer, this did not impact on Mrs C's outcome as the cancer was in the early stages and had not spread. We also found that it was not clear whether the results of an abnormal scan were highlighted to the gynaecology team through the multi-disciplinary team process. Although the subsequent delay did not have any impact on Mrs C's prognosis, it is important that radiology staff acknowledge that the referring team may not have the experience to interpret any identified abnormalities and action these appropriate. Whilst we made a recommendation to addr

Mr C complained on behalf of Mr A. Mr C said Mr A suffered from spinal damage which had required an operation but his treatment at Raigmore Hospital had been significantly delayed following his referral as it was unreasonably downgraded from urgent to routine and because the board lacked surgical capacity. Mr C was concerned that Mr A had not been examined properly. Mr A eventually underwent surgery outside the board area. Mr A had then required a second operation, which he felt had also been delayed. During his treatment, Mr A had not been communicated with adequately and Mr C's attempts to make a complaint on his behalf had been frustrated by the board's failure to follow its complaints procedures appropriately. Mr C said there was concern the delay had affected Mr A's recovery. We took independent advice from two medical advisers. They said Mr A was not an urgent case and it was appropriate for him to be seen as a routine referral. He had been examined appropriately and there was no evidence Mr A had suffered permanent damage between his referral and his first operation. The advice also stated the board lacked the capacity to perform this type of surgery within an acceptable clinical timeframe. It was also noted there was doubt over whether a second operation would provide Mr A with further significant improvements. The advice noted that the clinical correspondence with Mr A regarding his treatment had been of a reasonable standard. We found that Mr A had experienced an unreasonable delay in the provision of his surgery, but that there had not been an unreasonable delay in providing his second operation. We accepted the advice that Mr A had received a reasonable standard of communication from the board. We concluded that the board had failed to follow its complaints procedure appropriately and there had been an unacceptable delay in responding to Mr C.

Mr C said he had been referred to the ear, nose and throat clinic by his GP. He had been offered an appointment at a Raigmore Hospital which was too far from his home and had requested an appointment at Belford Hospital closer to where he lived. Despite this he had been offered a second appointment at Raigmore Hospital, before being offered an appointment at Belford Hospital. Mr C complained he was seen outside the waiting time guarantee of 18 weeks from referral to treatment. Mr C also complained that he had been offered an appointment with psychological services some 18 months after his referral, which also breached the referral to treatment target. We found the offer of an appointment to Mr C of an appointment at Raigmore was within the board’s published policies for appointment management. The board had mitigation in place due to the distances patients had to travel to attend these appointments. When Mr C refused this appointment, he was no longer covered by the Scottish Government waiting time target, so we did not uphold his complaint about delay for the ear, nose and throat clinic. We found there was an unreasonable delay in providing an appointment with psychological services and upheld his complaint about this. The board had, however, provided evidence that they had made significant improvements to their waiting list management and that waiting times had consequently been substantially reduced.

Mr and Mrs C complained to us on behalf of their teenage son (Mr A), following his stay in an adult psychiatric unit. They complained that he had been held in the adult unit for an unreasonable length of time, that he had been given medication without their consent, that he had been denied the company of his mother on his transfer to another unit, and that their complaints had been inappropriately handled. We began our investigations, including discussions with the Mental Welfare Commission who had also looked into Mr A's care and treatment. However, during the course of our investigations, Mr A moved away from home, and was not in contact with his parents. Therefore, we took the decision to close the complaint in line with our procedures, as we had no way of contacting him, and considered that we no longer had his consent to share his personal information with his parents. Related reading View Decision Report 201304134 as a PDF (11.04 KB) Updated: March 13, 2018

Ms C, an advocate, complained on behalf of her client (Mr A) about the infection control procedures used by Raigmore Hospital when he had a total hip replacement. When Mr A attended the pre-operative assessment when he was first scheduled for surgery, it was found that he had an in-growing toenail and surgery was delayed until this was treated. When the operation was re-scheduled, additional testing was undertaken to establish if Mr A had any on-going underlying infection and all the tests were negative. The operation took place and during the surgery samples of fluid and tissue were taken for laboratory analysis and Mr A was also given precautionary antibiotics (drugs used to fight bacterial infections). The samples taken were positive for infection which proved very difficult to eradicate, resulting in a long recovery period for Mr A, including that his hip replacement implant had to be removed while the infection was treated and then a new implant put in. We took independent advice from one of our medical advisers who was satisfied that the board's infection control procedures were compliant with national guidance and that these procedures were followed appropriately. The adviser commented that no testing can fully eliminate the possibility of deep-seated infection and the adviser was of the view that the infection present in Mr A's hip during his operation had probably originated from his previous in-growing toenail. The adviser also considered that the fact that Mr A was a diabetic contributed to the lengthy recovery period as diabetics do not fight infections as quickly as non-diabetics. Related reading View Decision Report 201400264 as a PDF (11.41 KB) Updated: March 13, 2018

