SPSO Individual Decisions

Mrs C complained about the care and treatment provided to her mother (Mrs A) when she was a patient at the Royal Infirmary of Edinburgh. Mrs A suffered from breathlessness and collapse and had three admissions to hospital. During her first admission to hospital, tests showed that Mrs A had pulmonary oedema (fluid on the lungs that can indicate heart failure). After Mrs A's second admission to hospital several months later, she was followed up by the respiratory clinic and referred to the cardiology team after further tests showed a heart condition. Mrs A continued to suffer from breathlessness and episodes of collapse. Shortly after her third admission to hospital, Mrs A suffered a heart attack and died. Mrs C said that staff unreasonably failed to notice the problems with Mrs A's heart and provide appropriate treatment within a reasonable time and that the failure to treat Mrs A led to her death. We took independent advice from a specialist in cardiology. We found that the board missed an opportunity to diagnose the cause of pulmonary oedema, which had been identified during Mrs A's first admission to hospital, and that as a result Mrs A's heart condition was not diagnosed within a reasonable time. This in turn meant that there was an unreasonable delay in referring Mrs A to the cardiology team for further assessment and treatment. However, it was unclear whether an earlier diagnosis would have led to a different outcome, due to Mrs A's medical history. It was our view that a potential opportunity for further treatment was missed and we therefore upheld Mrs C's complaint.

Mrs C complained about the care and treatment provided to her mother (Mrs A) when she attended her GP practice complaining of breathlessness and collapse. During this period, Mrs A also had three admissions to hospital. Shortly after her third admission to hospital, she suffered a heart attack and died. Mrs C said that the practice failed to take Mrs A's symptoms seriously and delayed in taking appropriate action. She also said that the practice should not have prescribed a certain medication in light of Mrs A's heart condition. We took independent advice from an adviser who specialises in general practice. We found that while the standard of medical care in relation to Mrs A's symptoms was reasonable, there were shortcomings in relation to a referral to hospital and the prescription of medication. While these shortcomings did not contribute to Mrs A's death, we upheld the complaint because of the prescription of medication that should not be given to patients with heart conditions.

Ms C complained about the care and treatment given to her father (Mr A) at the Western General Hospital. Mr A, who had cirrhosis (scarring of the liver as a result of continual, long-term damage), deteriorating liver function and liver cancer, was admitted to the hospital for a head scan to investigate possible brain metastasis (a cancer that has spread from its primary site). Ms C considered that staff gave Mr A inappropriate sedation, which rendered him unconscious, and failed to provide him with appropriate medication for alcohol withdrawal. Ms C believed this led to a sudden deterioration in Mr A's condition and his subsequent death in the hospital. We took independent advice from a consultant physician experienced in the management of liver disease and cancer of the bile ducts. We found that parts of Mr A's care and treatment were reasonable, in particular that there was no undue delay in carrying out Mr A's head scan and that the palliative care given to Mr A was appropriate. However, the adviser identified failings in relation to the sedation and medication given to Mr A, in the assessment of his alcohol dependency, and in treating his ongoing constipation. The adviser also considered there were shortcomings in parts of the board's alcohol withdrawal plan (AWP). However, the adviser concluded that despite the failings identified in Mr A's care and treatment, his death was not caused or hastened by these failings. We accepted this advice. Given that our investigation found failings in Mr A's care and treatment, we considered this to be unreasonable and upheld Ms C's complaint. In the course of our investigation, the board told us they accepted there had been a lack of documentation relating to the sedation administered to Mr A, for which they had apologised.

