SPSO Individual Decisions

Mrs C complained about the communication with her family during her late father (Mr A)'s admission to Cornhill Macmillan Centre for end of life care. She raised concerns that the family were excluded from most medical consultations and were not updated on changes to Mr A's condition or treatment. In particular, she complained that the family were not prepared for the fact that Mr A would not receive fluids once he was unable to take them orally. She said there was no continuity of care and there was no single member of staff who seemed to know Mr A well. She also complained that the visiting hours were overly strict, and that staff were defensive and did not support the family to make the most of Mr A's final weeks. We obtained independent advice from a nursing adviser, who noted that aspects of Mr A's care appeared to be of a very good standard. The adviser said that a reasonable level of discussion with the family was documented, although she acknowledged that their needs did not appear to have been met in this regard. She considered that the family's concerns should have been picked up on early in Mr A's admission and support offered to them through a named individual. She noted that the board's assessment and decision-making in relation to fluid provision was well documented and appropriate to the circumstances. However, she considered that an early explanation to the family of the planned approach could have reduced their distress. The adviser also considered that the visiting policy was overly strict and outdated, when it should be flexible and adaptable to the individual needs of patients. We were critical of the board that, after failing to resolve the concerns at the time, they did not use Mrs C's formal complaint to appreciate where things went wrong and identify specific learning opportunities. They developed an action plan in response to the complaint but we did not consider it to be robust enough. We felt that their response to the complaint

Mr C complained because he felt the care and treatment he received from the prison health centre was unreasonable. In particular, Mr C said that since taking his prescribed methadone he had been feeling ill. Mr C said a doctor concluded that he should not be prescribed methadone and made arrangements for an alternative medication to be prescribed. However, before that happened, Mr C was reviewed by another doctor who decided that the prescription for methadone should continue. Mr C was unhappy with that decision because he felt he was allergic to the medication. The board explained to Mr C that, following review, the doctor considered the symptoms he had were not because of the methadone and there were other potential causes that needed to be excluded. The doctor suggested Mr C undergo further assessment with the mental health team, and offered treatment to reduce the symptoms he was suffering, which Mr C declined. In addition, the doctor concluded that Mr C's symptoms were not severe enough to justify changing treatment. We took independent advice from one of our GP advisers and asked for their view on whether the care and treatment provided to Mr C had been reasonable. Our adviser considered that Mr C had been thoroughly assessed by the doctor. She also reviewed Mr C's medical records and noted he had a long history of multiple drug misuse. Our adviser commented that, in her view, with Mr C's history of multiple drug misuse and then stopping all drugs in favour of methadone, his symptoms could reasonably be interpreted by the doctor as having been related to drug withdrawal. As such, she said that the options offered to him – mental health assessment and a trial of allergy medication – and the reasons for not prescribing the alternative medication were reasonable. Our adviser commented that she could see no evidence that Mr C was not adequately assessed by an appropriate professional or that the treatment offered was inappropriate. In light of the evide

Ms C, who is an advice worker, complained on behalf of her client, whose husband (Mr A) had died following two hospital admissions at Perth Royal Infirmary a short period apart. Mr A had suffered two strokes in quick succession. Ms C complained that he had not been diagnosed quickly enough with a stroke on his first admission. On his second admission, Ms C complained that Mr A was not provided with medical review quickly enough and that nursing staff were slow to address his obvious pain and distress. As a result, although the family accepted that his second stroke was terminal, Ms C said that they were subjected to an unnecessarily distressing and undignified experience. We took independent advice from a nursing adviser and a medical adviser. The medical advice stated that Mr A had received the appropriate medical care on both admissions. On his first admission, he had presented with a complex combination of medical problems, including pneumonia and infection. The decision had been taken to stabilise his condition, which was reasonable in the circumstances. Our adviser said that his stroke had been diagnosed inside a reasonable time-frame. During his second admission, we found that Mr A had been provided with a medical review within the limits imposed by the responding doctor's clinical commitments. Our nursing adviser said there were shortcomings in the nursing care provided to Mr A, but that the board had recognised and apologised for these. The board had provided an action plan, which our adviser felt addressed the shortcomings identified and were able to evidence that it was being put into action. We found that Mr A had received reasonable medical care, although his nursing care had fallen below a reasonable standard. In view of the actions already taken by the board, however, we made no recommendations. Related reading View Decision Report 201406738 as a PDF (11.47 KB) Updated: March 13, 2018

