SPSO Individual Decisions

Mrs C complained on behalf of her client (Mrs A) about the board's care and treatment of Mrs A's finger injury. Mrs A attended the minor injuries and illnesses unit with an injury to her finger, but she was discharged as the nurse considered it a superficial wound. However, after some weeks, Mrs A's GP referred her to the orthopaedic unit, as she still could not bend her finger. After further investigation she was diagnosed with an incomplete tear of the flexor tendon (the tendon that connects the arm muscles to the bones in the finger). Mrs A was referred for physiotherapy, but this did not help, and the orthopaedic surgeon offered Mrs A surgery to try and improve the movement in her finger. Mrs A agreed, but the surgery was delayed four months while waiting on an echocardiogram (a scan of the heart), which Mrs A had been referred to by the general medical clinic (for an unrelated issue). Mrs C complained about the care and treatment and the delay in Mrs A's surgery, as well as about the board's response to her complaint to them. After taking advice from an orthopaedic surgeon and a general medical consultant, we upheld Mrs C's complaints. We found that the first assessment of the wound at the minor injuries and illnesses unit was inadequate, and may have missed an opportunity to diagnose Mrs A's injury earlier, although the later care and treatment by orthopaedics was reasonable. We also found that the delay in surgery was unreasonable, as the adviser said this scan should have been completed within weeks, rather than months (in this case it was delayed because the referral was missed). We also found that the board's response to Mrs C's complaint was inadequate, as they did not acknowledge failings which they were aware of at the time, and they did not explain the delay in Mrs A's surgery.

Ms C, who is an advice worker, complained that the care and treatment provided by the prison health centre to her client (Mr A) for pain in his arm was unreasonable. In particular, Mr A had been unhappy because a nurse had questioned why he was being prescribed a certain type of pain killer. Mr A felt the nurse did not have the authority to do that. We reviewed Mr A's medical records which confirmed the nurse had concerns about Mr A receiving the pain killer whilst also being prescribed methadone. His medical record also confirmed the doctor was unsure what kind of pain Mr A was feeling and felt further investigation was needed. The doctor prescribed the pain killer for a two week period and also referred Mr A's case to neurology. We took independent medical advice from a GP adviser who confirmed that there was no issue with a clinician - either a doctor or nurse - clarifying why a patient was being prescribed certain medication. Our adviser also confirmed that Mr A's case was reviewed regularly by the doctor and proper steps were taken to explore the type of pain he was experiencing. In addition, our adviser said Mr A was prescribed an appropriate alternative pain killer. Because of this, we did not uphold the complaint. Ms C also complained that the board's handling of Mr A's complaint was inappropriate. In particular, Mr A said that after he submitted his complaint form, he was called to a meeting with the doctor. He said that when he arrived in the doctor's room, the nurse who he had raised concerns about was there and she was holding his complaint form. Mr A said he understood his form would go to the board's complaints and feedback team. We reviewed the relevant Scottish Government guidance, Can I help you?, which outlines how health service providers should deal with complaints. In particular, it says that if a complaint is reasonably straight forward and non-complex it may be managed without the requirement for a detailed investigation. In Mr A

In January 2013, Mr A attended the medical practice as he had ongoing chest pain and a cough. A chest x-ray and blood tests were arranged and the results came back normal. However, as his pain was continuing he was given painkillers. In March 2013, Mr A attended the practice again because his symptoms were continuing and he was referred to hospital for a specialist opinion. Mr A was seen in hospital in May 2013 although, in the meantime, the practice prescribed him increasing painkillers and his tests were repeated but again with no result. After a difficult diagnosis pathway, Mr A was advised over the phone by his GP in September 2013 that he had cancer, and he died in May 2014. Mr C complained to the practice on behalf of Mr A's widow (Mrs A) that it had taken the practice too long to refer Mr A for appropriate tests and opinion and that there was a lack of urgency to provide him with any meaningful treatment. He further complained that a GP within the practice told Mr A of his diagnosis over the phone, which he said was inappropriate and showed a lack of compassion. We took independent advice from one of our GP advisers and we found that while Mr A was treated reasonably and appropriately and that efforts were made to treat his pain, he was not referred to hospital in line with national guidelines for suspected cancer. His referral should have been urgent rather than routine. Because of this, there was a delay in him being seen in hospital and a delay in his treatment being started. While it was confirmed that Mr A had been told of his diagnosis over the phone, this was for the best of intentions in order to explain his increasingly strong painkillers. Nevertheless, this should not have happened and arrangements should have been made for a house call or for Mr A to attend the practice. In light of the advice we received, we upheld Mr C's complaint.

