SPSO Individual Decisions

Ms C complained that, during her pregnancy, the board failed to give her reasonable care and treatment and that there was a failure to diagnose placental insufficiency (a complication in pregnancy where the placenta is unable to deliver an adequate supply of nutrients and oxygen to the fetus), or that her baby was too small. Ms C's baby was stillborn. We took independent medical advice from a consultant obstetrician, who told us that while ultrasound (a scan that uses sound waves to create images of organs and structures inside the body) provided the best estimate of fetal size, unfortunately it was not always accurate. Other tests (including measurements of the abdomen and blood flow in the umbilical artery) did not always pick up that a baby was small. Scans and other tests were also used to detect problems with the placenta but again were not foolproof. In Ms C's case, as she had already had two healthy births and had no apparent risk factors, all appropriate and reasonable steps were taken to properly monitor her pregnancy. While our adviser noted that with earlier delivery the baby would likely have survived, there was no indication for her to have been delivered earlier. Based on the evidence, we did not uphold Ms C's complaints about her care and treatment. Ms C also complained about the way her complaint was handled. We upheld this complaint, as we found that there had been numerous delays, and that these had added to her distress.

Ms C complained on behalf of her client (Mr A) who suffers from a delusional disorder (a mental health disorder where sufferers hold irrational beliefs). Mr A went to A&E in Lorn and Islands Hospital as he wanted them to check a mark on his leg. Staff were concerned about his mental wellbeing and spoke to the duty psychiatrist at another hospital who decided that he should be transferred and admitted there. In the event that Mr A was unwilling to go, it was agreed that his admission be facilitated with the use of an Emergency Detention Certificate (EDC). Documentation had to be completed for this and, before arrangements could be made for transfer, Mr A left Lorn and Islands Hospital. He was later brought back, handcuffed, by the police, sedated and transferred. Ms C complained that Mr A was not adequately assessed at A&E. She also said that staff did not follow the correct process/procedures in relation to the EDC and there was unreasonable delay in transferring Mr A between hospitals. She subsequently complained of the delay in responding to her complaint about this. We took independent medical advice from one of our psychiatric advisers. We found that, while it had been reasonable to prioritise Mr A's mental health over his concerns about his leg, the board had not first tried to establish whether he was a risk to others or himself, nor attempted to discuss his condition with his usual psychiatrist and review his records before deciding that he needed to be tranquilised. They also failed to follow the correct procedures (in terms of assessment and proper completion of the appropriate forms) for issuing an EDC. This led to Mr A being sedated against his will. Furthermore, the board delayed in dealing with Ms C's complaints. We, therefore, upheld these complaints. Ms C had also complained that the board delayed in transferring Mr A between hospitals, but we did not find evidence to confirm this, and did not uphold her complaint.

Mr C complained to us that the board had refused to investigate his complaint about his late partner (Ms A)'s medical treatment at Dunoon Hospital. The board had refused to respond to the complaint as Mr C was not Ms A's next of kin, and to have access to her medical records they would have to have permission from her next of kin. We found that the board had given Mr C's request for information about Ms A's clinical treatment careful consideration, and had consulted senior staff before reaching a final decision that they were not in a position to respond to the complaint. The board had also suggested that Mr C should contact Ms A's next of kin to ask for permission to release the information from Ms A's medical records, and that he had chosen not to do so. We were satisfied that the board had considered the matter carefully and we found no reason to question their actions. Related reading View Decision Report 201402434 as a PDF (10.97 KB) Updated: March 13, 2018

