SPSO Individual Decisions

Mrs C complained on behalf of her late husband (Mr A) about the orthopaedic care he received at the Royal Infirmary of Edinburgh and about the length of time it took for the board to respond to the complaint. Mrs C complained that the board unreasonably failed to offer Mr A the opportunity to obtain a second opinion within the NHS, that they unreasonably failed to arrange a scan and that they failed to respond to complaints in a timely manner. We took independent advice from an orthopaedic adviser. Although the board had said that Mr C had preferred to be seen privately for a second opinion, we did not identify sufficient evidence to indicate whether any discussion had taken place around the option of an NHS referral for a second opinion. We upheld this aspect of the complaint. We considered that the standard of Mr C's assessment by the orthopaedic staff at the hospital was of an entirely reasonable standard where an accurate diagnosis was reached without the need to perform a scan to confirm this. We did not uphold this aspect of the complaint. We found that the board had appropriately apologised for the time taken to respond to the complaint and have since accepted the delay was unreasonable. We also identified that they did not provide proactive updates regarding the delay or inform Mr C of his right to contact this office after the 20 working day response time was exceeded. We upheld this aspect of the complaint.

Mr C said that although he attended his medical practice concerning his back pain on a number of occasions over a period of two months, doctors failed to note his deteriorating condition. He said that he was given increasingly strong painkillers which failed to work and that although he was exhibiting 'red flag' symptoms, he was not referred for further investigation or imaging. Mr C said that it was not until he attended with his son that he was taken seriously and admitted to hospital as an emergency. He required an immediate operation. Mr C complained to the practice who said that while they noted that he was in significant pain, Mr C did not show any symptoms or clinical signs that would have triggered an immediate referral for surgery (there were no red flags). They believed that he had been treated appropriately and in accordance with guidance. We took independent advice from a GP and found that the practice had carried out appropriate examinations. Mr C's pain was regularly reviewed and his painkillers were increased accordingly. They repeatedly checked Mr C for red flag symptoms and an appropriate referral was made for him when his symptoms changed. We therefore did not uphold Mr C's complaint. Related reading View Decision Report 201602357 as a PDF (11.21 KB) Updated: March 13, 2018

Mr C said that until the age of 14 months, his son (child A) attended A&E at the Royal Hospital for Sick Children on several occasions. Mr C said that staff unreasonably failed to investigate child A's symptoms at these attendances and did not provide a correct diagnosis. Mr C believed that child A had had a lung infection since birth until the point at which he began to recover. We took independent advice from a medical adviser who specialises in paediatrics. We found that there was no indication that either a chest x-ray or the prescribing of antibiotics during child A's attendances were necessary and that the care and treatment given to child A was reasonable. The adviser noted that children under one often have symptoms of viral upper respiratory tract infection during nearly half of their first year, and that the diagnosis and treatment decisions at each attendance at hospital were reasonable. We therefore did not uphold Mr C's complaint. However, we found that there were shortcomings in relation to assessment of risk factors and made a recommendation to address this. We noted these did not have an effect on the outcome of the standard of care received.

Mrs C had a family history of DVT (deep venous thrombosis, a blood clot in a vein). During her pregnancy she suffered cramps and pain in her calves. She therefore underwent a scan of her right leg. This scan was clear but because she continued to complain of pain, Mrs C underwent a further scan. Mrs C said that the scan was of her left leg, although the board said it was of her right leg. After Mrs C gave birth, a further scan confirmed a pulmonary embolism (a clot in the blood vessel that transports blood to the heart and the lungs) and a DVT in her left leg. Mrs C complained to the board that despite her many complaints, they did not refer her to haematology (the specialism concerned with the study of blood and blood-related disorders) and that they failed to properly carry out the second scan. In response, the board said that Mrs C should have been reviewed by a senior doctor and probably referred back for a further scan. However, Mrs C still felt that the scan had been carried out incorrectly. We obtained independent haematology advice and found that although scans were a good diagnostic tool for DVT of the upper leg, they were not as reliable for the calf. We found that an examination had not shown evidence of a clot in Mrs C's lower leg. Furthermore, the scan about which Mrs C complained had been carried out in a reasonable way and Mrs C had been reviewed on three occasions during the five days after this scan. Despite the board's own conclusion, we found that the management and care received by Mrs C following her scan was reasonable. We therefore did not uphold Mrs C's complaint. Related reading View Decision Report 201601665 as a PDF (11.41 KB) Updated: March 13, 2018

