SPSO Individual Decisions

Mrs C complained about the treatment she received as an out-patient at Perth Royal Infirmary. She was being treated for a bladder complaint and was prescribed a drug (trospium chloride) as part of her treatment. Shortly after this she had a relapse of a previous mental health problem, and she attributed this to being prescribed the drug. Our investigation included taking independent advice from one of our medical advisers, who was of the view that the choice of drug was reasonable for a patient in Mrs C's age group, and with her medical history and medical condition. The adviser said that this type of drug was less, rather than more, likely to cause a worsening of a patient's mental health, that it was an appropriate choice of therapy and that Mrs C's reaction was very unusual. The outcome Mrs C was seeking was to have her medical notes annotated with a warning not to prescribe this drug to her in the future and the board had told us during the investigation that they had already put notes in the relevant records. We asked the board to confirm in writing to Mrs C, and to us, that this had been done. Related reading View Decision Report 201303271 as a PDF (11.14 KB) Updated: March 13, 2018

Mrs C complained that she had been refused cosmetic surgery based on an incorrect mental health diagnosis. She also said that the investigation into her complaint was not thorough. In our investigation, we considered the information provided by Mrs C and the board, along with her medical records, as well as obtaining independent advice from one of our medical advisers. The board said that they had not diagnosed a condition but, rather, had used a particular condition to explain Mrs C's symptoms. Our adviser recognised this but, as the symptoms were used as the reason to refuse surgery, took the view that the diagnosis was implicit. Our adviser also said that the diagnosis was clinically disputable, and so we upheld Mrs C's complaint about this. We found that the board dealt with her complaint in line with normal procedures, but our adviser pointed out that during their investigation they had not picked up that there had been a significant misinterpretation of the government guidelines about such treatment (the adult exceptional aesthetic referral protocol). We were concerned that they did not identify this, and we also upheld this complaint.

Ms C had surgery on her foot to treat bunions at Ninewells Hospital. She complained that the operation did not relieve her pain and discomfort, but made it worse, and so the operation was unsuccessful. After treatment, other possible surgical options were discussed with her, but Ms C was anxious about having further surgery without assurances that she would be properly assessed and treated in future. She was particularly concerned that no x-rays were taken before or after her operation. During our investigation, the board were unable to explain why they took no x-rays before surgery. We took independent advice from one of our medical advisers, who said that although it was not mandatory, it was normal practice to take x-rays. Because they were not taken, the adviser was not able to say with certainty whether the procedure Ms C had was appropriate. We were also critical of the board for not properly recording Ms C's consent for the surgery. The procedure carried out was different from that to which she consented and we were concerned that Ms C might not have been properly advised of the procedures involved in this or the potential for failure.

Mr C, who is a prisoner, complained that the board were failing to follow his agreed dental treatment plan and failed to provide adequate care and treatment for his sleep disorder. We found nothing in Mr C's dental records to suggest that the board were not following the plan suggested at his initial appointment. We took independent advice from our GP medical adviser about the treatment for his sleep disorder. After reviewing Mr C's medical records, our adviser said that the board's actions had been reasonable in the circumstances. We did not uphold either complaint. Related reading View Decision Report 201400126 as a PDF (10.84 KB) Updated: March 13, 2018

Mr C complained about his care and treatment while he was being treated by a consultant surgeon in Ninewells Hospital. He said that, although he had lost weight, lost his appetite and become increasingly thin and lethargic, the surgeon discharged him and referred him to the care of a consultant gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas). Mr C said that it was only by chance that the seriousness of his condition was appreciated. He also complained that the board delayed in responding to his complaint about this. We considered all the complaints correspondence and Mr C's relevant medical records as well as taking independent advice from one of our medical advisers. We found that a scan had showed that Mr C had a narrowing of his colon (part of the large intestine). A later review noted that he felt well, had no pain and his bowel habit was unchanged, and it was decided to keep him under review and to scan him again later. Some 14 months after this, he went to a surgical out-patients' clinic and as he was complaining of a swollen stomach and the inability to eat, a scan was arranged for the following month. This showed further thickening in his colon and in the small intestine, and doctors decided to review him again in six months. By that time, his symptoms had settled but he was lethargic and nauseous, and the surgical team felt that there was no surgical solution to the problem. They referred him to gastroenterology for advice and further management. Mr C continued to lose weight and was prescribed intravenous nutrition (fed directly into a vein), but his condition continued to decline and another scan was organised. This showed evidence of chronic small bowel obstruction and he was referred back for surgery. Because of this, Mr C felt that the surgical team should not have discharged him to gastroenterology when they did. Our adviser, however, said that given Mr C's symptoms at t