Mr C complained about the care and treatment that his wife (Mrs C) had received from the GP practice before her death from bowel cancer. Mr C said that Mrs C had attended the practice on a number of occasions over a three-year period with abdominal pain. He said that the practice had failed to provide Mrs C with appropriate treatment and had delayed in referring her to a specialist. We took independent advice on Mr C's complaint from one of our medical advisers, who is a general practitioner. We found that Mrs C had initially attended the practice on a number of occasions with heart burn/dyspepsia (persistent or recurrent abdominal discomfort or pain located in the upper abdomen). Heart burn/dyspepsia are not clinical symptoms identified in patients presenting with bowel cancer and Mrs C had received appropriate treatment for this. Mrs C had subsequently attended the practice with symptoms of abdominal pain, change in bowel habit and anaemia. She was then urgently referred to the colorectal service in line with the relevant guidelines and was diagnosed with bowel cancer. We found that Mrs C had attended the practice with two different sets of symptoms, which were not related. The practice had provided a reasonable standard of care to Mrs C and we did not identify any failings. We did not uphold the complaint. Related reading View Decision Report 201406670 as a PDF (11.22 KB) Updated: March 13, 2018

Ms C complained to us on behalf of her partner (Mr A), who had a history of gastroenterological problems (problems with the digestive system). Ms C had previously complained to the board about the care and treatment that Mr A was receiving from them. Ms C then made a second complaint which was considered during this investigation. Ms C complained that the board had not provided reasonable care and treatment to Mr A in the period covered by the complaint. Ms C was dissatisfied that they had been unable to reach a diagnosis for Mr A's condition, and was also concerned that her previous complaint had impacted on the subsequent care that Mr A received. After taking independent advice from one of our medical advisers, who is a gastroenterology consultant, we did not uphold this complaint. The adviser considered that, overall, the care and treatment provided by the board was reasonable. We did find that the doctor/patient relationship with one of the consultants who had been treating Mr A had broken down. Following this, although a letter was sent to Mr A's GP explaining the situation, the consultant did not arrange a referral to another consultant. The adviser said this had no impact on Mr A as the GP made a referral instead, but we have made a recommendation to draw this point to the attention of the relevant consultant. We found no evidence that Ms C's prior complaint had affected the medical treatment provided to Mr A.

Mrs C, who is an advice worker, complained on behalf of Mr A about the care and treatment he received from the medical practice. Mrs C said Mr A, who has cerebral palsy, was seen by doctors at the practice for a year with sharp abdominal pains but the practice failed to diagnose that Mr A had a hernia (a condition where an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall). Mrs C also complained that one of the doctors at the practice failed to carry out a physical examination of Mr A at one of the appointments. We obtained independent medical advice from one of our GP advisers. They said that they could see no evidence in Mr A’s medical records that he had either the symptoms or signs of a hernia during the 12 months that he was seen by the practice, and that the hernia identified at the end of the 12 months was most likely a new presentation. We found that Mr A was provided with a reasonable standard of care by the practice. Our adviser also explained that there was no requirement for a patient to be examined for a chronic condition every time they attended a GP practice and that if a patient presented with new symptoms or a significant change, then an examination would be reasonable. When Mr A was seen by the doctor, he did not present with any new symptoms, and as he had been seen 24 hours previously by a senior surgical doctor at Perth Royal Infirmary for an examination, we did not consider it unreasonable that the doctor did not physically examine Mr A. We did not uphold Mrs C's complaints. Related reading View Decision Report 201407708 as a PDF (11.37 KB) Updated: March 13, 2018