Mr C complained to the board that a decision had been taken inappropriately to reduce the number of gluten-free foods available on prescription for his mother (Mrs A) who suffers from a coeliac condition. Previously Mrs A was prescribed 18 units and this had been reduced to 14 units. The board maintained that Mrs A had been appropriately assessed in accordance with national guidelines and in view of her medical condition. We took independent advice from one of our medical advisers, and found that the dietitian had carried out a thorough assessment and that the prescribing of 14 units was appropriate. Related reading View Decision Report 201403471 as a PDF (10.86 KB) Updated: March 13, 2018

Miss A is profoundly deaf and uses British Sign Language (BSL). Ms C, an advocate, complained on her behalf that the board did not arrange a BSL interpreter for her. We found that Miss A was left in Ninewells Hospital without an interpreter for nearly three days, which was unacceptable. The board had initially tried to get an interpreter, but it was then left to Miss A's family to do so. When they could not, the board arranged for an interpreter to attend. There were also problems in ensuring that interpreters were there at the same time as doctors. The board agreed it is their responsibility, not that of the patient's family, to try to secure an interpreter. In responding to our enquiries, they told us that staff had been made aware of the complaint and knew the process for booking interpreter services. They had added phone numbers for five interpreters to staff guidance. Ward staff had been reminded to escalate to senior staff if they experienced difficulties securing an interpreter out-of-hours. The board also apologised for not providing an interpreter to support Miss A. After Ms C complained to us, they entered into a legal agreement with the Equality and Human Rights Commission and committed to trying to ensure that every patient with additional communication requirements receives the same level of services as those without such requirements. In view of this, although we upheld the complaint, we did not make any recommendations. Ms C also complained that wards did not display a poster advertising BSL interpreter services. The board told us that all wards are required to display this, but could not confirm that it was displayed in the wards Miss A was in when in hospital. Because of this, on balance we upheld this complaint. However, we did not make recommendations, as the board now carry out a weekly audit of posters, ensuring that they are displayed in every clinical area. Related reading View Decision Report 201305243 as a PDF (11.54 KB) Update

Mr A suffered from advanced cancer, and was admitted to Ninewells Hospital for treatment to control his pain. While there, he fell and a fractured hip was suspected, although it was established this was not the case. He was transferred back to a palliative care centre (a place providing care to prevent or relieve suffering only), but was semi-conscious on arrival, and died shortly afterwards. Mr A's daughter (Ms C) complained that her father had not received adequate care. She said Mr A's mobility problems had not been properly addressed, which had contributed to his fall. His pain had not been properly controlled and staff had failed to communicate properly with the family. The family felt Mr A was not properly assessed after his fall and should not have been transferred. The board accepted that there were failings in Mr A's care, and apologised for these, explaining that changes had been made to procedures as a consequence. They said the decision to transfer Mr A was appropriate, although he had deteriorated during the transfer. They also said that he was properly assessed after his fall and his pain had been adequately managed. The board told the family they had an action plan to improve care, and this would be shared with them. We took advice from a palliative care adviser, a nursing adviser and a geriatric medicine adviser. The palliative care adviser said Mr A had suffered a reaction to his medication. His dosage had been reduced, but it had later been increased again. She was also critical that Mr A was not medically reviewed before transfer. Our nursing adviser criticised the standard of nursing care, but noted that the board had taken action to remedy the majority of the failings. The geriatric medicine adviser agreed that the decision to transfer Mr A was appropriate, but was critical of the failure to review him immediately prior to transfer, or to discuss the decision with the family. We found the decision to transfer Mr A was reasonable, bu