Mr C complained that the board failed to diagnose his condition properly when he attended an out-of-hours (OOH) service at Raigmore Hospital. Mr C was diagnosed with a viral infection, and he was discharged. A few days later, however, he became very unwell and was admitted to hospital where he was later diagnosed with legionnaires' disease. Mr C said that the OOH service should have considered this as a possible diagnosis, particularly as he had mentioned recent travel abroad. We took independent advice from one of our medical advisers, who is a GP. The adviser said that the examination of Mr C was thorough and well recorded. The adviser also reviewed the Health Protection Scotland (a government body that monitors infectious and environmental hazards) website, and noted that at the time of Mr C's admittance there were no notifications of increased incidents of legionella (the bacteria that causes legionnaires' disease) in the location Mr C had visited. Therefore, no alert would have been sent to GPs and OOH services to increase vigilance for the condition. We, therefore, concluded that in light of the symptoms Mr C presented with at the time, he was provided with a reasonable diagnosis. Related reading View Decision Report 201403620 as a PDF (11.22 KB) Updated: March 13, 2018

Mrs C complained about the treatment she had received from her GP when she reported a lump in her breast. Mrs C attended the medical practice twice before being referred to the breast clinic where she was later diagnosed with breast cancer. Mrs C said that she should have been referred to the breast clinic sooner and was concerned about the GP's attitude. Mrs C also said that when she was referred, the referral should have been classed as urgent rather than routine. During our investigation we asked for independent advice from one of our GP advisers. Our adviser found that the GP had conducted a thorough examination of Mrs C and gave her appropriate advice regarding monitoring the lump. The adviser said that it was hard to judge the attitude of the GP through the medical notes, however, based on the record of Mrs C's condition at the time of the referral, and relevant National Institute for Health and Care Excellence (NICE) guidance, a routine referral was appropriate. We did not uphold Mrs C's complaints. Related reading View Decision Report 201404053 as a PDF (11.09 KB) Updated: March 13, 2018

Ms C had been living abroad but returned to Scotland, although she still had connections overseas. She was experiencing difficult personal circumstances and she was referred for psychiatric review. She received mental health care but complained that her treatment was inadequate and that the board failed to provide appropriate support. In particular, Ms C complained that after a referral to psychological services, it took too long for her to be seen; that although she was frequently suicidal, she was not admitted to hospital; and that there was a general failure to respond to her needs which contributed to her acute mental distress. She said as a consequence, this led to her child being taken into care. We took independent advice from one of our advisers who specialises in mental health. We found that Ms C's initial assessment and plan were appropriate and a psychiatric review took place on schedule. At times of crisis, there was a good response with reasonable follow-up arrangements being put in place. However, although it was not considered that Ms C required compulsory treatment, her management was complicated by her continuing treatment overseas and her travel between the two countries and, at various times, she declined psychiatric appointments. However, we found there was an extended delay before Ms C was seen by psychological services and so we upheld her complaint about this. The board had already apologised to Ms C for the delay, so we did not make a recommendation about this, but we did make two other recommendations.

Mr C complained to us about the care and treatment he had received from a dentist. He had attended the dentist for emergency treatment, who had extracted a badly broken tooth. Mr C was given an antibiotic and advised to return to the surgery for a more detailed examination to be carried out to assess what other dental treatment was required. Mr C returned to the dentist two days later and complained of pain and swelling. He said that he had been unable to eat. It was noted that a small swelling was present at the border of the lower jaw and there was pus discharging from the area where the tooth had been extracted. The dentist diagnosed a dry socket (an infected wound at the site of an extraction) and Mr C was prescribed another antibiotic and an antiseptic mouthwash. A dressing was not applied, as this was too uncomfortable for him. Mr C attended his GP on the following day, as he was still in some pain. He was then admitted to hospital later that day with a submandibular (inside the lower jaw) abscess, which was spreading into the tissue spaces. This was leading to extensive swelling, which was threatening his breathing. He was also suffering from a fever. Mr C was admitted in order that the hospital could drain the infected fluid from the abscess. There was nothing to indicate the presence of the abscess when Mr C had the tooth extracted on his first visit to the dentist. However, when Mr C attended again two days later, the dentist noted unusual symptoms, including a spreading infection, that did not fit the normal pattern. The development of an abscess of the type Mr C experienced following dental extraction is a very rare occurrence. After taking independent advice from our dental adviser, we found that that the dentist should have arranged an urgent referral to the local maxillofacial surgery department (the specialty concerned with the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) when Mr C had returned complainin