Mr C complained about statements made by a GP at an adult protection case meeting held in relation to the care of his wife (Mrs A). Mrs A suffered from an illness that affected her ability to care for herself and was in hospital at the time of the meeting, which was organised to discuss the possibility of discharging her home. We took independent advice from a GP adviser. The adviser noted that Mrs A was a patient who did not have capacity to make decisions about her care, which meant that the GP was responsible for deciding on the appropriate medical treatment to safeguard or promote the physical or mental health of Mrs A. The adviser considered that the statements made by the GP were supported by the medical records and were, therefore, accurate. The adviser explained that an adult protection meeting is a forum in which care providers share information and that in this context, it was appropriate for the GP to share their concerns with the meeting. We did not uphold this complaint. Mr C also raised concerns about a letter the GP had sent to him following the meeting. In particular, Mr C felt that the letter inferred that he had mistreated Mrs A. We found that the letter from the GP sought to explain the GP's reasons for the statements made in the previous meeting. The adviser did not consider that the letter inferred that Mr C had mistreated Mrs A, and overall felt that the letter was appropriate. We therefore did not uphold this aspect of Mr C's complaint. Finally, Mr C expressed concern that the practice had not communicated with him reasonably in relation to arranging a meeting to discuss his complaint to them. We found that Mr C had spoken to the practice manager about a meeting, yet we noted that this did not take place. We considered that both Mr C and the practice manager had different expectations about who would take the next step to arrange a meeting. It was not possible for us to determine what was said and agreed in this conversation, and f

Mrs C complained that one of the board's clinicians failed to provide her late daughter (Ms A) with appropriate treatment. Ms A suffered from epilepsy and cerebral palsy. The clinician prescribed a particular medication for Ms A due to an increase in her seizures. Over the following months Ms A attended A&E at a number of points due to seizures and was seen by the board's A&E clinicians. Approximately 18 months later Ms A was taken to hospital where it was identified that she was suffering from end stage renal failure, and she later died. Mrs C said that she raised concerns about the prescription of the particular medication to Ms A, which she linked to Ms A's death. She said the board should have further monitored Ms A. The board considered that the care and treatment had been appropriate, and said that there was no link between the medication and Ms A's deterioration. After obtaining independent medical advice we did not uphold Mrs C's complaint concerning the board's clinician. We found that the board's clinician had followed national guidance regarding the medication and that the decision to prescribe this was reasonable in the circumstances. We found no link between this medication and Ms A's outcome. While we did not uphold the complaint Mrs C brought to our office, we found evidence that clinicians within the board had not acted on high blood pressure readings taken from Ms A on two A&E attendances. We made a number of recommendations to the board regarding this issue.

Mrs C complained about the care and treatment provided to her husband (Mr A) during hospital admissions to the Royal Infirmary of Edinburgh (RIE), Liberton Hospital, the Western General Hospital and Ellen's Glen House in the months prior to Mr A's death. Mrs C also complained about communication and the board's complaints handling. The board arranged a meeting for Mrs C with staff from the hospitals involved, and provided several written responses to her complaints, including an independent clinical review of some of the complaints. The board acknowledged a number of failings, including that significant decisions to complete a 'do not attempt cardiopulmonary resuscitation' (DNACPR) form and a 'verification of expected death' form were not discussed with her or Mr A, that the nursing documentation from Ellen's Glen House was completed to a poor standard, and that all of the medical records from Mr A's admission to RIE had been lost. However, Mrs C was not satisfied with the board's response. After taking independent medical and nursing advice, we upheld Mrs C's complaints. We found some additional failings in medical and nursing care, including that Mr A was discharged from RIE when he was not fit to be discharged, and that nursing staff did not contact the family or carry out a neurological assessment when Mr A suffered a minor head injury. In relation to Mr A's missing medical records, we were advised that the board's actions in relation to the management of files were relevant but not sufficient. We also found failings in the board's complaints handling. On several occasions the board agreed to take action, but did not follow through on this, and the independent clinical review provided to Mrs C included inaccurate findings, which were contradicted by the board's later responses. However, in making our decision we acknowledged that the board devoted considerable time and effort to addressing the numerous points Mrs C raised, including meeting with her and w