Mr C complained that there was a delay in his GP practice diagnosing him with skin cancer. He also said that they did not take his concerns seriously and that there was a delay in him receiving medication for nerve damage. We took independent advice from one of our medical advisers who is a GP and found that the GP practice provided Mr C with a reasonable standard of treatment, making referrals to hospital specialists based on his symptoms. Whilst we were critical that Mr C could have been referred to a dermatology specialist sooner, this was not a significant delay. Furthermore, we did not consider it had any material impact on the time it would have taken for him to be seen. In addition, there was evidence to show that reasonable attempts were made by the GP practice to communicate with Mr C following his surgery. Although the GP practice apologised for the delay in giving Mr C his medication, we found that they were not entirely at fault. However, we upheld Mr C's complaint that the GP practice did not provide him with appropriate explanations about the reasons for the delay in prescribing his medication. Related reading View Decision Report 201404508 as a PDF (11.15 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment that her late mother-in-law (Mrs A) had received. Mrs A had been referred to an orthopaedic consultant (a doctor who specialises in conditions involving the musculoskeletal system) and was seen in January 2013. She was re-referred by her GP practice in May 2013 but was not seen again until late July 2013. Mrs A died of widespread secondary cancer in October 2013, having been diagnosed a matter of weeks previously. Our role was to assess whether the evidence indicated that Mrs A’s treatment was reasonable in the circumstances at the time. We took independent advice from our medical adviser, who said the steps taken by the orthopaedic consultant had been reasonable. In light of the symptoms Mrs A displayed in January 2013, the advice we received was that it would not have been normal practice to have carried out additional investigations for cancer. The board did, however, acknowledge their delay in arranging Mrs A’s second appointment (the GP practice’s re-referral appeared not to have been acted upon promptly). We considered this to have been unreasonable and, although the advice was that this did not affect Mrs A’s overall outcome, the board acknowledged that earlier diagnosis would have led to better pain control and palliative care. We recognised the importance of receiving such care and so, on balance, we upheld Mrs C’s complaint because of the delayed second appointment and its possible impact on Mrs A’s palliative care. We also made two recommendations.

Mr C complained that when he called the out-of-hours (OOH) service, the first GP he spoke to did not provide proper care or treatment. Mr C said the GP had been unable to access his medical records and had refused to admit him to hospital, offering an appointment at the OOH centre, which Mr C could not attend because of the level of pain he was suffering. When Mr C had called the OOH service the following morning, a second GP arranged for an ambulance to take him to hospital, where his knee was then treated. Mr C said the second GP had told him that the first GP would have been able to access his medical records and that hospital admission was the only appropriate treatment for his knee. We took independent advice from one of our GP advisers. They said that Mr C did not constitute an emergency case, and that the first GP had acted appropriately by not admitting him to hospital. The second GP had not followed procedure in arranging Mr C's admission for treatment which meant that Mr C had an unreasonable expectation of what the first GP should have done. We found that the first GP had acted reasonably and in line with the board's policies in the care and treatment he had provided. Therefore, we did not uphold Mr C's complaint. Related reading View Decision Report 201406593 as a PDF (11.17 KB) Updated: March 13, 2018

Miss C raised a number of issues about the time taken by the health board to arrange her appointment for day surgery and that, when it eventually took place, it was outwith the timescales for the Treatment Time Guarantee (TTG) of 12 weeks. Miss C also mentioned that she had told staff she was willing to take a cancellation if that meant earlier surgery but that this was not noted in her records. She was also dissatisfied with the time taken to deal with her formal complaint. We found that the board had in fact noted that Miss C was willing to take a cancellation and that they had arranged for an earlier admission which would have met the TTG but that it had to be cancelled due to the unavailability of a bed. We found that the board were taking action behind the scenes but this was not adequately communicated to Miss C. We also found that there were delays in the complaints handling and that there was a failure to keep Miss C updated on developments. Therefore, we upheld Miss C's complaints. We were also concerned to note that the board said that, according to their access policy, they would not routinely contact another health service provider should they not be able to meet the TTG. However, there is a requirement for boards to contact alternative health service providers when they are not able to meet the TTG. We also made a recommendation to the board in this regard.