Ms C, who is an advocate, complained to us on behalf of her client (Mr A) that the board's response to his complaint was inadequate. Mr A had complained to the board about the conduct of a nurse. The board investigated Mr A's complaint and, in their written response, acknowledged that his experience was distressing and they apologised. The board explained to Mr A that their investigation had been conducted in line with their Management of Employee Conduct Policy, and that they were unable to share any actions arising from the investigation due to the confidentiality of employee matters. In a further letter to Mr A, the board confirmed that he would not be notified of the outcome of any internal board process. We concluded that it was reasonable in the circumstances that the board did not tell Mr A whether his complaint was or was not upheld. This was because the standard complaints procedure, under which Mr A submitted his complaint to the board, was superseded by the Management of Employee Conduct Policy due to the nature of the allegations made in Mr A's complaint. This was why the board decided they could not tell Mr A whether his complaint about the nurse had or had not been upheld, as to have done so would breach employee confidentiality. Although we thought that they could have explained the sequence of events more clearly, we considered that the board's response to Mr A's complaint provided relevant information that they were able to share with him in the circumstances, and we did not uphold the complaint. Related reading View Decision Report 201403778 as a PDF (11.28 KB) Updated: March 13, 2018

Mr A was admitted to the Royal Northern Infirmary for rehabilitation. He was suffering from lung cancer as well as recuperating from a stroke and a broken arm. He had a stoma bag (a surgically made pouch on the outside of the body) as a result of an earlier ileostomy (a surgical procedure on the small intestine). It was hoped that he would be able to recover some of his mobility whilst in hospital, but Mr A became unwell after a few days and was transferred to another hospital, where he later died as a result of a blocked bowel. His daughter (Ms C) complained to us about the care and treatment her father received at the Royal Northern Infirmary towards the end of his life. We took independent advice on Mr A's care from our nursing adviser. We found that as a result of Ms C's complaint, a significant event review was carried out which included several recommendations and actions to be taken. While we found that there were issues about the lack of end of life care and poor communication with Ms C and the rest of the family, we found that the pain assessment, nursing and stoma care Mr A received was reasonable. We, therefore, did not uphold Ms C's complaint about her father's care and treatment. Ms C also complained that the board failed to deal with her complaint according to their policies and procedures. As we found that there were considerable delays in responding, we upheld this complaint. Related reading View Decision Report 201305891 as a PDF (11.29 KB) Updated: March 13, 2018

Mrs C complained on behalf of her son (Mr A) that the board failed to provide him with an earlier diagnosis of Asperger's syndrome. She said that for many years he had been under the care of mental health services in both England and Scotland. In 2010 he saw a consultant psychiatrist in New Craigs Hospital, and continued to see him until early 2011. During this time, Mr A was not considered to show signs of mental illness, although he spent time in hospital for assessment. He was encouraged to become more active and independent, establish proper sleep hygiene and reduce his medication. Mr A requested a second opinion and was moved to the care of another consultant psychiatrist. No formal diagnosis was made and, again, Mr A was encouraged to develop independent structures in his life. While he appeared content with this, Mr A also mentioned the possibility of Asperger's. He was referred to a consultant neuropsychologist for review and was diagnosed with Asperger's later that year. Mrs C complained that it took too long to provide this diagnosis and that meanwhile her son had been treated incorrectly, which was very traumatic for him. She also complained that his medication was withdrawn too quickly and without proper support. We took independent advice from one of our medical advisers, who is a mental health specialist. Our investigation found that this kind of diagnosis was very difficult to make, particularly where the condition was mild and where the spectrum for the diagnosis overlapped with the general population. We noted that there was no specific treatment for such a diagnosis. We found that Mr A was treated reasonably and appropriately during his treatment, and that referrals were made in a timely way. Although an earlier diagnosis was not made, this did not have an adverse effect on his management and treatment. There was no evidence that Mr A's medication was unreasonably withdrawn or that he was not given appropriate support, and we did not u