Mrs C's father (Mr A) was treated with radiotherapy for cancer of the tongue. Following his treatment, Mr A was cared for in the community with regular reviews at a joint cancer clinic and input from dieticians in another health board. He also received speech and language therapy (SALT) as part of the cancer clinic for about six months, and was then referred back to the other board for ongoing SALT care. In the 18 months following his treatment, Mr A had increasing difficulty swallowing and suffered from recurrent mouth ulcers and pain. He also had several short hospital admissions with bleeding from the mouth. He was subsequently admitted to hospital (in another health board) in June 2014 with weight loss, decreased ability to swallow and stridor (noisy breathing caused by a narrowed or obstructed airway). He underwent endo-tracheal intubation (insertion of a tube to maintain an open airway to the lungs) and was transferred to St John's Hospital (for intensive care and ear, nose and throat (ENT) investigations), and then to the Royal Infirmary of Edinburgh (for gastrointestinal investigations). Mr A suffered a major haemorrhage (bleeding) from the throat and died in hospital. Mrs C complained about Mr A's care during this period, and raised concerns that clinicians failed to adequately respond to Mr A's mouth pain, malnutrition and weight loss, as well as infections in his mouth. Mrs C also raised concerns about care and communication during the hospital admissions in June 2014. After taking independent advice from an oncologist, a consultant in general medicine, an ENT surgeon and a SALT therapist, we upheld three of Mrs C's four complaints. We found that, although Mr A had regular reviews and involvement of appropriate clinicians in his care, there was a lack of integration and cohesion in the team's approach, which meant that Mr A's symptoms were not adequately addressed. We also found failings in relation to communication during Mr A's final admissions

Mrs C complained to us about the care and treatment provided to her late father (Mr A) in Western General Hospital and St John's Hospital. We took independent advice from a consultant physician and a nurse. Though we found Mr A's medical treatment reasonable, we identified a number of other concerns. In particular, we found that communication of Mr A's prognosis was not carried out reasonably with Mr A or his family. We also had concerns about the adequacy of record-keeping by nursing staff in relation to Mr A's stay in St John's Hospital. We were also concerned that no arrangements had been put in place for a member of Mr A's family to travel with him in the ambulance when he was transferred from St John's Hospital to hospice care.

Mr and Mrs C complained on behalf of their daughter (Miss A) regarding the dental care and treatment she received from the board. Mr and Mrs C complained that Miss A's anxiety was not taken into account whilst the board were attempting to remove two of her teeth over several dental appointments, and that it was decided that the dental treatment was not necessary. We took independent dental advice and found that the care and treatment provided to Miss A had been reasonable and the board had made many attempts to acclimatise Miss A to receiving dental care. In addition, we found that whilst it had been reasonable for the board to pursue treatment over several months, it was reasonable that they eventually decided not to carry out the treatment as the benefits of treatment no longer outweighed the risks of Miss A's anxiety becoming worse. Therefore, we did not uphold this complaint. Related reading View Decision Report 201602927 as a PDF (11 KB) Updated: March 13, 2018

Mr C complained that he was not warned about the possible specific side effect of developing cataracts (a clouding of the lens of the eye leading to a reduction in vision) when taking steroid drugs via an inhaler. Mr C had been treated by his GPs and specialists for a number of years for respiratory conditions. He was prescribed inhalers and nasal drops, some of which were steroids. Mr C was diagnosed with cataracts on both eyes while on holiday overseas and had surgery there to remove the cataract from one eye. He was told by his surgeon that the cataracts had been caused by his steroid inhaler. We took independent medical advice and found that although recognised as a possible side effect, cataracts were such a rare occurrence that it was reasonable that this would not have been specifically discussed with Mr C. Information was available about this in the patient information leaflet supplied with each new batch of the drug. Our view, therefore, was that the actions of the practice were reasonable and in line with relevant General Medical Council guidance to GPs. Related reading View Decision Report 201600319 as a PDF (11.16 KB) Updated: March 13, 2018

Mr C complained that the board failed to provide the results of a scan that he underwent at the Western General Hospital. He said that his GP had not been given the results of the scan, and that when he called the board he was given results over the phone by a secretary who had not been able to explain the results in full. He also complained about the board's handling of his complaint. We took independent advice from a hospital consultant. We found that it was the responsibility of the consultant who ordered the scan to report the results back to Mr C, and that this was not done. Whilst there was some limited evidence that the consultant had notified the GP of the results, there was no evidence of what form this notification took. We found that when the results were viewed by the requesting consultant, a letter should have been sent to both Mr C and his GP. We therefore upheld this aspect of Mr C's complaint. In addition, we found that the board's response to Mr C's complaint contained several inaccuracies and upheld Mr C's complaint in this regard.