Mrs C said her son was admitted to Ninewells Hospital with a suspected infectious disease and was kept in hospital for two nights. Mrs C said she was told that her son's treatment would be free, but during the discharge process she was advised she would have to pay for his treatment as they were visitors to the UK. Mrs C complained that it was unreasonable that she was charged for his care and treatment. Her concerns included that her son's treatment was not immediately necessary and the board's actions were contrary to Scottish Government Guidance CEL 09 (2010) (Overseas Visitors' Liability to Pay Charges for NHS Care and Services) as she was not given the opportunity to make an informed decision about whether, or to what extent, to proceed with treatment. We obtained independent medical advice on the complaint from one of our medical advisers, a consultant in general medicine. The evidence showed that the initial impression provided to Mrs C by the board was that her son's treatment would be free. The board failed to follow the Scottish Government guidance with sufficient accuracy, and there were opportunities that should been taken to discuss the likely charges with Mrs C at the time of her son's admission to hospital. However, the type of treatment her son received was chargeable. It seemed unlikely that, had Mrs C been presented with the 'undertaking to pay' form at the time of her son's admission to hospital, she would have refused to sign the form, as he was clearly very unwell and in need of medical treatment. We also noted that Mrs C signed the 'undertaking to pay' form at the time of her son's discharge. We therefore considered that, on balance, it was reasonable that Mrs C was charged for her son's care and treatment.

Ms C complained that, during a phone consultation, an out-of-hours GP asked a care home nurse if Ms C's father (Mr A) had a do not attempt cardiopulmonary resuscitation (DNACPR) note in his records. Ms C said the GP asked about the DNACPR with the implication that, if there was one in place, the GP should not bother coming to visit Mr A. Ms C also complained that the GP inappropriately prescribed amoxicillin (an antibiotic drug used to treat bacterial infection) to Mr A, which she said was not effective for him, and could be detrimental to his health. We looked at Mr A's clinical records and a copy of the board's complaint file, and we took independent advice from one of our medical advisers. We asked the board for the audio recording of the phone call between the GP and the care home nurse, but it was no longer available. We found that DNACPR refers to cardiopulmonary resuscitation in circumstances where a patient's heart stops, and does not refer to any other element of a patient's clinical care. We concluded that it was normal for a triaging doctor (triage is the process of deciding which patients should be treated first based on how ill or injured they are) to ask whether a DNACPR form has been completed for a patient. We also found that there was nothing in the available medical records to indicate that Mr A was allergic to amoxicillin. We concluded that the final prescribing decision has to lie with the doctor who is assessing the patient at the time, that the GP prescribed medication in line with relevant guidance, and that Mr A was provided with a reasonable standard of care in the circumstances. We did not uphold Ms C's complaints. Related reading View Decision Report 201405098 as a PDF (11.44 KB) Updated: March 13, 2018

Mrs C complained about the board because she said she had concerns about the way in which it managed her waiting time before she received a clinic appointment. She also complained about the appointment itself, the examination and conclusions. Mrs C said she was left frustrated and depressed as a consequence, and sought private treatment to have a knee operation. She said that, if the board had treated her appropriately, this should have been the outcome of her clinic appointment. We investigated the complaint and took independent advice from a consultant orthopaedic surgeon (a surgeon specialising in the musculoskeletal system). We found that in relation to waiting times, the board followed Scottish Government guidance. As Mrs C had informed the board that she would not be available for three periods of time during the indicated waiting time period (12 weeks), her waiting time was put back by a similar time. In the event, she was seen 13 weeks after the appointment was requested. Similarly, notwithstanding her private treatment, Mrs C's examination and management of her knee problem was in accordance with National Institute for Health and Care Excellence guidance. We did not uphold her complaint. Related reading View Decision Report 201406436 as a PDF (11.19 KB) Updated: March 13, 2018