Ms C, an advocate, told us that her client (Mr A) was referred to the neurology department at Ninewells Hospital because of continuing back pain. In November 2012, a neurologist (a specialist in diseases of the nerves and the nervous system) decided that further investigations, including an magnetic resonance imaging scan (MRI scan - used to diagnose health conditions that affect organs, tissue and bone), would not be beneficial as it was extremely unlikely that further back surgery would be considered. The following month, Mr A was admitted to hospital for a different problem but his back and leg pain were noted. An anaesthetist suggested that the neurosurgical team review him but they declined, saying he had been seen three weeks previously. Mr A continued to suffer back pain and in March 2013 his GP wrote to the neurosurgical team requesting an MRI scan, who responded saying that this would not be helpful. In June 2013, because of the level of his pain, Mr A paid for a private MRI scan which was forwarded to the neurosurgical team. Several weeks later, an out-of-hours (OOH) doctor saw Mr A, again because of his pain, and phoned the hospital about admitting him. Mr A was not, however, admitted and said that a member of the neurosurgical team refused to see him again. However, after reviewing the MRI scan the neurosurgical team did then arrange decompression surgery (used to treat some conditions affecting the lower back that have not responded to other treatments), which was carried out at the end of July. Ms C complained that Mr A had to organise and pay for the MRI scan himself. He was concerned that his assessment in November 2012 was inadequate, and that a scan should have been arranged then. He felt that his pain and distress was not taken seriously and that the neurosurgical team should have acted on the reports from the anaesthetist and the OOH doctor. He was also concerned that his records said that he was to be treated for sciatica, which he bel

Mr C had a shunt (a thin tube that drains fluid from the brain to another part of the body) in place in order to relieve his severe headaches. He complained to us that when he was having this replaced at Ninewells Hospital, he contracted an infection. Mr C was readmitted to the hospital several days after the operation, with a severe abdominal infection. It was thought that the infection came from the new shunt and this was subsequently removed. Mr C said that he had been unable to return to work after contracting the infection. After obtaining independent medical advice from a consultant neurosurgeon, we found that it had been reasonable to carry out the operation. It was difficult to be sure about the origin and type of infection that Mr C experienced, but our adviser thought it likely that bacteria from the skin had transferred to the shunt during the surgery. There is always a risk of infection in these types of operations, and we found that this risk was included in the consent form Mr C signed before the operation. The surgical team had prepared Mr C's skin correctly before the operation and had given him an antibiotic to try to prevent infection, in line with the relevant guidelines. As we found no evidence of any failings by the surgical team and there was nothing they could have done differently to prevent the infection, we did not uphold the complaint. Related reading View Decision Report 201402018 as a PDF (11.28 KB) Updated: March 13, 2018

Mr C complained that staff at Perth Royal Infirmary refused him permission to take his elderly mother (Mrs A) out of hospital on a specific occasion, and about the board's handling of his complaint. We looked at the board's file on Mr C's complaint and at Mrs A's medical records, and took independent advice from one of our medical advisers. Where there are differing accounts of what was said or what took place during a particular event or incident, it can be difficult to prove what actually happened. Although this does not mean we believe one account over another, given the differing accounts of what happened on the day Mr C complained about, we were unable to resolve exactly what was said and so we based our findings on the written records. We found that the medical and nursing records were consistent and provided sufficient evidence to allow us to conclude that it was reasonable in the circumstances for staff to advise against Mrs A leaving hospital that day, taking into account her state of health, their concerns and their responsibility to care for Mrs A. The board's file on Mr C's complaint showed that they conducted a reasonable investigation by contacting relevant staff and referring to Mrs A's medical records. Their letter to Mr C accurately reflected Mrs A's medical records and, although it could have contained additional information that Mr C might have found helpful, it was reasonable in the circumstances. There was a delay in the board dealing with Mr C's complaint, but we found that they had accepted this, explained why, and apologised to Mr C. Related reading View Decision Report 201303648 as a PDF (11.38 KB) Updated: March 13, 2018