Mr C, who is a prisoner, complained that the health centre at his prison did not provide appropriate treatment for his difficulties in coping with a recent bereavement, which included lack of sleep. To investigate this complaint, we needed Mr C's written consent for us to get his medical records. We asked for this and reminded him about it, but Mr C did not provide consent. We, therefore, closed his complaint as we could not carry out an investigation without it. Related reading View Decision Report 201305064 as a PDF (10.8 KB) Updated: March 13, 2018

Mr C complained that he did not have continuity of mental health care, as he had been seen by eleven different consultant psychiatrists. Mr C said this was frustrating for him, and caused him concern about whether he was receiving consistent care and treatment. We looked at Mr C's medical records, and took independent advice from our mental health adviser. We also asked the board what they were doing to deal with staffing issues in community mental health. The board explained the reasons for the lack of consistency in staffing, and provided reassurance about the steps being taken to improve the situation. They also remedied Mr C's specific situation by placing him on the caseload of a senior member of staff. Our adviser said that although there was a lack of consistency in the consultants who saw Mr C, there was no evidence in the medical records that his care and treatment were adversely affected in a significant way, or that there was a lack of continuity in his treatment. The standard of medical record-keeping and communication with his GP was reasonable, and ensured that important clinical information was appropriately passed on. Our adviser also said there had been greater consistency in terms of community psychiatric nursing provided, which helped offset any difficulties created by the problems with medical staffing. Related reading View Decision Report 201303995 as a PDF (11.25 KB) Updated: March 13, 2018

Mr C complained that the board failed to appropriately investigate the cause of his severe back pain following his admission to Perth Royal Infirmary. He said the board failed to carry out an MRI scan (used to diagnose health conditions that affect organs, tissue and bone) to allow an accurate diagnosis to be reached at an earlier date, and that he had to arrange for this to be done privately. We obtained independent medical advice on Mr C's case from one of our medical advisers, a consultant in orthopaedic and trauma surgery. Our adviser explained that Mr C's clinical picture after he was admitted should have guided the board's management of his condition. He explained that this could only be properly ascertained after taking an adequate history and clinical investigations. It appeared that the consultant orthopaedic surgeon did not fully examine Mr C, and relied on a junior doctor's examination, but this was reasonable as long as the junior doctor's assessment was thorough. However, as the board were unable to provide a copy of Mr C's medical notes for his time in hospital, we could not say whether he was properly examined. On the MRI scan, our adviser said that Mr C was not displaying 'red flag' (warning sign) symptoms but that, in view of his condition, the benefits of arranging an MRI scan outweighed the risks. He said that an MRI scan could have been arranged either as an in-patient or after Mr C's discharge, but this did not happen. Having considered the matter carefully, we were unable to say that Mr C's symptoms were appropriately investigated while he was in hospital to find the cause of his pain. If an MRI scan had been arranged when Mr C was an in-patient, he would not have had to arrange one himself, and if one had been arranged for him as an out-patient, then it was unlikely he would have arranged his own scan. We, therefore, considered it reasonable for the board to reimburse Mr C the cost of his private MRI. We were also very critical of th