Mrs C complained on behalf of her client (Mrs A) about the board's handling of assessments of Mrs A's child in relation to diagnosing autism spectrum disorder (ASD). Mrs A first reported concerns about her child when they were about two years old, as she felt they had some developmental issues. When the child was between four and five years old, community paediatrics undertook two formal assessments for ASD, both of which concluded that the child did not have ASD (although showed some ASD traits). Mrs A was dissatisfied with these results and sought the opinion of a private psychologist, who also considered her child had some ASD traits, although did not fulfil all the diagnostic criteria for ASD. Over the next nine years, the child continued to have developmental problems and was in on-going contact with health professionals and social workers. The child was also referred on several occasions to the children's reporter, including for non-attendance at school and for lack of parental care. While Mrs A asked on a number of occasions for a further assessment of ASD, the board considered that this had already been ruled out, and did not agree to offer a second opinion. When the child was ten, Mrs A's solicitor obtained an independent psychologist's opinion for the children's reporter hearing, which found that there had not been appropriate assessments of ASD to date. Mrs A then asked her GP for a second opinion from a different NHS board, and the GP arranged an admission to a hospital outside the board area. As a result of that admission, the child was diagnosed with ASD. In view of the different diagnosis, the board undertook a significant event review (SER). The board also planned to meet with the hospital team which had diagnosed ASD, to discuss the case, although this had not been done at the time of our investigation. Mrs C complained about the board's failure to undertake appropriate assessments and their handling of Mrs A's complaint. After taking inde

Mr C complained that the board failed to provide him with adequate care and treatment following his admission to A&E at Raigmore Hospital with stroke symptoms. Mr C said that he was not given a thrombolysis injection ('clot buster' therapy which may reverse neurological deficit) and raised concerns about CT scans (scans that use a computer to produce an image of the body) and the prescription of perindopril (a blood pressure lowering agent). We obtained independent medical advice from a consultant in emergency medicine (adviser 1) and a consultant in general and elderly medicine with a special interest in stroke medicine (adviser 2). Adviser 2 said that thrombolysis was not indicated at any point in Mr C's treatment and would not have been likely to result in Mr C having a better recovery. Had it been indicated, however, it was clear that by the time this was determined it would have been too late to safely administer it. Adviser 1 identified unreasonable delays in A&E and said it was not clear that the nurse who assessed Mr C recognised that his symptoms might be due to a stroke. The advisers found no evidence that the appropriate assessment tool was used when triaging Mr C (deciding where he should be treated based on his condition), and there was also an error in completing a checklist for stroke thrombolysis. Delays in treatment resulted in an unreasonable delay in a CT scan being carried out. However, our advisers said there was no requirement for the board to carry out a second scan after what Mr C believed was a second stroke after he arrived at hospital. Adviser 2 said that a blood pressure lowering agent such as perindopril should have been prescribed for Mr C on discharge. The board acknowledged their failing in this area and took appropriate remedial action.

Ms C complained on behalf of her client (Ms A) about the care and treatment provided to Ms A for anorexia nervosa (an eating disorder) when she was admitted to New Craigs Hospital (a psychiatric hospital). Ms A had been placed on a short term detention certificate and her medical records show that on admission she had a low body mass index. It was also noted that she was at high risk of refeeding syndrome (a potentially lethal disorder that can occur when a person is recovering from a period of starvation), and it was decided that refeeding should take place in a medical unit at another hospital. There were, however, no beds available there at that point. Ms A was sipping water and was aware of the plan to transfer her to the other hospital, where she might be fed with a nasogastric tube (a narrow tube passed into the stomach through the nose). However, she was not admitted there until five days later. By this time her mental and physical state had deteriorated, and she had lost weight and become unresponsive. Ms C complained that despite suffering from anorexia and a low body mass index, Ms A was not offered anything to eat or drink for four days. She said that as Ms A was under a short term detention order, staff could and should have started nasogastric feeding. Ms C also said it was inappropriate to transport Ms A in a patient transport vehicle instead of an ambulance, given her serious condition. We took independent advice on this case from two of our medical advisers. We found that the medical records indicated that Ms A was offered food and fluids, and that it was reasonable to monitor her and allow voluntary feeding instead of nasogastric feeding, particularly in light of the risk of refeeding syndrome. Although, given the nature of her medical needs, our advisers said that Ms A should have been admitted to the medical unit sooner, we were satisfied that the evidence showed that her care and treatment at New Craigs Hospital were reasonable. In the

Mrs C's child had a history of behavioural problems, and was referred to the board's community paediatric department for assessment. A number of developmental disorders were considered and ruled out and a plan put in place to seek further information from the child's school before deciding what follow-up action might be required. Due to staff leaving the department, a period of eight months went by before the case was progressed, and it was a further two months before the board contacted Mrs C telling her that no concerns had been raised about her child, who had been discharged. Mrs C continued to be concerned about her child's behaviour and sought a further assessment. This ultimately led to the child being diagnosed with high functioning autism / Asperger's syndrome. Mrs C complained to us about the delay in diagnosis and about poor communication from the board. We upheld her complaint about delay. We found that the initial assessment of her child was not in line with national guidance for the assessment of children and young adults with autism disorders. Autism should have been considered and developmental disorders should not have been ruled out before information was gathered from the school. We found the eight-month delay before the case was progressed unreasonable, and there was a further excessive delay after Mrs C's child was referred back to the community paediatric department. We were critical of the board for not communicating with Mrs C for ten months while the case did not progress, but overall found their communication to be reasonable.