Mrs C complained that she had contacted the practice in the late afternoon to request that a GP attend and assess her partner (Mr A)'s mental health condition as she was seriously concerned that he was having a psychotic episode. Mr A was at another address and she was concerned about his safety. The GP listened to Mrs C's concerns and sought advice from the mental health services. It was decided that it would not be appropriate for them to visit Mr A that evening and that a visit would be made the following morning. Mrs C subsequently reported Mr A missing to police and he was found dead near to the address that Mrs C had highlighted. The GP explained that he had taken Mrs C's concerns seriously, and that he had sought specialist advice and reviewed Mr A's previous medical history and, as there was no immediate risk to Mr A or others, a visit the following morning was appropriate. We took independent advice from a GP adviser who felt that the GP had not put himself in a position to obtain a first hand assessment of Mr A's mental health condition. The adviser felt that Mrs C's information was concerning enough to warrant action that evening. However, after careful consideration we felt that the GP had acted appropriately by seeking advice from the mental health services about Mr A's previous contact with them, and that there was no indication that Mr A was at risk to himself or others at the time. We found that the GP had treated Mrs C's concerns seriously and that a mental health assessment was appropriate, but that it could wait until the following morning. We did not uphold the complaint. Related reading View Decision Report 201406447 as a PDF (11.33 KB) Updated: March 13, 2018

Mrs C was referred by her GP to the Acute Medical Unit of Ninewells Hospital after reporting a ten-day history of increasing chest and upper abdominal pain. She was admitted in the afternoon and blood tests and a measurement of her heart-rate were taken. She was then reviewed by a consultant later in the evening who told Mrs C that her condition was 'not cardiac' (not related to her heart). The blood test results were not available during this review and were not checked until the following morning. Mrs C was placed on a heart monitor overnight but when she needed to use the lavatory, she was taken off the monitor and not reconnected when she returned to bed. Mrs C was reviewed the following morning by a different consultant who told her that the blood test results confirmed she had had a heart attack. Mrs C complained to us about the care and treatment she received from the board; about entries in her medical records; and about the response to her complaints. Our investigation, which included taking independent advice from a medical adviser and a nursing adviser, found that while some of her care and treatment was reasonable, there were some failings. In particular, the delay in reviewing the blood test results and in not reconnecting Mrs C to the heart monitor were not considered to be reasonable. Mrs C was also concerned that there were inaccuracies and/or fabrications in her medical records but we found no evidence of this. There was one entry which related to blood test results for another patient which had been entered into Mrs C's records. The board had acknowledged this and although we upheld this complaint, we made no recommendations in view of remedial action already taken. Finally, Mrs C was concerned that the responses to her complaints had been unreasonable. While our investigation identified that some improvement could be made, we also found that genuine efforts had been made to address Mrs C's concerns.

Mr C complained that his dental practice had failed to make a referral to the dental hospital within a reasonable timescale. Mr C had teeth which required extraction, and he said that it had taken a long time to get an appointment for this procedure to be carried out. Mr C had other health conditions which meant that once they had received his referral, the dental hospital had made contact with other health professionals involved in Mr C's care to ensure that his treatment could take place. Whilst we recognised that the delay was frustrating for Mr C, we did not find any evidence that any delay was caused by the practice. Mr C also complained that he had been asked to make a payment to secure an appointment with his dentist and was told this was because he had previously cancelled appointments. Mr C was unhappy with this as he said he had always had good reason to cancel and had given sufficient notice. We considered that the dentist had acted reasonably as Mr C had cancelled a number of appointments late or failed to attend. It was, therefore, not unreasonable for the dentist to apply the practice's policy of charges for failed appointments. Related reading View Decision Report 201406169 as a PDF (11.14 KB) Updated: March 13, 2018