Mrs C, an advocacy worker, complained on behalf of her client (Mr A). She said that Mr A's medical practice had not passed on information to him that the hospital had given to them about a change in his treatment plan. We sought independent advice on this from one of our medical advisers, who said that it was the hospital's responsibility to pass this on, unless the hospital or patient asked the practice for information. We also noted from Mr A's medical records that a particular letter from the hospital to the practice would have led the practice to believe that the hospital had made Mr A aware of the change. The practice had also written in Mr A's medical records that they were having difficulties dealing with his family, and that they were trying to resolve the situation but so far this had not been successful. In the meantime, a locum doctor would normally see Mr A and his family at the practice or at the hospital, although the GPs at the practice would see them if there was an emergency. Mrs C complained that the practice had not told the family that they considered there were difficulties and that, if the family had known earlier, they would have changed to another medical practice. The evidence in Mr A's medical records, however, showed that the practice were proactively and constructively trying to address and repair the relationship problem, and our adviser saw no reason why they should have passed on the information in the records. We also noted that, although it would have been open to the practice to warn the family that if the situation did not improve they would be removed from the list of patients, the practice did not do this but were appropriately trying to resolve matters, which was good practice. Mrs C also complained about a point in relation to the practice's handling of her complaint, but we could not establish the facts about this. We did not uphold any of Mrs C's complaints. Related reading View Decision Report 201304600 as a PDF (11.

Mr C's father (Mr A) suffered from Parkinson's disease and was admitted to a care home, where he lived for the last few years of his life. A few years after Mr A's death, Mr C applied to the board for a retrospective award of funding for Mr A's care. In response to Mr C's application, the multi-disciplinary team involved in Mr A's care retrospectively undertook an assessment of his needs, and the board declined Mr C's application. Mr C appealed this decision. The appeal was considered first by the clinical director, who recommended granting the application. However, the appeal was decided by the medical director, who personally reviewed Mr A's records and chose not to accept the clinical director's recommendation, instead declining Mr C's application. Mr C complained that the board's assessment of his application was unreasonable. He raised concerns that the multi-disciplinary team's assessment was unreasonable, that the board did not refer to relevant medical records, and that they did not take account of the fact that the decision not to transfer Mr A to a hospital was made on social, rather than medical, grounds. Mr C also said that the medical director gave no reasons for not accepting the clinical director's recommendation. After taking independent advice on this complaint from one of our medical advisers, we did not uphold Mr C's complaint. The medical adviser said that the multi-disciplinary team's retrospective assessment of Mr A's needs was reasonable in the circumstances. There was no evidence that the medical records that Mr C thought had been overlooked existed, so we found that the board had not overlooked evidence in this regard. We also found that the medical director had taken account of the argument that the decision not to transfer Mr A to a hospital was based on social, not medical, grounds but had nevertheless decided not to uphold the appeal. Finally, we found that the medical director's decision not to accept the clinical director's

Mrs C complained on behalf of her mother (Mrs A) that the care and treatment of her grandmother (Mrs B), had been unreasonable. Mrs C and Mrs A felt that it was not appropriate to put the Liverpool Care Pathway (LCP - an end of life care planning system) in place in view of the state of Mrs B's health, and said that the family were not told that it was in force. We investigated the complaint and took independent advice from an experienced registered nurse. The investigation showed that when Mrs B arrived in hospital with her son (Mr B) who was her next of kin, she had an ischaemic leg (where the blood supply to the leg is poor, causing the tissue to die). Her condition was so poor that amputation was discussed. Mrs B, who had capacity to make her own decisions, said that she did not wish an amputation even though she was aware that her decision would lead to her death. She said that she wanted to be kept comfortable and out of pain. Immediate steps were taken to do this and the LCP was initiated. We found that the board had acted in accordance with Mrs B's wishes, which was appropriate. Mr B, as next of kin, was involved in the discussions and, although Mrs A believed that matters should have been put on hold until she arrived and they could be discussed with her, this was not reasonable or appropriate in the circumstances. Related reading View Decision Report 201400125 as a PDF (11.29 KB) Updated: March 13, 2018