Mr C's father (Mr A) suffered from lung cancer, and was being treated with palliative erlotnib therapy (a drug used to treat some types of cancer) by a consultant at Ninewells Hospital. Mr A became ill while on holiday with his family and was admitted to hospital. When the family returned home, Mr A was transferred to Ninewells as he was too ill to go home. At a meeting with Mr A and his family, the consultant decided to discontinue the erlotnib therapy and focus on symptom control. Medical staff recommended that Mr A be transferred as an in-patient for palliative care, but Mr A and his family decided that he wished to be discharged home. A package of care was requested to support this, but Mr A passed away on the morning of his planned discharge. Mr C complained to the board that they had failed to arrange a care package in time to enable Mr A to die at home, as he had wished. Mr C also raised several concerns about Mr A's care, record-keeping and communication with hospital staff. The board responded four months later. Staff from the board then met with Mr C and his mother, and agreed what they would do in response to the complaint. In response to Mr C's enquiries, the board wrote to him about the outcomes of these actions. However, Mr C remained dissatisfied with their response, and their handling of his complaint, and complained to us. After taking independent advice from our medical and nursing advisers, we upheld some of Mr C's complaint. We found that the board had handled his complaint poorly, and had not complied with their own complaints handling procedure or NHS guidance. We also found evidence of poor communication and record-keeping. However, we did not find evidence that Mr A's medical and nursing care was unreasonable. We also found that hospital staff had taken reasonable and timely steps to try to help Mr A achieve his wish to die at home, although this did not happen.

Mrs C had an operation at Perth Royal Infirmary, after which she experienced complications and was transferred to Ninewells Hospital for more surgery. Her husband (Mr C) complained on her behalf about how clinical and nursing staff responded to her pain levels and other concerns. He also complained that, after Mrs C was transferred, there was a delay before she was taken to an operating theatre. Finally, he said that the risk of the complications (perforation of the uterus and damage to the bowel) were not included in the information leaflet sent to her before the surgery. During our investigation, we took independent medical advice from a consultant obstetrician and gynaecologist, and nursing advice from a nursing adviser. Our medical adviser said that Mrs C had an appropriate operation in Perth Royal Infirmary, and experienced a recognised complication of the procedure, for which she received appropriate treatment. We did, however, uphold Mr C's complaints. There was no written record by doctors at Perth Royal Infirmary, so our medical adviser could not say whether there was a delay in diagnosing the perforation or whether a consultant should have been contacted earlier. Because of this lack of records, we also could not confirm whether there was a delay in transferring Mrs C. We were concerned that her consent for the procedure had not been properly obtained. The board explained that their consent process for hysteroscopy (a procedure that lets the doctor look inside the womb) was being reviewed to ensure that it follows guidance from the Royal College of Obstetricians and Gynaecologists. Our nursing adviser said that, given Mrs C's level of pain, nursing staff at Perth Royal Infirmary should have increased the frequency of their observations, and should have told the nurse in charge. They did not follow guidance on the Scottish Early Warning Scoring System (a set of patient observations to assist in the early detection and treatment of serious cases and

Mrs C complained to us about aspects of her care and treatment by the gynaecology and obstetrics department at Ninewells Hospital. We began an investigation into her concerns, but did not complete it as Mrs C decided to take legal action against the board. Related reading View Decision Report 201300300 as a PDF (10.69 KB) Updated: March 13, 2018