Ms C said that after having two teeth filled, she began to experience progressively worsening pain. She said that this prevented her sleeping and caused her much distress. However, she said that her dental practice refused to provide her with further treatment on the basis that they considered the cause of her pain to be as a consequence of complex regional pain syndrome (a poorly understood condition where the person experiences persistent and debilitating pain) for which she had been diagnosed in 2008. Ms C then left the practice. She said that the next day she attended an emergency appointment with another dentist. They determined that she had some decay, a dying nerve and a bleeding root canal and she was given treatment which she said provided immediate relief. She then complained that the original dentist failed to treat her appropriately. We took independent advice from one of our dental advisers. The investigations showed that given Ms C's symptoms, the source of her pain had been difficult to establish and diagnose and that, in the circumstances, it had been reasonable to suggest that the cause was complex regional pain syndrome. We also established while an x-ray might have helped with a diagnosis, the dentist concerned had, nevertheless, provided Ms C with reasonable care and treatment. The complaint was not upheld. Related reading View Decision Report 201401744 as a PDF (11.29 KB) Updated: March 13, 2018

Mr C told us that when he attended Ninewells Hospital after he was referred by his GP he was told on arrival by a doctor that he should be at a different hospital. He said that another doctor then arrived in the waiting area, apologised for the mix-up and referred him to the phlebotomy department (which deals with taking blood samples). Mr C wrote to the board to complain about the conduct of staff on duty whilst he was at the hospital. Mr C disagreed with the board's response that the staff concerned could only remember limited information, and brought his complaint to us. We did not take Mr C's complaint about staff conduct any further as there was no way for us to independently verify the truth of statements given. We upheld Mr C's complaint about the board's handling of his complaint as we found the board failed to deal properly with Mr C's complaint about staff conduct. The board failed to seek clarification on Mr C's specific concerns and consider all points. We did not make any recommendations as the board have already taken steps to prevent a re-occurrence of the problems Mr C experienced. Related reading View Decision Report 201403582 as a PDF (11.13 KB) Updated: March 13, 2018

Mr C sustained an injury to his right hip/leg, which he said was caused when he fell off a chair. Mr C attended the prison health centre regarding his injury on several occasions. Mr C complained that the prison health centre failed to provide him with appropriate care and treatment. He said there was an unreasonable delay in the prison health centre carrying out an x-ray of his hip. He also said the prison doctor inappropriately failed to see him at a scheduled appointment. We obtained independent medical advice on the complaint from one of our advisers who is a GP. The evidence showed that Mr C had seven consultations with medical staff at the prison health centre over a four week period following his injury. Our adviser said that Mr C's assessment and management by the health centre staff was of a reasonable standard. She explained that Mr C's symptoms and risk factors were not consistent with a hip or pelvis fracture. She said an x-ray was not clinically necessary in Mr C's case and instead seemed to have been arranged after his request, rather than because of clinical suspicion of fracture. As such, she did not consider that Mr C's x-ray should have been done more quickly. The board said Mr C's scheduled appointment with the prison doctor was cancelled because of security and health and safety reasons. Our adviser explained that health and safety decisions were taken in the best interests of both prisoners and staff and the prison heath centre's actions were reasonable. Related reading View Decision Report 201402360 as a PDF (11.3 KB) Updated: March 13, 2018