Mr C complained about the orthopaedic treatment he had received from the board. In particular, he complained that he had undergone a number of operations on his shoulder and had contracted an infection. We took independent advice from a consultant orthopaedic surgeon. The advice we received was that the orthopaedic treatment Mr C received was reasonable and that, while his care pathway had resulted in a poor outcome for him, there was nothing the board could have done differently to achieve a better outcome for him. The advice we also received was that there was no way of knowing when the persistent infection Mr C contracted had developed. In the circumstances we did not uphold the complaint. Related reading View Decision Report 201601259 as a PDF (10.91 KB) Updated: March 13, 2018

Mr C complained to us that the medical practice had failed to provide appropriate care and treatment to his son (Mr A). He said that a GP had prescribed oxycodone (opiate medication) over the phone to Mr A on the morning that he died from a medication overdose. Mr C was also concerned that there had been an entry in Mr A's clinical records from his previous GP surgery noting that Mr A was not to be prescribed opiates. The practice said that practitioners are aware of the need to balance the potential benefits of a drug against any possible harm. The practice were aware of the previous GP surgery concerns that Mr A used illicit drugs and that care should be taken about the strength of any opiates prescribed. Mr A had recently undergone significant surgery and he reported that his pain control was ineffective. It was also noted that Mr A was attending orthopaedics and the pain clinic. We took independent medical advice from a GP who noted that Mr A had been referred to orthopaedics and the pain clinic and that he was regularly reviewed in either face-to-face consultations or phone contact. When required, his pain relief was increased and this was considered reasonable care. The adviser had no concerns about the actions of the GP who prescribed the oxycodone, as they had taken note of the previous GP practice's concerns about drug misuse and made a reasonable clinical judgement based on the recorded evidence available. We did not uphold the complaint. While we did not uphold the complaint, we noted that the practice and the previous GP practice operated different electronic record recording systems and that there was a failure of the first practice to transfer all relevant information over when Mr A joined the new practice. We made a suggestion to both practices which may have allowed more clarity, although it may not have altered the GP's decision to prescribe the oxycodone. Related reading View Decision Report 201606304 as a PDF (11.51 KB) Updated: March 13,

Mr C complained that his wife (Mrs A) was inappropriately diagnosed as having suffered a miscarriage and that she was not provided with appropriate and timely treatment. Mrs A was in the early stages of pregnancy when she experienced bleeding. During the night, Mr C and Mrs A attended the gynaecology out-of-hours service at the Royal Infirmary of Edinburgh. After waiting, they were seen by a doctor, who examined Mrs A. A procedure was offered and it was noted that this would not harm the baby should the pregnancy still be viable. Miscarriage was recorded as being very likely and the couple were sent away to return the following morning for a scan. The scan confirmed that the pregnancy was ongoing and that the bleeding had been caused by a haematoma (a collection of blood outside the blood vessels). Mr C felt that the lack of scanning facilities at night time meant they had an unnecessary wait to find this out. Mr C also said that the doctor they had seen told them that Mrs A had miscarried and that he was concerned about the procedure that was offered. After taking independent advice from a consultant gynaecologist, we upheld Mr C's complaints. The board previously acknowledged that there had been an inappropriate diagnosis of miscarriage and had apologised for this. The advice we received was that the doctor had mistaken blood clots that were present during the examination for tissue and that it was inappropriate to make a firm statement about miscarriage without a scan taking place. We noted, however, that the availability of scanning facilities at the hospital was in line with the relevant guidance. We found that there were issues with record-keeping and that the procedure offered by the doctor was not clinically necessary.