Mr A had suffered a morphine overdose and become unwell. An ambulance was called and the crew assessed Mr A. He was nauseous and vomiting, had abdominal (stomach) pains and was unable to keep down food or drink. He was taken to Perth Royal Infirmary, where he was triaged and sent to the out-of-hours service. He was assessed there by a primary care nurse, and deemed fit to be discharged. His niece (Mrs C) complained on behalf of Mr A. She said that when Mr A had been discharged he had phoned her and was confused and disorientated. Mrs C complained that her uncle was not reasonably assessed at the hospital and should not have been discharged. During our investigation we took independent advice from both a GP adviser and a nursing adviser. Both advisers expressed concerns that the assessment of Mr A was not thorough. The nursing adviser was concerned that Mr A's recent morphine overdose history was not noted and that his abdomen was not examined, in light of the pain reported to the ambulance crew. The GP adviser was also concerned that Mr A was not assessed for dehydration due to his inability to keep down liquids. In light of the advice we received, we upheld Mrs C's complaints.

Miss C complained there was an avoidable delay before her hip replacement surgery was carried out. We took independent advice from one of our medical advisers, who explained that total hip replacements are best avoided in younger patients until all other possibilities have been considered. This is because such replacements have a limited time span and in younger patients they wear out and loosen earlier due to physical activities. In such cases the patient might need at least one further surgery, if not two. As Miss C was a younger patient, the delay before surgery was appropriate as it was important to explore all other non-surgical options before operating. We also found that Miss C asked to delay the surgery further, for personal reasons, and so not all of the delay was caused by the surgeon. Miss C had replacement surgery on both hips. While the right hip surgery was successful, Miss C experienced pain after the surgery on her left hip and needed another operation. She complained that there was a failure to take timely action or arrange appropriate investigations to try to diagnose the cause of her pain. Our adviser said, however, that the investigations carried out on this were reasonable and appropriate. In particular, after unsuccessful surgery there may be complications with a further operation, and the adviser said that it was reasonable to wait and see if a patient's symptoms settled down (which in many cases they do) before taking further action. Although we did not uphold Miss C's complaint, our adviser noted that the cause of Miss C's pain and her dissatisfaction with the surgery on her left hip was likely a direct consequence of the hip replacement socket being badly positioned. Our adviser said that in this respect her care and treatment fell below an acceptable standard, and we made recommendations about this.

Mrs C, who is an advice worker, complained on behalf of her client (Mrs A) about the care and treatment given to Mrs A's late husband (Mr A) before he died. Mr A had bowel cancer and his prognosis (the forecast of the likely outcome of his condition) was not good. He was discharged home from hospital into the care of his GP and the district nursing service. After being at home for a short while, Mr A died. Mrs A complained about the various agencies involved in her husband's care and was particularly unhappy because she considered that district nurses had failed to properly care for her husband in the final weeks and days of his life and that levels of support, communication and standards of care had been poor. In responding to her complaint, the board agreed that there were failures in the support and care offered to Mr and Mrs A, and apologised for this, but Mrs A remained concerned that lessons had not been learned nor had procedures been put in place to prevent this happening again. She also complained about the way in which her complaint had been handled. We took independent advice on this case from our nursing adviser, an experienced registered nurse. Our investigation confirmed that the board had admitted that there were shortcomings in Mr A's care, and we found that they took too long to deal with her complaint. We, therefore, upheld the complaint, while noting that the board had put processes in place to address the problems with Mr A's care and had apologised sincerely to Mrs A for the failings. As our investigation also found that the board had taken Mrs A's concerns most seriously and that the processes put in place provided a good response to them, we did not find it necessary to make any recommendations. Related reading View Decision Report 201304138 as a PDF (11.48 KB) Updated: March 13, 2018