Miss C, an advice worker, complained to us on behalf of her client (Miss A) about the handling of Miss A's Shetty Gastro-Jejunostomy (SGJ) procedure (the insertion of a feeding tube into part of the intestines). Miss A suffers from gastroparesis (paralysis of the stomach) which does not allow food to empty from her stomach. She was scheduled for the procedure as a day-surgery case and told that a particular radiologist would carry it out. On the day, however, a different radiologist tried to perform the procedure, without success. They were only able to insert a tube into Miss A's stomach, to prepare for a later attempt to insert the SGJ. Miss A suffered pain after the procedure and was kept in overnight for pain relief. Miss C also said that no written information was passed to the ward about the problems encountered during the SGJ. Miss A eventually had a SGJ inserted some seven weeks later. Our investigation included taking independent advice from one of our advisers, who said that the attempted SGJ was done in a reasonable manner with evidence of good, and even best, practice. The adviser said that this is a difficult procedure and Miss A's condition made it particularly so. There was no evidence that the radiologist who attempted it did not do so in a reasonable way. The adviser also said that the board's decision to allocate Miss A's procedure to the first available suitably qualified radiologist was a reasonable clinical decision, and that the radiologist's decision to insert a tube into the stomach to help a further attempt of the SGJ procedure was good practice. There are two approaches that could have been taken towards a further attempt - either to do so a few days after the first, or to wait for the track made by the stomach tube to mature (a period of four to six weeks) before making a second attempt. Either approach is reasonable and in this case the clinicians chose the latter, which was successful. Overall, we were satisfied that the car

Ms C said that she had a contraceptive implant fitted and when it was near the end of its life, she attended her GP for a replacement. She complained that she was told that because of her high blood pressure (BP) it was not possible to do so. As it appeared that Ms C was not taking her medication to reduce her BP, she was advised to do so and return to the practice in six to eight weeks time for review. Ms C attended again to have her implant reinserted but again her BP was noted to be very high. She was told that if there was an attempt to replace it there was a risk of uncontrolled bleeding and it was agreed that she should attend a local hospital for replacement. Ms C felt that she had been given unreasonable care and treatment because the reason why she had an implant fitted in the first place was because of her BP. She complained that the GP's actions left her without effective contraception. During our investigation, we took independent advice from one of our medical advisers, who is a GP. The adviser said that although the GP said she had acted in Ms C's best interests and followed national advice on implantable progesterone contraception like the type used by Ms C, she had in fact misunderstood the advice. In cases similar to Ms C's, the benefits of remaining on the contraceptive, despite her BP, would likely outweigh the risks as it was recognised as a safer option for women with high BP. In the circumstances, we considered it unreasonable that Ms C was left without an effective form of contraception for over seven weeks.

Mr C's son (Mr A) had been suffering from headaches and vomiting for several days. When Mr A's condition got worse, Mr C took him to the emergency department at Perth Royal Infirmary. They arrived at 01:17, and at 01:29, a triage nurse assessed Mr A and gave him paracetamol (triage is the process of deciding which patients should be treated first based on how sick or seriously injured they are). She arranged for Mr A to see an out-of-hours GP in the department at 03:15, and, without having taken any observations (temperature, blood pressure, pulse and oxygen levels) sent him home to wait for that appointment. After arriving home, Mr A's condition deteriorated further, and he could not move his neck or lift his knees. Mr C returned with him to the hospital at around 03:00, where Mr A saw a GP and was admitted to a medical ward at 03:36 with suspected meningitis, which was confirmed by tests. He was treated with antibiotics and discharged a week later. Mr C complained that the board failed to provide Mr A with a reasonable standard of care and treatment, in that the triage nurse failed to take any observations and recognise the seriousness of Mr A's condition. He also said that the delay of two hours between Mr A being seen by the nurse and by the GP was not reasonable in light of the serious and potentially life-threatening disease Mr A was suffering from. He complained that the board failed to respond appropriately to the complaint, including that they failed to adequately explain why the nurse did not undertake observations when she examined Mr A. We took independent advice on this case from our nursing adviser, who said that the care and treatment Mr A received from the triage nurse fell below a reasonable standard. She did not carry out a set of observations, which meant that her decision to refer Mr A to the out-of-hours service was based on minimal information that might have resulted in his further deterioration. The adviser was also critical that Mr