Ms C was admitted to the Royal Edinburgh Hospital. She complained that her care and treatment during her two-day admission was not reasonable. She also complained about record-keeping. Ms C said that during her admission, an earlier misdiagnosis of personality disorder was relied upon and a more recent diagnosis of post partum psychosis (the onset of psychotic symptoms following childbirth) was ignored. Ms C also said that her medical records did not reasonably portray where she wished to go after her discharge. During our investigation we took independent advice from a consultant psychiatrist. We found no evidence that the board had relied upon the diagnosis of personality disorder that had been previously made, nor that they had ignored the more recent diagnosis of post partum psychosis. We also found that the care and treatment provided to Ms C during her admission was reasonable. Finally, we found that medical records relating to where Ms C wished to go after her discharge were reasonable. We therefore did not uphold Ms C's complaints. Related reading View Decision Report 201507706 as a PDF (11.04 KB) Updated: March 13, 2018

Mr C complained about the care and treatment provided to his wife (Mrs A) when she was admitted to the Western General Hospital for radiotherapy to treat a spinal condition. Mr C said that nursing staff failed to provide reasonable care in relation to the taking of blood samples, pressure ulcers and use of a pressure-relieving mattress, and said that the failings caused Mrs A pain and distress. We took independent advice from a nursing adviser. We found that the standard of nursing care in relation to blood sampling and pressure ulcer care was reasonable, but that there were shortcomings in relation to record-keeping and the explanation about the mattress and we made recommendations in relation to this. However, on balance we were satisfied that the standard of nursing care and treatment on the whole was reasonable and we did not uphold Mrs C's complaint.

Mrs C complained about the care and treatment she received at the Royal Infirmary of Edinburgh when she has a hysterectomy (surgical removal of the womb). Mrs C was concerned that the surgery should not have gone ahead given that she had been suffering from a cold and cough a couple of weeks earlier. Mrs C became significantly unwell after surgery and further tests identified that she had internal bleeding and a blood clot. Emergency surgery was carried out and she also developed a chest infection. We took independent medical advice and found that there was evidence to show that Mrs C was fit for surgery with no evidence of active infection or respiratory problems. We considered that the hysterectomy was performed appropriately and that the problems she experienced after surgery were recognised complications of the surgery, rather than failings in care. Whilst we did not uphold the complaint, we were critical that there was a lack of clear documentation to demonstrate that Mrs C was fully appraised of all the relevant risks and complications associated with hysterectomy. Therefore, we made two recommendations to the board in order to address the matter.

Mr C complained that the board failed to provide reasonable care and treatment following his report of concerns about his testicular health. He also complained that the handling of his complaint about these concerns fell below a reasonable standard. We took independent advice from a GP adviser. They noted that the actions taken by the doctors who saw Mr C had been in keeping with the appropriate guidelines relating to problems with the testicles. Mr C had been appropriately referred for review by a specialist, although his case did not meet the threshold for an urgent referral. We found that although Mr C had experienced a delay in receiving assessment by a specialist at hospital, this was not the fault of the GP who referred him. When Mr C complained about the delay, the GP contacted the appropriate hospital department and requested an update on Mr C's appointment. We therefore did not uphold Mr C's complaint about the care and treatment provided to him. In terms of the handling of Mr C's complaints, we found that although the board had exceeded their 20-day target for responding, they kept Mr C informed of the progress of their investigation. We found that the handling of Mr C's complaints was reasonable. We therefore did not uphold this aspect of Mr C's complaint. Related reading View Decision Report 201508081 as a PDF (11.16 KB) Updated: March 13, 2018

Mr C complained that the prison health centre unreasonably opened mail that was addressed to him. The board were unable to identify who opened Mr C's mail, but they acknowledged that it appeared to have arrived at the health centre unopened. They accepted that the item should not have been opened by staff and that an apology should have been issued to Mr C as soon as it was identified that it had been opened in error. We therefore upheld Mr C's complaint.