Mr C complained on behalf of his daughter (Ms A) about the care and treatment she received at Perth Royal Infirmary and Ninewells Hospital. In particular, he said there was a protracted period of complacency by the staff involved in his daughter's care. At the time Mr C complained to us, Ms A had been experiencing severe and debilitating pain for over 18 months. A number of diagnoses had been suggested, and while treatments were ongoing, no single definitive cause had been found for her pain and other related symptoms. Mr C said that the medical team had ruled out endometriosis (a condition where cells similar to those that line the womb lie outside it) without adequate investigation or involving a colorectal surgeon. In response to the complaint, the board apologised for the delays and the lack of communication between departments. They explained the reasons for and outcomes of the various tests that had been arranged, along with organising further clinical review for Ms A. We took independent advice from three specialist clinical advisers - a gynaecologist, a gastroenterologist (a specialist in the treatment of conditions affecting the liver, intestine and pancreas) and a radiologist (a specialist in the analysis of images of the body). The radiologist said that a scan had been incorrectly interpreted, as he considered it did not show evidence of endometriosis. However, he did not consider this to be a major error of judgement requiring further action. In addition, whilst we identified that there was some confusion over referrals and some delays in arranging treatment, our advisers said that the tests and treatments offered were all appropriate in light of what was known at the time. On balance, we did not uphold Mr C's complaint as we found that although there were some errors in Ms A's care, no department had acted unreasonably and there were no serious failings. However, we did make a number of recommendations to the board.

Mrs C had suffered from knee pain for a number of years. She was diagnosed with degenerative changes in her knee and a meniscal tear (a tear in the pad which provides shock absorption and other functions in the knee). She also had a meniscal cyst (a cyst often found in the presence of a meniscal tear and which can cause pain and discomfort). Following an initial course of physiotherapy, Mrs C had surgery at Perth Royal Infirmary to treat her meniscal tear and decompress the cyst. Although she experienced some initial improvement, her knee pain returned. She had further physiotherapy and a second operation. However, again her pain returned and in fact became worse. She complained that the board did not adequately treat her knee problems or provide appropriate follow-up care. We took independent advice from one of our medical advisers, who explained that meniscal cysts can return and knee pain can persist following surgery. We were satisfied that this was explained to Mrs C before her first operation. We could find no mention of the cyst in the notes for the first operation. Whilst this could have indicated that the cyst could not be found, or that it was treated successfully, the absence of records meant we had to conclude that the cyst was not treated during the first procedure. That said, we found that it was treated appropriately during the second procedure and overall, we were satisfied that Mrs C was discharged and re-referred to the orthopaedic department appropriately as required when her knee pain flared up. We were also satisfied that physiotherapy was used appropriately. We did not uphold Mrs C's complaint, but we did ask the board to apologise to Mrs C in relation to the uncertainty surrounding her first operation.

Mrs C complained that the board failed to diagnose her with rheumatoid arthritis while she was under their care. Although she had a number of appointments in just over a year, Although she had a number of appointments in just over a year, Mrs C was only diagnosed with this after she moved out of Scotland.. She said that this was despite the fact that there had been sufficient indicators present to have confirmed this. She said that, as a consequence, she was not properly treated and that she had subsequently lost her independence. We investigated the complaint and took independent advice from a consultant rheumatologist. Our adviser said that diagnosing rheumatoid arthritis is neither straightforward nor easy and other conditions can mimic its presentation. Accordingly, great care has to be taken in making a diagnosis, and also in prescribing appropriate drugs, some of which have significant side-effects. We found that in the time period about which Mrs C was concerned, and faced with a complicated picture, clinicians responsible for her care had carefully monitored her, formed appropriate working diagnoses and treated her appropriately. At about the same time as Mrs C moved, the evidence about her condition became much clearer and the findings and updated treatment were summarised to her new clinician when her treatment recommenced. Related reading View Decision Report 201401164 as a PDF (11.25 KB) Updated: March 13, 2018