Mrs C complained on behalf of her brother (Mr A), that staff at the Royal Infirmary of Edinburgh failed to ensure he was safely transferred to a trolley. In addition, Mrs C raised concern that the incident was not properly investigated, that Mr A was not reviewed following the incident, and that the complaints handling by the board was poor. We took independent medical advice. We found that Mr A was not transferred to the trolley in accordance with the moving and handling plan that had been put in place following his mobility assessment. Furthermore, when the incident was reported to a nurse later that evening, we were critical that the nurse did not take appropriate steps to formally record the incident on the hospital's system for reporting adverse events. We considered this would likely have resulted in the incident being investigated in a timely manner, and that Mr A would have been reviewed by a doctor sooner. We were also critical of the board's handling of the complaint. Specifically, that they had inaccurately said that a nurse had been present at the time of the trolley transfer for which they apologised. We also found that the board had not acknowledged that the porter's recollection of the transfer was contrary to the manual handling plan documented in Mr A's clinical records. We therefore upheld the complaint.

Mr C had been taking warfarin (a blood-thinning medication). Following a review at an out-patient cardiology clinic, his International Normalised Ratio (INR, a blood test that checks how long it takes for blood to clot) target range was changed to between 2 and 3. Previously, it had been 2.5 to 3.5. Mr C's GP practice did not update the change on their systems and Mr C only became aware of the change 18 months later. Mr C complained to the practice and was dissatisfied with their handling of his complaint. Whilst the practice accepted that they failed to update Mr C's INR target, the advice we received was that this failing was not significant. The adviser said the change in Mr C's INR target was not clearly communicated by the cardiologist to the practice as it did not contain a sufficient alert to notify the change in his INR target level. Furthermore, the practice could not be expected to be aware of national changes. We accepted this advice. The adviser also commented that as Mr C's INR target was to be reduced rather than increased, there was no significant clinical risk resulting from the failure of the practice to update the target. Taking account of this advice, we did not uphold this aspect of the complaint. We accepted that the practice had provided Mr C with an apology and an explanation for the error but they had delayed in doing so. While we accepted the delay was due to difficulty in obtaining information that they needed from the cardiology department, we considered the practice could have made Mr C aware of this. We also found that the practice's response to Mr C's complaint did not contain details for this office. We upheld this aspect of the complaints.

Mr C received treatment from the board over a two-year period for urinary incontinence and erectile dysfunction, which he developed following surgery at the Western General Hospital for prostate cancer. After communicating with the board about his dissatisfaction with his treatment, Mr C obtained penile implant surgery privately abroad and asked the board to reimburse him for the cost of his treatment. The board refused. Mr C complained that the board acted unreasonably when assessing his request for reimbursement, because they failed to take into account that, despite being aware of his concerns about the delay and his intention to seek treatment privately, they did not properly inform him of the alternative options that were available within the NHS. We obtained independent advice from a consultant urologist. The adviser said that where a patient raises concerns about delays in treatment and their intention to look for treatment elsewhere, the board should advise the patient of the options to obtain treatment elsewhere in the NHS or the European Union. It was clear that Mr C made the board aware of his concerns about the delays in investigation and treatment of his conditions. However, Mr C advised the board that he had already agreed private treatment with a urologist outwith the UK, that he would be pursuing that course of action and that he did not expect a response from the board on this matter. The adviser noted that the board said Mr C should have had a full assessment of his urinary incontinence and agreed treatment plan (which had yet to be completed), prior to undertaking any surgery for erectile dysfunction. The adviser said this was entirely reasonable. While we acknowledged the delays in Mr C's treatment, we considered that the board's assessment of Mr C's request for reimbursement was reasonable, as the equivalent treatment in the UK or EU at that time would have been to continue to treat his urinary incontinence rather than perform implant sur