Miss C complained that her medical practice failed to fit her intrauterine contraceptive device (IUCD) appropriately and that it had perforated her uterus. She complained to the practice but it was their view that it had been fitted reasonably. We took independent medical advice and found that prior to the procedure to fit the device, in accordance with national guidance, Miss C had been fully informed about its risks and benefits, including that the IUCD could perforate the uterus. There was no evidence to suggest that the IUCD had been fitted inappropriately and the complaint was not upheld. Related reading View Decision Report 201600303 as a PDF (10.87 KB) Updated: March 13, 2018

Ms C complained about the care and treatment in hospital of her daughter (Miss A) who suffers from complex regional pain syndrome (a painful condition normally treated with desensitisation and physiotherapy). Miss A was admitted to the hospital where she has remained for over a year without improvement to her condition. Ms C raised concerns that Miss A was not receiving appropriate specialist input as staff at the hospital did not have experience with Miss A's condition. Ms C also said Miss A was not able to get quality sleep due to her position on the ward, which Ms C considered was impacting on her rehabilitation and exacerbating her pain. The board said Miss A had received appropriate care from an experienced team but she had not felt able to participate with the physiotherapy and desensitisation program, so her condition had not improved. The board explained that the decision to keep Miss A in a central location was due to her high falls risk. While they agreed that lack of sleep was not desirable, they did not consider that this was impacting on Miss A's rehabilitation. After taking independent advice from a consultant in pain management and a nurse, we did not uphold Ms C's complaint. We found Miss A's care involved appropriate input from a multi-disciplinary team. The medical adviser considered that the team were appropriately experienced and qualified to manage this case and noted that the team had also discussed the case with clinicians both within and outside the UK. In relation to Miss A's position on the ward, both advisers considered this was appropriate in view of the risk assessments carried out by staff. Related reading View Decision Report 201508328 as a PDF (11.37 KB) Updated: March 13, 2018

Mr C complained that although he suffered from mental health issues, the diagnosis of Asperger's Syndrome he had been given was incorrect. Mr C said that he had not been listened to by medical staff and that his opinion and symptoms had been ignored. Mr C believed that medical staff had chosen to inaccurately record his symptoms, in order to protect their colleagues who had given him the original diagnosis of Asperger's Syndrome. Mr C said his assessments had not been properly carried out and the appropriate diagnostic tools and techniques had not been used. Mr C said the board were unreasonably refusing to provide him with a second opinion. We took independent medical advice and found that Mr C had been diagnosed following a period of observation and assessment. This included a detailed history as well as information supplied by other mental health professionals and direct observation of Mr C. The diagnostic process was reasonable and in keeping with the current guidelines and had taken place over four separate assessments. The adviser said it was reasonable for further assessments to be refused by the board, as Mr C had had a number of assessments by different doctors, which had all reached the same conclusion. Additionally, Mr C's focus on his diagnosis was preventing him from following his treatment programme. As another assessment was unlikely to reach a different conclusion, it would not be helpful for Mr C. We found Mr C was assessed reasonably by the board, who were able to demonstrate they had followed the appropriate guidance. We therefore did not uphold Mr C's complaint. Related reading View Decision Report 201600399 as a PDF (11.37 KB) Updated: March 13, 2018

Mrs C attended an out-of-hours GP service with sinus congestion and ear pain. Mrs C complained that medication was unreasonably prescribed without proper checks being carried out into allergies. Mrs C was asked about known allergies by a nurse practitioner and declared the one she knew about. The nurse practitioner did not check her electronic care summary. Mrs C was then prescribed a drug she had previously suffered an adverse reaction to. The drug made her feel unwell. Mrs C only discovered she had a recorded allergy to the drug prescribed when she went to hospital for unrelated treatment. We took independent medical advice. We found that the nurse practitioner should have checked the electronic care summary. We therefore upheld Mrs C's complaint. However, we were satisfied that the failure to check the electronic care summary was one of human error rather than evidence of a deficit in the training or clinical ability of the nurse practitioner. We found evidence that the practitioner and the out-of-hours service had reflected appropriately on the sequence of events and had apologised to Mrs C. Related reading View Decision Report 201600743 as a PDF (11.11 KB) Updated: March 13, 2018

Miss C complained that her dentist failed to provide her with appropriate dental treatment. Miss C was advised by her dentist that she needed a crown on one of her teeth. She subsequently suffered problems with her tooth and had to receive further treatment. She questioned the advice to place the crown. Miss C also complained about subsequent treatment and the management of her pain during this time as well as the dentist's handling of her complaint. After receiving independent advice from a dentist, we upheld Miss C's complaints. We found that the dentist failed to provide Miss C with appropriate options, including risks and benefits, and therefore failed to get informed consent. We also found that placing the crown was not the best option, given Miss C's periodontal (gum) disease. Finally, we found that the dentist failed to respond to Miss C's formal complaint in line with the NHS complaints procedure.