Mr C complained on behalf of his wife (Mrs C) who suffers from various life-limiting medical conditions, including Raynaud's Disease (a condition where the blood supply to the extremities is severely restricted, causing pain and ulcers). Mrs C receives regular infusions of a drug to help with this condition, and Mr C complained about the way this treatment was administered during one period of time. He also complained about the way the board handled his complaints about this. Mrs C is admitted to Ninewells Hospital every three months to have a series of seven-hour infusions over a five-day period. Normally 17 hours of rest are allowed between infusions. However, the board's protocol for the treatments says that they can be given with a minimum of 12 hours between them. During one admission Mrs C's treatment was compressed according to this protocol, to allow her to be discharged from hospital earlier. Mrs C developed severe headache, nausea and vomiting, and asked that this should not happen again. Despite this, she felt that her treatment was compressed on her next admission. Our investigation included taking independent advice from a medical adviser with experience in treating patients with Raynaud's Disease. The adviser said that there are no national guidelines on administering this treatment, but that the board's protocol was in line with normal NHS practice to give infusions over a six to eight hour period across three to seven days. The adviser reviewed Mrs C's treatment and found that the infusion was given after less than a 12 hour break only once - when one was given after 11 hours. However, the adviser was of the view that this was still within normal NHS practice. They also said that staff took appropriate action to address the side effects Mrs C suffered, and noted that headache, nausea and vomiting were common side effects. After considering this advice, we did not uphold Mr C's complaint about treatment as we were satisfied that, overall, this was rea

Mr C requires regular blood sampling due to the medication that he is prescribed. At one appointment there was difficulty obtaining a blood sample and Mr C was in pain. He attended his GP who referred him to a neurologist who diagnosed nerve damage, possibly caused by the attempt to take blood. Mr C complained that the board had not provided him with a reasonable standard of care and that they had not properly responded to his complaint. We took independent medical advice on this complaint from our nursing adviser. Our investigation found that the board had apologised for the distress caused and had made arrangements for Mr C to have future blood samples taken by another team. We considered these actions to be reasonable and did not uphold the complaint. However, we did not consider the time taken by the board to respond to Mr C's complaint to be reasonable, so we upheld this aspect of his complaint and recommended that the board apologise to Mr C for the delay.

Mrs C, who is an advice worker, complained to us on behalf of her client (Mrs A), about the care and treatment of Mrs A's late husband (Mr A). A GP from the medical practice had examined Mr A earlier in the day and prescribed antibiotic tablets and a throat spray. Mrs C complained that the GP then failed to reattend Mr and Mrs A's home to visit Mr A when he began having breathing difficulties. Mr A died later that day. We took independent advice on this case from one of our medical advisers. Our adviser explained that the GP recorded a thorough history and examination in keeping with an upper respiratory infection. She said that the GP examined Mr A's chest and noted that it was clear. With regards to Mrs A's specific concern about the GP's failure to reattend, the adviser reviewed the notes relating to a phone call and was satisfied that it did not contain anything to suggest an increasing severity of Mr A's condition. Based on the advice received, we were satisfied that the GP's care and treatment was reasonable. Related reading View Decision Report 201402321 as a PDF (11.11 KB) Updated: March 13, 2018

Mr C raised a number of concerns regarding the care his father (Mr A) received in Ninewells Hospital. Mr A had existing diagnoses of lung cancer and diabetes when he was admitted to the hospital with an infection. Mr C said that his father's initial treatment was excellent, but when he was later transferred to another ward, the standard of care dropped. Mr C raised a number of concerns regarding the standard of clinical and nursing care on that ward, where Mr A died three days after his admission. Mr C complained that family members were not made aware of Mr A's deterioration. He also complained that staff failed to adequately manage Mr A's diabetes and food and fluid intake. Mr C believed his father's death was caused by a failure to identify and treat hypoglycaemic shock (severely diminished blood sugar levels), rather than as a result of his underlying cancer and infection as the board suggested. After taking independent advice from a nursing adviser and a medical adviser, we upheld Mr C's complaints. We were satisfied that Mr A's condition was appropriately assessed upon admission and that the proposed treatment with intravenous antibiotics was appropriate. That said, we were concerned by the ward staff's management of his blood glucose levels. Mr A's diabetes was clearly recorded when he was admitted to hospital, but we found evidence to suggest that the ward was not equipped to react to significant changes to his blood glucose levels, and the board's own procedure for managing hypoglycaemia was not followed. We also found that medication was omitted from the list of existing medications for Mr A and that this likely contributed to his hypoglycaemic episode. However, we accepted medical advice that the hypoglycaemic episode was ultimately dealt with appropriately and that there was no evidence to suggest that this contributed to the decline in Mr A's condition, or to his death. We were, however, critical of the board for failing to contact the family when Mr A