Mr C complained about the board's decision not to offer him surgical treatment for his condition. The board said that the decision to proceed with surgery was subject to the Adult Exceptional Aesthetic Referral Protocol, which details the limited criteria in which surgery can be provided for a range of conditions. The board said that because Mr C did not meet criteria within this protocol, he did not qualify for surgery for his condition. We found that Mr C was assessed by a plastic surgery registrar and a clinical psychologist before a multi-disciplinary team made a decision on whether Mr C met the criteria. We took independent advice from a consultant plastic and reconstructive surgeon and a consultant psychiatrist. Based on the advice we received, we concluded that the assessments carried out prior to the decision-making were reasonable. Although we found that the board had not undertaken the assessments in the order specified within the protocol, the advisers did not consider that this would have prejudiced the subsequent decision of the multi-disciplinary team. We concluded that the board's decision not to offer Mr C surgery was reasonable, and for this reason we did not uphold this complaint. Related reading View Decision Report 201602038 as a PDF (11.15 KB) Updated: March 13, 2018

Mr C complained that the board failed to provide him with appropriate treatment in relation to removal of a fatty lump on his neck/shoulder area and provided him with misleading information regarding waiting times. He also said the board failed to adequately respond to his formal complaints about these matters. Mr C felt that the removal of the lump could have been carried out under local anaesthetic at a nearby hospital, instead of under general anaesthetic at a hospital further away as planned by the board. He also said that the board failed to consider his request to change his attendance time from 08:00 to 11:00 to accommodate his travel arrangements. We took independent medical advice and found that the expertise required for the procedure was only available at the further away hospital. The adviser also said that the decision to carry out the procedure under general anaesthetic was reasonable, as it reduced the risk of complications. We did not uphold this aspect of the complaint. However, we did make a recommendation in relation to the board's handling of Mr C's request for a different attendance time. Mr C said that the board unreasonably changed his treatment time guarantee (TTG) date, said that he was unavailable for a two-week period, and unreasonably offered him a re-scheduled appointment at very short notice. We found that it was not reasonable for the board to offer a re-scheduled operation at short notice, at the weekend, at some distance from a patient's home, without taking the lack of public transport into account or offering to provide transport for Mr C. We upheld this aspect of the complaint. Mr C was also concerned that the phone line he was required to use to discuss his appointment was unanswered. However, we found that the board had taken reasonable action to address this issue. In relation to the handling of Mr C's complaint, we found that the board took six and a half months to provide him with a response, instead of doing so wit

Following a fall, Mrs C attended the A&E department at St John's Hospital with a painful and swollen left arm. X-rays were taken and Mrs C was diagnosed with a dislocated left elbow. Mrs C's elbow was moved back into position (reduced), she was given a plaster cast and further x-rays were taken. An emergency medicine consultant reviewed the x-rays and did not identify any fractures. Mrs C was discharged the same day. Mrs C's records and x-rays were later reviewed by an orthopaedic and trauma surgeon at the hospital's virtual trauma triage clinic. The surgeon agreed there were no evident fractures. Mrs C was issued with a follow-up appointment to attend the fracture clinic. In the interim, Mrs C returned to A&E as her cast had become loose and she was in continual pain. An x-ray was taken which showed the elbow had dislocated again and she had a displaced radial head fracture (a fracture of the bone at the top of the forearm). Mrs C was referred the same day to the Royal Infirmary of Edinburgh for surgery. Mrs C complained that there was an avoidable delay in staff diagnosing she had suffered a fractured arm. We took independent advice from advisers in emergency medicine and orthopaedics. We found that Mrs C's injury was managed correctly when she first attended A&E and she was appropriately referred to the virtual clinic for review. We also found that the x-rays taken before Mrs C's elbow was reduced showed a fracture which was missed on review. We noted that the x-rays taken after Mrs C's elbow was reduced were not of sufficient quality to rely upon for a diagnosis and that further x-rays should have been obtained. While the problems Mrs C experienced in terms of her outcome were due to the severity of her injury and not her treatment, if further x-rays had been ordered, it is likely the severity of the injury could have been diagnosed and the injury treated sooner. We therefore upheld Mrs C's complaint. We accepted the advice we received that the boar