Shortly after being placed on the waiting list for a day surgery procedure in hospital, Mr C had a phone call offering him an appointment for the following week. He did not receive the pre-operative information leaflet in the post until two days after the surgery. On the day of the operation he was told that he had been moved to last on the theatre list. When he asked why, he was told it was because he previously had methicillin-resistant staphylococcus aureus (MRSA - a bacteria that is resistant to some common antibiotics, can cause infection and can be difficult to treat). This caused Mr C some distress. He complained that his history of MRSA had impacted on how his surgery was managed, although he had told staff - both at his pre-operative appointment and on the morning of the operation - that he had been given the all-clear a few years before. In responding to Mr C's complaint, the board acknowledged that it was unfortunate that he did not receive the information booklet in advance. They also said that there was no requirement to screen day surgery patients for MRSA, and that their infection control policy did not require MRSA-positive patients to be last on the theatre list, as measures were in place to mitigate against cross infection risks. However, they then went on to say that the consultant had placed Mr C last on the list as he had a history of MRSA and there was nothing in his records indicating that he was clear of the infection. As part of our investigation, we obtained independent advice from one of our medical advisers. Having done so, we upheld the complaint. We noted that the board had failed to provide pre-operative information to Mr C at the right time. We also found that they had deviated from their normal policy without properly explaining the reason for this. Their response to Mr C's complaint had been contradictory, in failing to explain why the consultant had not adhered to their policy.

Mr C attended his medical practice suffering from vomiting, diarrhoea and pains in his stomach. A GP diagnosed gastroenteritis (inflammation of the stomach and intestines) but some five days later Mr C was taken to hospital, where it was found that his appendix had burst, leading to peritonitis (inflammation of the tissue lining the abdomen). He had to have further surgery when he developed complications including kidney problems and a haematoma (a localised collection of blood outside the blood vessels). Three months after the original appendectomy he developed a fistula (an abnormal opening between organs) which had to be closed with a skin graft. Mr C complained to us that the GP failed to diagnose that he was suffering from appendicitis. We took independent advice on this from one of our medical advisers, and did not uphold the complaint. The adviser said that the GP had made a reasonable assessment and diagnosis of Mr C's symptoms, which were highly suggestive of gastroenteritis. The GP had asked Mr C to return to be reviewed if his symptoms did not settle down, but he did not do this. Our adviser pointed out that there is a shared responsibility between doctor and patient, and it was not the doctor's responsibility that Mr C did not return when his symptoms did not improve. Related reading View Decision Report 201304080 as a PDF (11.28 KB) Updated: March 13, 2018

Mrs C complained that her medical practice had removed her from their list of patients. She had visited the practice to try to get an emergency appointment. She had a sore throat and had lost her voice so she used a pen and a scrap of paper to communicate with the receptionist. As a suitable appointment was not available she became frustrated and left the practice. The following day, the practice wrote to Mrs C saying that because of her behaviour, and after seeing relevant CCTV footage, they had no option but to immediately remove her from the practice list. Mrs C told us that she disputed the practice's interpretation of her behaviour. We explained that the practice were entitled to act on any concerns they had and that it was not our role to comment on the incident itself. We confirmed that our investigation would focus on the process the practice followed in removing her from their patient list. We reviewed the relevant regulations and guidance, and discussed the case with one of our medical advisers. In order to remove a patient with immediate effect, the incident must have been reported to the police. Failing this, the practice should send the patient a warning letter. Only where a warning has been issued in the preceding 12 month period can they remove the patient without having involved the police. We upheld the complaint, as we found that in this case, the practice did not issue Mrs C with a warning, nor did they contact the police.