Mr C complained that the board unreasonably advised the Scottish Prison Service (SPS) that it was safe for him to be subject to metal detecting equipment, although he has an implantable cardioverter defibrillator (ICD) (a device that regulates irregular heart rhythms). Mr C also complained about the board’s handling of his medication. He said that staff altered his medication inappropriately, and made mistakes in administration. He also said that there was no reason for his medication to be supervised (taken in front of prison staff, rather than given into the patient’s keeping), as it was degrading to be required to open his mouth to show he had taken the medication, and this supervision resulted in him being harassed and bullied for his medication. After investigating Mr C’s complaints and taking independent medical advice from several specialists, we upheld Mr C’s complaint about the administration of his medication. We found that, although a doctor decided to stop Mr C’s naproxen (a drug used for pain relief and anti-inflammation, which can contribute to poor kidney function), Mr C’s prescription record (kardex) was not updated to reflect this. This was because the kardex had to be recalled from the prison halls, and a different doctor was on duty when the kardex was returned to the health centre. As a result, Mr C was inappropriately given a further dose of naproxen in the next weekly medications. We also found that it was unreasonable for a hospital doctor to decide to restart Mr C’s naproxen, although his clinical history showed that this had been stopped due to poor kidney function. Finally, we found that Mr C had been given incorrect dosages of medications on one occasion. We did not uphold Mr C’s complaint about security screening. Although health centre staff gave slightly different advice about this to prison staff at different times, we found that all of the advice given was reasonable. We also did not uphold Mr C’s complaint about supervision

Ms C complained on behalf of her late partner (Mr A) about his care and treatment at A&E at Ninewells Hospital. She said that Mr A was not assessed properly and she was unhappy that he was referred under the board's redirection policy to a primary care doctor (a doctor providing day-to-day medical care, such as a GP) rather than being seen and treated in A&E. Ms C said that the board had refused to treat Mr A. During our investigation, we took independent medical advice from two emergency medicine consultants and from a consultant neurologist. The advice we received was that overall Mr A’s care and treatment was reasonable. The emergency medicine consultants said that it was reasonable and appropriate, after triage (the process of deciding which patient should be treated first based on how sick or seriously injured they are) and assessment by a senior doctor, to refer Mr A to primary care for further assessment. They were also satisfied that an adequate medical history was taken in the triage room and sufficient information gathered to decide that Mr A should be referred to a primary care doctor. We also received advice that the senior doctor who assessed Mr A had the skills and experience to assess the urgency of his case and that the clinical notes detailed the rationale for redirecting Mr A. However, we were concerned that, given Mr A's symptoms, there was no measurement of his vital signs when he attended A&E. Although our advisers said that this did not compromise his care, they also said that measurement of these vital signs may in some cases reveal a condition meriting emergency care. Documentation of the vital signs would also add weight to the decision to redirect a patient from A&E after assessment by a senior doctor.

Mrs C complained about her treatment at A&E at Ninewells Hospital. She told us that when she attended with a broken foot she was fitted with a moon boot (a removable cast) and told, since it was the weekend, she was to return home and wait for a phone call on Monday. Mrs C said that she was in extreme pain at home and she said she noted trauma blisters on her foot. She said she phoned the hospital for some advice. She said that the staff member that answered the phone did not give any guidance and said that it was Mrs C's choice as to whether she went back to the hospital or not. Mrs C received a call from an orthopaedic consultant the following day who told Mrs C that she should not have been sent home and asked her go to hospital immediately. Mrs C believed that the delay in treatment had contributed to having to spend more time in hospital and having to have two operations. As part of our investigation we took independent advice from one of our medical advisers, who said that the doctor reviewing the initial x-ray failed to correctly act on the information that identified that Mrs C’s foot was indeed broken. In relation to Mrs C’s complaint about the phone advice she was given following her discharge from A&E, our adviser also said was also of the opinion that all requests for clinical advice should be recorded and that when Mrs C reported on-going symptoms, clear advice about returning for further review should have been given. The board apologised and described the action they would take to avoid a re-occurrence of this situation, although our adviser expressed disappointment that it had taken a formal complaint to identify a training need.