Ms C, who is an advice worker, complained on behalf of her client (Ms A) about her care and treatment. Ms A's GP referred her to Raigmore Hospital because she had been experiencing backache, painful urination and pain in her thighs, and she was admitted as an emergency. She was treated for a urinary tract infection and, as she also had back pain, arrangements were made for her to have an x-ray after she was discharged. Less than a month later, Ms A was seen in hospital again but when she was examined, no pulse could be found in either of her legs below her knee. She was started immediately on aspirin and a statin (a drug to reduce cholesterol in the blood) and an MR angiogram (magnetic resonance angiogram, a type of imaging) was carried out. Subsequently, Ms A was admitted to hospital where she underwent a femoral distal bypass (an operation to bypass the blocked part of an artery, carried out when a patient is threatened with amputation). This was re-done on two further occasions and the possibility of amputation of one of Ms A's legs was discussed. Ms C complained about the care and treatment Ms A received on her first admission to hospital and said that she had not been properly examined and appropriate tests had not been carried out. She also said that an inaccurate diagnosis was made and Ms A was discharged without appropriate follow-up arrangements. Ms A thought that if she had been kept in hospital for tests, the outcome might have been different. We took independent medical advice from a consultant surgeon as part of our investigation. We found that when Ms A was first admitted to hospital she showed no signs of peripheral vascular disease (a common condition, in which a build-up of fatty deposits in the arteries restricts blood supply to leg muscles) and she did not report any pain in her legs or discolouration in her feet. Accordingly, her treatment had been appropriate. Similarly, before she was sent home, she had been assessed as fit for disch

Ms C complained that the board failed to diagnose a large volume of fluid on her lungs when she was treated in hospital in Scotland. She said that when she was treated later in another country a large amount of fluid was drained from her lungs. We obtained independent advice on this case from one of our medical advisers. Our adviser explained that the records showed that the board did diagnose fluid on the lungs but that it was a small amount. Having looked at Ms C's chest x-rays our adviser said that this was the correct description and there was no evidence of the litres of bloody fluid that Ms C told us she had drained later. The adviser said the difference might have been due to progression of her condition over a period of time, which is not uncommon. Based on the advice received, we were satisfied that the board's care and treatment of Ms C was reasonable. Related reading View Decision Report 201400064 as a PDF (11.02 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment provided to her late husband (Mr C) following his diagnosis and treatment for cancer in 2010. Mr C was diagnosed with cancer of the oesophagus (gullet), and in November 2010 had chemotherapy (treatment with toxic drugs to kill or reduce cancer cells) and surgery. He attended regular follow-up appointments, firstly with the surgeon who treated him, and then with a nurse specialist from the surgeon's team. During these appointments Mr C reported that he was suffering nausea and 'gagging' when eating and that although he had a reduced appetite, he was forcing himself to eat to try to regain his health. In the late summer of 2012 he became increasingly unwell and his GP referred him back to the surgeon. The surgeon reviewed Mr C and ordered a computerised tomography scan (CT scan - which uses a computer to produce an image of the body), which took place in early October. As Mr A continued to deteriorate, he was admitted to Raigmore Hospital a few days later. When the scan was reviewed Mr C was diagnosed with a recurrence of his cancer, which was inoperable. He died later that month after being transferred to a hospice. During our investigation we took independent advice from a medical adviser who is a cancer specialist with experience of oesophageal cancers. Mrs C told us that she was concerned that no CT scan was carried out after surgery to confirm that all the cancer had been removed, and that regular CT scanning was not part of the follow-up programme. The adviser said that there is no scan or test that can definitely say that all cancer has been removed and, similarly, national guidance on the management of oesophageal cancers did not recommend regular CT scanning as no benefit has been found in this. The board's local follow-up protocol mirrored that guidance. The adviser also said that Mr C's ongoing symptoms were common in patients who have had oesophageal cancers, and can take a year or more to settle down. The advi