Miss C complained about the care and treatment she received at St John's Hospital. She had been diagnosed with skin cancer and had an operation in the hospital to remove the cancer. She said that, after the operation, the anaesthetist refused to give her further pain relief without having seen her when she asked for this. We took independent advice from an anaesthetist. We found that Miss C had been seen by the anaesthetist when she requested additional pain relief and that their decision that she had already received appropriate and adequate pain relief was reasonable. We did not uphold this complaint. Miss C also complained that there was an unreasonable delay by nurses in providing her with pain relief she had requested later that day. We found that there had been an unreasonable delay in providing the pain relief and upheld the complaint. However, we were satisfied that the board had apologised for this and had taken action to prevent such delays occurring in the future. Miss C also complained that the surgeons had not discussed her concerns with her at an appointment, as the board's response to her complaint said they would. We found that the board had written to Miss C to say that they had shared her concerns with the surgeons and they would discuss the matter at her next appointment. However, Miss C's concerns were not discussed at the appointment, as they had not been shared with the surgeons. We also upheld this aspect of Miss C's complaint. However, we were satisfied that the board had apologised to Miss C for this and had offered to arrange a further meeting. Finally, Miss C complained about the board's handling of her complaint. We also upheld this complaint, as we found that there had been an unreasonable delay in responding, although the board had apologised for this and had provided us with evidence that they had taken action to prevent such delays in the future. Related reading View Decision Report 201600725 as a PDF (11.35 KB) Updated: Ma

Mr C complained about the treatment he received for his wrist injury at the Royal Infirmary of Edinburgh, including that there was a delay in referring him for a surgical opinion. During our investigation we took independent advice from a specialist in trauma and orthopaedics. The adviser felt there was evidence to favour both surgery and non-surgical treatment for Mr C's injury. They considered that Mr C was reviewed in a timely manner and the decisions taken at those reviews were in keeping with good practice. The adviser did not consider there was a delay in referring Mr C for a surgical opinion. We therefore did not uphold Mr C's complaint. Related reading View Decision Report 201606017 as a PDF (10.89 KB) Updated: March 13, 2018

Following a private hernia operation, Mr C was referred to the Royal Infirmary of Edinburgh for pain management. Mr C had various appointments with a consultant over a nine-month period, and required further surgery. Mr C later complained that the consultant had failed to complete appropriate clinical records which fully explained why he needed further treatment. Mr C told us the lack of records had caused him a problem when he went to get insurance when travelling abroad for work. We took independent clinical advice. We found Mr C's medical records were of the standard, and in the detail, expected of NHS clinical records. We were satisfied the reason Mr C required surgery was appropriately documented. We did not uphold Mr C's complaint. Related reading View Decision Report 201600680 as a PDF (10.95 KB) Updated: March 13, 2018

Mr C complained about the prison health centre's decision not to prescribe him sleeping medication that he had previously been prescribed by his community GP. The information available confirmed that the prison health centre had checked the medications prescribed to Mr C by his community GP. This confirmed that he had been given a two-week supply of the sleeping medication to take as needed. We took independent clinical advice. The adviser noted that the sleeping medication should only be prescribed for short periods and long-term use was to be avoided. They also noted that Mr C had been prescribed an appropriate detox whilst in prison and that because of this, the decision to not prescribe the sleeping medication was reasonable. Our adviser also confirmed that Mr C was being prescribed appropriate medications for the symptoms he had reported. We did not uphold Mr C's complaint. Related reading View Decision Report 201603113 as a PDF (10.97 KB) Updated: March 13, 2018