Mrs C said that her medical practice did not provide a reasonable response to phone calls she made when she became unwell. Specifically, she had to phone three times before her call was returned towards the end of the working day by a GP. We found the practice had no record of the first two phone calls Mrs C made, although they did not dispute she had made them. We took independent advice from a GP adviser. We concluded that the response from the practice to Mrs C's calls was a reasonable one as she received a return call and telephone consultation the same day she requested it. Therefore we did not uphold Mrs C's complaint. Mrs C also complained that the GP she spoke to on the phone failed to check her records for allergies. In doing so, the GP missed that a drug prescribed to Mrs C by an emergency out-of-hours GP was one that she had previously suffered an adverse reaction to. We therefore upheld this complaint. The GP practice apologised to Mrs C for the distress and discomfort she suffered. Related reading View Decision Report 201602009 as a PDF (11.1 KB) Updated: March 13, 2018

Mr C complained that the medical practice unreasonably failed to offer his son (Mr A) a referral for varicose vein surgery. Mr C was concerned that this was affecting Mr A's mental health. He was of the view that the practice were refusing to refer him for surgery because of Mr A's mental health problems. We took independent clinical advice. We found that the practice had carried out a proper examination of Mr A and had noted that his varicose vein was not causing him discomfort. As a result of this, the practice were correct in following the board's guidance on the treatment of varicose veins which said that in instances such as this, varicose veins should be treated conservatively and surgical referrals should not be made. As a result, we did not uphold Mr C's complaint. Related reading View Decision Report 201600674 as a PDF (10.96 KB) Updated: March 13, 2018

Mr C complained to us about the care and treatment his wife (Mrs A) had received from the board. Mrs A had been diagnosed with functional disease (where the functioning of the body is disturbed in the absence of any disease). Her condition deteriorated significantly and she died. A post mortem was carried out and it was found that she had motor neurone disease (a rare condition that progressively damages parts of the nervous system). Mr C complained to us about the care and treatment provided to Mrs A and about the failure to diagnose motor neurone disease. We took independent advice from a consultant neurologist and a general medical adviser. We found that the initial diagnosis of functional disease had been reasonable and the care and treatment Mrs A had received in relation to this had been excellent. However, when Mrs A then displayed other symptoms that were not typical of functional weakness, staff failed to reasonably investigate these symptoms. It was likely the further tests would have led to a diagnosis of motor neurone disease, although this could not be proved. In view of this, we upheld Mr C's complaints that the board did not provide reasonable care and treatment to his wife and that they failed to diagnose motor neurone disease. Mr C also complained that the board failed to arrange a package of home care for Mrs A. We found that the actions of staff had been reasonable given Mrs A's initial diagnosis. The correspondence from the board had set out the type of support she would require in the future. We could not say definitively that a diagnosis of motor neurone disease would have been made had the relevant tests been carried out. On balance we did not uphold this aspect of the complaint. Finally, Mr C complained about the board's handling of his complaint. We did not find failings by the board in relation to the issues Mr C had raised and we did not uphold this aspect of his complaint.