Mrs C complained that communication from staff and the care provided to her husband (Mr C) in Caithness General Hospital were inadequate. Mr C had been taken to A&E after collapsing, and although Mrs C thought he had symptoms of a stroke, he was discharged. The board said that this was because Mr C did not want to stay in hospital overnight. He suffered a significant stroke shortly afterwards. Mrs C also complained about the nursing care after her husband was admitted to hospital, saying that when visiting him the next day she found him in a side room, lying on a mattress on the floor. She was distressed that Mr C's dignity was compromised, as he was not wearing pyjama bottoms. After taking independent advice from one of our medical advisers and our nursing adviser, we upheld all Mrs C's complaints. We found that the junior doctor and the consultant physician involved did not give enough consideration to Mr C's diagnosis, particularly to the likelihood that he had suffered a minor stroke. Had they done so, it might have led them to have assessed the risk of this happening again and provided treatment if appropriate. However, our medical adviser pointed out that the outcome for Mr C might not have been different even had he been admitted to hospital at the start. Although both the nursing staff and the doctors had indicated in the clinical records that Mr C did not want to stay overnight, there was no clear written information to show that they had recommended that he should be admitted before having an urgent scan in the morning. As the doctors had not indicated what they thought was wrong with Mr C, he would not have been aware of any potential risks in being discharged. We considered that the communication with Mr and Mrs C fell below a reasonable standard. We also found that the nursing staff should have told Mrs C before she visited that they were nursing Mr C on a mattress on the floor, to reduce the likelihood of him falling out of bed. The board h

Mrs C has a complex medical history. She told us that because she had been experiencing extreme pain in her feet (to the extent that she could not walk) she needed to contact her medical practice on a number of occasions. She complained about a lack of support from the GPs at the practice. In particular, she said that, despite telling a GP that tramadol (a drug used to treat moderate to moderately severe pain) did not work for her, he continued to prescribe it. Another GP refused her a dosette box (a pill organiser that helps people on multiple medications to take these at the right time) and prescribed an anti-inflammatory gel, which she said the pain clinic she had previously attended had told her not to use. Mrs C said that both GPs left her without support and in great pain. We obtained independent advice from one of our medical advisers, who is a GP. After taking all the relevant information into account, including the complaints correspondence and Mrs C's medical records, we did not uphold Mrs C's complaints. We found that she was previously prescribed tramadol for chronic pain, and the new, acute pain she was experiencing had a different cause. Our adviser said that this pain might respond differently to tramadol, so the prescription was not unreasonable. Similarly, an anti-inflammatory gel could be used safely where anti-inflammatory tablets could not. Although Mrs C wanted a dosette box, we found that she did not qualify for this under the health board's criteria. Related reading View Decision Report 201304348 as a PDF (11.37 KB) Updated: March 13, 2018

Miss C and Mr C had twice taken their son (Master A) to a medical practice with hay fever symptoms. These persisted despite treatment with two different forms of antihistamines, and assessment by an ophthalmologist (a doctor who examines, diagnoses and treats diseases and injuries in and around the eye) that there was nothing apparently wrong with his eyes. Miss C and Mr C then took their son to a hospital out-of-hours service, where they were seen by the same GP they saw at their practice, as he was working as a locum. At this appointment, the doctor was concerned that Master A's symptoms were persisting despite treatment, and referred him to a paediatrician (a doctor dealing with the medical care of infants, children and young people). Miss C and Mr C complained that, at the appointment, the GP made an inappropriate remark about them seeing him at the hospital as well as at his surgery. They were also concerned that the GP had not done enough to diagnose their son's condition and make a more urgent referral. We sought independent advice from one of our medical advisers, who is an experienced GP. The adviser said that the GP had clearly been concerned about Master A's condition, and that his referral was appropriate, given Master A's symptoms. He also said that if the doctor had made the comments suggested, this was unprofessional and inappropriate. However, we did not find evidence to uphold this concern. We found that Master A's care and treatment was appropriate. Related reading View Decision Report 201304808 as a PDF (11.31 KB) Updated: March 13, 2018