Miss C complained about the care received by her brother (Mr A) at the Royal Infirmary of Edinburgh following a suspected drug overdose. During his admission, Mr A was drowsy and had slurred speech. Mr A was moved to the acute medical unit and received treatment for a chest infection. He also had a scan to check for a blood clot on the lung. No blood clot was found and Mr A was to be discharged. On the morning of his discharge, he experienced a cardiac arrest and died. We took independent nursing and medical advice. The nursing adviser was satisfied that nursing staff had noted Mr A's condition but raised concerns that Mr A's oxygen saturation (the relative measure of the amount of oxygen in the blood) was abnormally low during the admission. Whilst nursing staff had noted this, they had not informed medical staff. The medical adviser considered that Mr A had received appropriate care and treatment for the first two days of his admission, but that Mr A's low oxygen saturation should have resulted in a medical review on the evening before discharge. They noted that a possible explanation for the omission of a review was that staff considered his oxygen levels to be low as a result of drug use, rather than his chest infection. The medical adviser noted that staff could have considered administering a medication which temporarily reverses the sedative effects of drugs to help them determine the reason for low oxygen levels. The adviser could not say whether better care at this time would have prevented Mr A's death. However, they considered that the treatment provided to Mr A was unreasonable. We upheld this aspect of Miss C's complaint. Miss C also complained that staff had failed to respond reasonably to concerns raised by Mr A's family. The medical adviser noted that Miss C had spoken to a doctor on the evening before the planned discharge. The adviser was critical that the doctor had informed Miss C that Mr A was well enough for discharge, when the ev

Ms C was referred to the sleep clinic at the Royal Infirmary of Edinburgh. She attended on a number of occasions over the following four years but her symptoms did not improve. She said that a consultant physician contacted her clinical psychologist but provided inaccurate and misleading information which detrimentally affected her future treatment. Ms C also complained about the way the board responded to her complaint. We took independent advice from a consultant respiratory and general physician. We found that while Ms C's consultant physician provided her professional opinion to other health professionals, she did not provide incorrect or misleading information. We therefore did not uphold this aspect of Ms C's complaint. We noted, however, that the information could have been written more sympathetically and that the board had already spoken to the consultant physician about this. We also found that after Ms C complained, the board took too long to reply to her and their letter provided little explanation. We therefore upheld this aspect of Ms C's complaint.

Mr C complained that he had not been provided with appropriate clinical treatment in relation to his diabetic neuropathy (nerve damage) and a slipped disc in his back. However, during the course of our investigation, Mr C withdrew his complaint. Related reading View Decision Report 201604495 as a PDF (10.69 KB) Updated: March 13, 2018

Ms C, an advocacy and support worker, complained on behalf of Ms A about the care and treatment given to Ms A after she was diagnosed with breast cancer. Ms A was treated with surgery followed by chemotherapy and radiotherapy at the Western General Hospital, from which she appeared to be recovering well. However, part way through her course of chemotherapy, Ms A was not given a review appointment to establish how she was progressing, as per a local protocol. Ms A maintained that she had been 'lost to the system' and received inadequate care. Ms C also said that the board failed to respond reasonably to Ms A's complaint. We took independent advice from a consultant oncologist. We found that Mrs A's treatment had been given in terms of national guidelines and had been reasonable and appropriate. While it had been intended to review her part way through her chemotherapy, Ms A was seen a few weeks later and her treatment continued. We did not uphold this aspect of Ms C's complaint. However, we noted that the board failed to deal with Ms A's concerns about her treatment in a timely manner and we therefore upheld this aspect of Ms C's complaint.

Mrs C was referred to St John's Hospital for her first maternity appointment. Mrs C complained that during her pregnancy, community midwives failed to provide her with a reasonable level of care and that she was not given antenatal blood screening as she said she required. Mrs C's baby was stillborn. We took independent advice from a specialist in haemostatis and thrombosis and from a midwife. We found that as Mrs C had a family history of deep veinous thrombosis, she was correctly referred to a specialist clinic for tests. These tests showed no evidence of personal risk for Mrs C and as such no further blood testing was required. However, it was agreed to offer her blood thinning medication after the baby's birth. While Mrs C believed that if further blood screening tests had been carried out she may not have lost her baby, we found no evidence of this. We found that the midwifery care and treatment given to Mrs C had been of a reasonable standard. We therefore did not uphold these aspects of Mrs C's complaint. Mrs C said that her placenta was lost when it was sent for testing. We found that when the placenta was sent to the laboratory, it was not accompanied by the appropriate paperwork and for this reason it was destroyed. We upheld this element of Mrs C's complaint. The board apologised for this and put new procedures in place to prevent the same happening again. Related reading View Decision Report 201603943 as a PDF (11.29 KB) Updated: March 13, 2018