Ms C was diagnosed with breast cancer. Following treatment, she decided to have reconstructive breast surgery. Ms C was placed on a waiting list and was told that the Patient Rights (Scotland) Act 2011 applied, which meant that her treatment would start within a maximum of 12 weeks. After 12 weeks, Ms C contacted the board and found out they could not meet the treatment time guarantee. Ms C complained that the board acted unreasonably by failing to meet the 12-week waiting time; that they did not acknowledge her request to meet with the chief officer or medical director; and that they failed to respond to her complaint within a reasonable time. We took independent advice from a specialist in plastic surgery. We found that the lack of expertise available at the private-sector service provider chosen by the board was a reasonable reason for Ms C not being treated elsewhere. However, it appeared that the board had not taken sufficient steps to consider the provision of treatment by other NHS providers throughout the UK who may have had the required expertise. We determined that the board did not reasonably take into account their statutory responsibility to take all reasonable and practical steps to arrange treatment with other service providers. Also, while the board explained satisfactorily the reasons why Ms C's surgery could not be provided within the 12-week treatment time guarantee, it was unacceptable that she had to take the initiative to find out what was happening once the 12 weeks had passed. We were also concerned about the lack of information provided to us about arrangements the board have in place when they cannot meet the treatment time guarantee within their own area to arrange the provision of treatment by alternative service providers. The board apologised that a meeting was not arranged to address Ms C's complaints. We also found that there was an unreasonable delay in providing a response to Ms C's complaint.

Miss C attended her dentist and reported mild discomfort in an upper tooth. Following an examination including x-rays, Miss C was advised that she required either extraction or root canal treatment of the tooth. Miss C chose to proceed with the root canal treatment which was carried out a few weeks later. Afterwards, Miss C experienced pain and swelling that resulted in her attending at the local out-of-hours service, where she received antibiotics for an abscess. Miss C returned to the dentist and was unhappy with the follow-up service. After taking independent dental advice we did not uphold Miss C's complaint. We found no failings in the care and treatment that Miss C was provided with. The advice we received was that the treatment provided was appropriate and that the risk of the abscess had been covered in the risks and benefits information provided to her. Related reading View Decision Report 201507822 as a PDF (11.02 KB) Updated: March 13, 2018

Ms C complained to us about the care and treatment she received when she was admitted to the Royal Infirmary of Edinburgh with significant pelvic girdle pain (a collection of uncomfortable symptoms that can cause severe pain due to a misalignment or stiffness of the pelvic joints at either the back or front of the pelvis) in the late stages of pregnancy. She also complained that the board did not reasonably respond to her complaints. We took independent midwifery advice. We found that the care and treatment provided to Ms C in relation to pelvic girdle pain and pitting oedema (a build-up of fluid under the skin that holds the imprint of a finger when pressed) had been appropriate. We also considered that the pain relief provided to her was appropriate, although we acknowledged that pelvic girdle pain is difficult to manage in severe cases. Ms C's pressure areas had been frequently checked in the hospital and the steps taken once the sore skin on her inner thighs had been noted was appropriate and timely. However, we found that the board had not followed the guidance from NICE (National Institute for Health and Care Excellence) on caesarean sections as they had not provided her with information in order for her to make an informed choice on her mode of delivery given her concerns and anxiety about childbirth at that time. The delivery plan should have been reassessed when Ms C was admitted to hospital with excessive pain and mental health concerns. There was also a delay in providing her with a swivel turntable and other disabled-friendly equipment and the nursing records indicated delays in emptying her catheter. In addition, Ms C should have had an occupational health review prior to discharge to ensure she was safe to manage and care for her baby at home and had the assistance she required. We therefore upheld her complaint. We found that there was a delay in the board responding to Ms C's complaint. We therefore upheld this aspect of Ms C's complaint.

Mr C was referred by his GP for a possible hernia operation. Mr C complained to us that the board failed to arrange his operation within the 12-week treatment time guarantee under the Patients Rights (Scotland) Act and that they failed to advise him of his rights under that Act. He also complained that they failed to arrange his treatment at another health board. We found that there was a delay in Mr C's case, though this was in arranging his out-patient appointment rather than the operation. We therefore did not uphold Mr C's complaint. However, the board failed to meet the 12-week waiting time target for out-patient appointments but apologised and explained this was because of staff shortages which had now been addressed. We found delays in the handling of Mr C's complaints to the board and we therefore upheld this aspect of his complaint. The board apologised to Mr C and said they are taking steps to address future delays. Related reading View Decision Report 201600464 as a PDF (11.04 KB) Updated: March 13, 2018