Mr C complained that an out-of-hours (OOH) dentist had failed to provide him with appropriate treatment when extracting one of his teeth. He said that the dentist was unable to administer the anaesthetic competently, causing him unnecessary pain and discomfort. Mr C said that the extraction was also incompetent, causing the fracture of the tooth and damage to the adjacent tooth. Mr C raised his concerns with the board, and they investigated his treatment. They found that the records of his appointment were too brief for the treatment to be assessed. They asked the dentist in question to voluntarily remove himself from the OOH rota until he had received training on his record-keeping. The board apologised to Mr C for his dissatisfaction with the treatment he had received and arranged for him to be reviewed by a senior member of the OOH dental service. We took independent advice on the case from a dental adviser, who said that the standard of record-keeping was inadequate. Because of this, it was not possible to comment on Mr C's description of his treatment. The adviser said that the extraction was appropriate, given Mr C's symptoms and that in difficult extractions, damage could occur to surrounding teeth. There was no evidence from later treatment, however, that the extraction had caused damage. Our investigation found that although the record-keeping was inadequate, the board had taken action to address this before Mr C made his formal complaint. The lack of records did not allow us to comment on how Mr C's treatment was carried out, but we found that extraction was the appropriate treatment in the circumstances. Related reading View Decision Report 201303934 as a PDF (11.38 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment that her late mother (Mrs A) received in Belford Hospital. Mrs A had been admitted to hospital after collapsing. She was discharged home some fifteen days later with a package of care, and was later moved to respite care. Her condition, however, deteriorated and she died about a month after being discharged home. Mrs C said that hospital staff did not encourage Mrs A to eat or drink; did not tell her if Mrs A had a urine infection while she was in hospital; did not go through the discharge medication with her, and discharged Mrs A before she was ready. We took independent advice on this complaint from our nursing adviser, who said that hospital staff had taken reasonable steps to encourage Mrs A to eat and drink, and there was no evidence that she had a urine infection. We also found that, taking into account the detailed notes and the fact that Mrs A was medically fit for discharge, it had been appropriate to discharge her home with a package of care in place. We found that, on balance, the level of communication with Mrs C had been reasonable. Although there was no record that the discharge medication was explained to Mrs C, this would not always be recorded. In view of all of this, we did not uphold this aspect of Mrs C's complaint. Mrs C also complained that a community nurse's actions in respect of Mrs A's catheter (a thin tube used to drain and collect urine from the bladder) were unreasonable. Mrs A had a long-term catheter and this meant that there was a high risk of urinary infection. Good hygiene and prevention were, therefore, important. Mrs C said that the community nurses failed to change the catheter when it was reported to be badly blocked with sediment. We found that a catheter care plan had been completed, which was good practice, and a good record of the care required. Our nursing adviser also said that community nurses had provided good care in relation to the catheter and had followed the

Mrs C complained that, after her husband (Mr C) died in Raigmore Hospital, the board lost his property. Mr C was very ill and was on a high-dependency ward before he died. The board had said that although they understood this had been very distressing for Mrs C, they would not offer compensation for the loss of Mr C's watch and hearing aid. During our investigation we looked at correspondence provided by Mrs C and the board. We also looked at the board's personal property disclaimers, and we took advice from a nursing adviser with practical experience of dealing with cases like this on hospital wards. We found that, while the board's disclaimers clearly say that patients remain responsible for their personal property when in hospital, there are circumstances when the situation is less clear. In Mr C's case, there was uncertainty over whether some or all of his property had been lost, and the board could not provide an adequate explanation of why an inventory of his property was not taken when he died. We also found statements in the board's responses about this to be contradictory. We took the view that any items of property belonging to a deceased person, no matter the amount or nature, are their personal belongings, and should be catalogued and held until they can be passed safely to the person's next of kin. To do otherwise in such circumstances is disrespectful and, therefore, unreasonable. We upheld Mrs C's complaint and made a number of recommendations.