Mrs A lives in a care home and needs 24 hour nursing care as she has numerous medical conditions. Her son (Mr C) considered that her medical and nursing needs met the criteria for continuing care funding (funding provided by the NHS for specialist clinical or nursing treatment) set out in the Scottish Government's guidance document (CEL6). The board assessed Mrs A's needs, but did not consider that she met the criteria for continuing care funding. Mr C appealed this, but funding was again refused. He complained to us about the board's assessment of his mother's eligibility. He did not believe the assessment process had been followed correctly or that he and the professionals who directly care for his mother were sufficiently involved in it. We found that, in terms of the assessment of Mrs A's clinical and nursing needs, the board took an appropriately multi-disciplinary approach, using a single assessor to gather information and comments from various professionals involved in Mrs A's care. We did not uphold the complaint, as we were satisfied that the board had suitable tools in place to properly assess Mrs A's eligibility for continuing care funding and that the assessor was able to reach a clear, reasoned and evidence-based conclusion. The overall assessment was appropriate and well-documented. That said, we considered the board failed to properly involve Mr C and the care home in the initial assessment and made recommendations relating to this. We were also critical of their communication and explanations of the assessment process and the purpose of a meeting that Mr C attended. However, we noted that these issues were largely resolved at the appeal stage.

Mrs C complained about the care and treatment that a hospital provided to her brother (Mr A) after he was admitted with increasing confusion and suspected pneumonia. Mrs C, who was her brother's welfare guardian, was concerned that he was not given enough fluids and food; he was discharged prematurely and was readmitted a few hours later; there was a failure to diagnose his fractured leg; changes were made to his medication; and about poor communication. After taking independent advice from three of our medical advisers (a nurse, a consultant physician and a consultant psychiatrist), we found that nursing staff did not fully take into account Mr A's specific needs. He had a long standing mental illness and, despite knowing that there was a problem with him eating and drinking, there was no specific information on how to manage this. We found that Mr A's fluid intake was not properly monitored and there was a lack of consideration given to blood test results that indicated possible signs of dehydration. We did not consider that Mr A's discharge was unreasonable, because dehydration is difficult to diagnose. Hospital staff had taken steps to speak with Mr A's community psychiatric nurse (CPN) to establish his usual behaviour, and it was agreed that the CPN would visit him at home later that day to see if he needed psychiatric review. In addition, when it was known that his blood test results were abnormal, he was readmitted to hospital. Although we could not be certain when Mr A fractured his leg, he was promptly reviewed and diagnosed after bruising and swelling were identified. We were also of the view that it was appropriate to stop some of Mr A's medication (which had a sedating effect) because this could make his pneumonia worse. However, we considered that medical staff could have explained this to the family when Mr A was first admitted to hospital. In addition, although we found that the hospital obtained appropriate information from Mr A's GP, we thou

Mr C's mother (Mrs A) suffers from angina and vascular dementia (a common form of dementia, caused by problems in the supply of blood to the brain). Mr C holds welfare power of attorney for her. Mrs A was admitted to hospital after she collapsed. She was discharged home after two days but was readmitted several weeks later, following episodes of dizziness and falls. She was discharged again, but six days later was admitted (by her GP) for a third time due to chest pain, shortness of breath and poor balance. It was noted in her medical records that at the point of admission she was not 'coping in her social environment'. Mr C said that he only found out on the day of the second discharge that Mrs A was being sent home to an empty house with no other family members present. This was despite Mr C specifically requesting that Mrs A's return home should be fully coordinated with the local care team to ensure her effective transition from hospital to home. He said that there was no effective liaison with the local care team. When he raised concerns, the hospital arranged for a health care assistant to accompany Mrs A home. Mr C also said that the referring GP had asked the board to carry out a medical and social care assessment of Mrs A in relation to her third admission. Nearly two weeks after she was admitted, he found out it had not been completed and that staff were not aware of the request. He said that staff assumed Mrs A would return home on the same care package. The review was then carried out, but Mr C believes this was only because he insisted. After taking independent advice on this case from one of our medical advisers, we upheld Mr C's complaints. Our adviser said that when people with dementia are being transferred home from hospital, there should be a proactive risk assessment. This should consider the person's physical and cognitive abilities, the home circumstances and whether anyone will be at home to receive them on arrival. The board fai