After Mr C's daughter (Miss A) was in a road traffic accident, paramedics took her to A&E at Ninewells Hospital strapped to a spinal board (a specialised stretcher, designed to protect patients with spinal damage). Mr C complained that the board then failed to adequately assess and treat Miss A, and said that she was not x-rayed at any point before she was discharged. Following her discharge she remained in significant pain and discomfort and Mr C took her to the family GP who, after a brief examination, referred her as an emergency to a different hospital. An x-ray taken there revealed a fractured vertebrae in Miss A's back and a CT scan (a scan that uses a computer to create an image of the body) revealed two further fractures. We took independent advice from one of our medical advisers. He said that while the initial examination of Miss A was of a reasonable standard, a second more comprehensive examination should have identified the need for an x-ray of the spine. The adviser also said there was no record of Miss A's mobility having been assessed and that, as she was suffering pain in her abdomen, she should have been assessed for liver damage, given the speed at which the vehicle was travelling immediately before the crash. In light of this advice we upheld Mr C's complaints, as we concluded that the board had failed to adequately assess and treat Miss A and had unreasonably failed to arrange for x-rays or scans to be taken of her spine.

Mrs C's son (Mr A) sustained a head injury while playing sport. He attended A&E at Perth Royal Infirmary where he was examined and discharged. He was later found to have suffered a fracture to his neck which required surgery to correct. Mrs C complained that her son was not properly assessed in A&E and should have been sent for medical imaging. The board stated that they had followed established guidance on the decision-making process regarding medical imaging and that on the information available at the time regarding Mr A’s symptoms there was no reason to perform any medical imaging. We took independent medical advice on this complaint from one advisers, who told us that Mr A's assessment in A&E was thorough and adhered to the relevant guidance. The adviser also said when Mr A was examined there was no obvious reason to refer Mr A for imaging. We considered Mr A’s treatment to have been reasonable and did not uphold the complaint. Related reading View Decision Report 201401557 as a PDF (11.07 KB) Updated: March 13, 2018

Mr C had an accident at work and was taken to Perth Royal Infirmary A&E, where his back and neck were examined and x-rayed. No bony injuries were identified and Mr C was discharged. He said that he told hospital staff that his arms and shoulders were extremely painful and heavy, but the only test that they carried out was that he was asked to squeeze the doctor's fingers. Mr C continued to have pain in his shoulders and arms and his GP referred him for an MRI scan (magnetic resonance imaging - used to diagnose health conditions affecting organs, tissue and bone). This showed that he had torn the rotator cuffs (the muscles around the shoulder joint) in both shoulders. Mr C continued to have shoulder problems, and complained that the A&E examination was inadequate and did not properly assess the extent of his injuries. After taking independent advice from one of our medical advisers, we found that Mr C was examined in line with good practice. The range of movement in his arms and shoulders was checked and the finger squeezing test was carried out to check for nerve damage (which might have indicated a neck injury). The examination indicated that Mr C had soft tissue injuries, which would not show up on an x-ray. We did not uphold his complaint,as we found the decision to allow his injuries time to settle, with pain medication, to be appropriate. However, we noted a delay to Mr C's MRI scan and diagnosis when his pain did not resolve and made a recommendation related to this.