Ms C said that, when she had eyelid surgery as a day patient, Raigmore Hospital did not provide her or her GP with a discharge letter. There was confusion about where her stitches would be removed, and who would remove them, and it was only when Ms C asked her GP about this that the fact that there was no discharge letter was picked up. Ms C also needed further clinical care for her eye before the stitches could be removed, as it had not healed correctly. For this she at first went to another hospital, before deciding to go to the accident and emergency department of Raigmore Hospital, where she had successful corrective surgery. We took independent advice from one of our medical advisers, who examined all the evidence provided. After taking account of his advice alongside all the documentation from Ms C and the board, we upheld the complaint. The adviser said that Ms C had received appropriate treatment and advice at the hospitals, but there appeared to be a lack of clarity as to what and with whom follow-up arrangements were to be made. This was made worse when the hospital did not provide a discharge letter. We also found that the board had not fully responded to Ms C's complaint.

Miss C complained about the care and treatment she received at Raigmore Hospital. Miss C said that when she arrived at the accident and emergency department (A&E) with abdominal (stomach) pain, her symptoms were not taken seriously enough and staff dismissed her view that she had an ulcer, even when she told them she had been treated for one in the past. She also said that after she was transferred to a ward, staff inappropriately gave her a drug, which she said caused her ulcer to bleed or perforate (break open the stomach wall) and her pain to treble, resulting in her needing immediate surgery. Miss C said that, as a result of the board's failings, she had to have an operation that she did not need and now has an unnecessary scar. We obtained independent advice on this case from one of our medical advisers, a consultant surgeon specialising in gastrointestinal (digestive system) surgery. The adviser said that the consultant who initially examined Miss C in A&E mistakenly concluded that her bowel might have been obstructed. However, as the consultant was not sure of that diagnosis, he correctly sought advice from the surgical team and organised a prompt referral to the on-call senior surgical trainee for further assessment and observation. The senior surgical trainee, however, failed to recognise that Miss C's signs and symptoms suggested peritonitis (inflammation of the lining of the abdomen) and despite these signs, placed undue reliance on the x-ray appearance of possible constipation. He failed to seek advice from the consultant gastrointestinal surgeon and/or arrange further investigations. He prescribed a drug that was advised against, given Miss C's condition, and which may have exacerbated her pain. The adviser explained that Miss C's ulcer had almost certainly perforated when she initially went to A&E and so it was highly unlikely that the treatment she received from the board influenced her need for surgical intervention. However, the senior surg

Mrs C complained about the medical and nursing care and treatment provided to her late husband (Mr C) under the Liverpool Care Pathway (LCP - a care planning system for dying patients) when he was in Raigmore Hospital. Mr C had suffered a spontaneous intracranial haemorrhage (bleeding within the skull), the effects of which had possibly been magnified by warfarin (a type of medicine that is given to stop clots forming in the blood) that he had, appropriately, been taking. We took independent advice from one of our medical advisers who explained, after examining Mr C's medical records, that the prospects of any sort of meaningful recovery from such a severe brain injury were non-existent. The records showed that the doctor's conclusion had been that Mr C's condition had deteriorated, and the family had accepted this and that the implementation of the LCP would be appropriate. The adviser said that the principal aims of the LCP were to ensure that patients who were dying were not subjected to unnecessary investigations such as blood tests that would not alter the outcome, but that they would receive all care necessary to maintain their comfort and relieve any distress. In view of this, we found that it had been reasonable to place Mr C on the LCP and then to keep him on it. We also found that the LCP had been implemented appropriately. In addition, we found that the medical and nursing care records indicated that Mr C received good and entirely appropriate care while he was in hospital. There were also detailed records of discussions with Mrs C and her family. In view of all of this, we did not uphold Mrs C's complaint. Related reading View Decision Report 201300118 as a PDF (11.44 KB) Updated: March 13, 2018