Mrs C complained on behalf of her client (Mrs A) who was unhappy with the care and treatment she received from her GP practice in relation to a finger injury. After injuring her finger, Mrs A attended the hospital minor injuries and illnesses unit, but she was discharged. A week later, she attended the practice as she was still unable to bend her finger. The GP examined her finger and prescribed antibiotics. Mrs A returned a week later and a different GP prescribed different antibiotics. Mrs A returned again another week later, and at this appointment she mentioned that soon after the first injury, she had had a second injury which stretched her finger. The third GP then considered that Mrs A might have an injury to her flexor tendon (the tendon that connects the muscles in the forearm to the bones in the finger), and referred her to the orthopaedic clinic as a routine referral. After further investigations, Mrs A was diagnosed with an incomplete tear of the flexor tendon. After taking independent medical advice from a GP adviser, we upheld the complaint. We found that, although the first two GPs did not know about the second injury, in view of Mrs A's symptoms they should still have considered the possibility of a flexor tendon injury and referred her for specialist assessment. Although the third GP acted appropriately in referring Mrs A to orthopaedics, this should have been an urgent referral, rather than routine. We were concerned that the GPs' failures to refer Mrs A appropriately led to a delay of over three weeks in her treatment, which our adviser said was significant as flexor tendon injuries are normally treated within a few days.

Mr C complained about care and treatment provided to his daughter (Miss A) at Perth Royal Infirmary when she attended the eye clinic there. Mr C believed that her condition was misdiagnosed, and that the treatment prescribed may have aggravated her condition and led to her sudden death. Mr C told us that Miss A was being treated by her GP for acute conjunctivitis. The common treatment is with antibiotic (drugs to fight infection) drops or ointment and in some cases also steroid (drugs to fight inflammation) drops or ointment. The GP prescribed an antibiotic only. When her condition worsened, Miss A went back to the GP and was referred urgently to the eye clinic. Miss A attended the clinic the following day and a specialist doctor there diagnosed marginal keratitis (MK - an eye condition), with a possible allergic reaction to the antibiotic prescribed by the GP. The specialist changed the antibiotic, added a steroid and arranged a follow-up appointment for a week later. Three days later, however, Miss A died suddenly. Mr C told us that he disagreed with the stated cause of her death. He was of the view that she had in fact been suffering from a more serious infective eye condition and that the treatment provided was not only wrong, but contributed to her death by increasing pressure and inflammation in the brain. Our investigation included taking independent advice from one of our medical advisers, who was of the view that appropriate examinations and investigations were carried out and that Miss A had been correctly diagnosed with, and treated for, MK. The adviser said that although the two conditions have similar symptoms, sufferers of the more serious condition also experience other symptoms, which Miss A did not have. The adviser was, therefore, of the view that Miss A's diagnosis, care and treatment were reasonable, appropriate and timely and there was no evidence that these contributed to her sudden death. Amendment to summary text When it was originally publis

Mr C complained on behalf of Mrs A, the widow of Mr A. Following a referral by his GP, Mr A was seen in Ninewells Hospital for advice and investigation in May 2013. He was given a computerised tomography (CT) scan (which uses x-rays and a computer to create detailed images of the inside of the body) which showed an abnormality on one of his ribs which was suspected to be sinister. In July 2013, a biopsy was attempted but this failed because it was too uncomfortable for Mr A. The following month, a further CT scan was taken as was a biopsy under general anaesthetic. The results confirmed that Mr A had cancer. Mr A had further investigations the following month and a treatment plan for him was discussed by a multi-disciplinary team. Mr A was advised of his diagnosis and plan in October 2013. Regrettably, Mr A's condition continued to deteriorate and he died in May 2014. Mr C questioned why early tests and investigations given to Mr A failed to show evidence of his illness and said that there had been delays in providing him with treatment. Mr C said that as a consequence, Mr A had lost time with his family. Mr C also complained that there had been delay in issuing correspondence to Mr A. On behalf of the hospital, the board said that it had been very difficult to diagnose Mr A's illness and that while tests showed that something was wrong, this could have been for a number of reasons; there had been a delay in getting biopsy results but this had been unavoidable. Similarly, they said that there had been a delay in sending out letters because of administrative problems but that this had not affected Mr A's treatment overall. We took independent advice from a consultant clinical oncologist and found that it had been very difficult to diagnose Mr A's cancer and to establish information by biopsy to determine the type of treatment he needed. This was not unreasonable in the circumstances. However, it had not been reasonable not to have treated Mr A as a susp