Mr C was undergoing treatment for leukaemia and had to have a 'Hickman Line' (a small tube to give long-term access to a vein to administer chemotherapy) inserted. Mr C complained that this procedure was not performed correctly as it had caused him a great deal of pain. He also complained that his complaint about it was not dealt with reasonably. Our investigation, which included taking independent advice from one of our medical advisers, found no evidence that the procedure was not carried out properly. The adviser said that different patients experience differing levels of pain in such a procedure and there was no evidence that anything went wrong with the first insertion. However, no record of the problems Mr C experienced was made at the time. The radiologist who performed the procedure had, after speaking to Mr C after the procedure, agreed to make a record in the clinical notes and to put an alert on the electronic records saying that Mr C required sedation for any future insertion. This did not happen and, when Mr C had to be admitted for a further line to be inserted, he was distressed that the team were not aware of his experience. Because of this, although we did not uphold the complaint about the procedure, we made recommendations about record-keeping. On the matter of the complaints handling, it was clear from our investigation that for a number of reasons, there were extended delays in the handling of Mr C's complaint. Some of these were outside the board's control but some were not, and so we upheld this complaint.

Miss C complained that out-of-hours hospital staff did not take account of her recent bowel surgery in providing diagnosis and treatment when she attended there because she had not opened her bowels for several days. Miss C said that as a result of this, she developed peritonitis (inflammation of the tissue lining the abdomen) and had to undergo further surgery, including having a colostomy bag. After taking independent advice from one of our medical advisers, we found that the assessment carried out by the out-of-hours service was appropriate and there were no signs of peritonitis at this time. The records showed that the nurse who dealt with Miss C carried out appropriate examinations, and sought advice from medical staff when giving medication. We could not say for certain what the nurse said to Miss C, but there was evidence to suggest that Miss C was given the opportunity to be admitted to hospital (although we noted that she did not consider that she was in any position to make this decision at the time). We concluded after seeing the medical records that Miss C developed clear signs of peritonitis after she was admitted the following day to a different hospital, but that these symptoms had not been apparent when she attended the out-of-hours service. Related reading View Decision Report 201205097 as a PDF (11.21 KB) Updated: March 13, 2018

Mrs C complained about the children's waiting arrangements in a hospital accident and emergency department (A&E). She said that when she had to go there with her grandson she was appalled that children waited together with adults and were, therefore, exposed to bad language and inappropriate behaviour. She said that despite complaining to the board's chief executive little action was taken and the board failed properly to deal with her complaint. We carefully considered all the available information, including all the complaints correspondence, and the response to our formal enquiries to the board. Our investigation confirmed that at the time Mrs C made her complaint, the board were simply required to provide emergency care 'within a safe environment' which could have been provided in a variety of ways. Since then, new standards have been introduced which are more than mere recommendations. The board are currently exploring the feasibility of creating a children's waiting area in A&E and reviewing how this could be achieved. However, it would seem that progress is slow. Although we did not uphold this complaint, we made a recommendation in order to monitor this. The investigation also showed that the board took too long to respond to Mrs C's complaint, so we upheld her complaint about this. We noted that the board have introduced new ways of working to avoid this in the future, and made relevant recommendations.

Mr C complained on behalf of his daughter (Ms A) about the care and treatment she received when twice admitted to hospital. Mr C questioned whether Ms A was properly assessed on both admissions and why, although he said she had suicidal thoughts, she was discharged on the second occasion with a large amount of drugs, before taking an overdose. He believed that this would not have happened if things had been handled differently, and that they should have dealt with her medical problems holistically. The complaint was investigated and all the relevant information, including the complaints correspondence and the relevant medical records, was given careful consideration. We also obtained independent psychiatric advice from one of our medical advisers. As part of the investigation, the adviser reviewed Ms C's records with specific reference to the assessments made on her admissions and the circumstances of her discharge. He was satisfied with these and had no criticism to make about them. While Mr C believed his daughter had psychiatric problems which meant she should have stayed in hospital, our investigation found that on both admissions, she was a voluntary patient. She had been admitted primarily in relation to her excessive drinking and her admissions were based on an agreement that if she was found to possess or use alcohol she would be discharged. As Ms C had broken that agreement, she was discharged, and the records showed that reasonable outside support arrangements had been put in place for her. We did not uphold the complaint but as our adviser said that, though they would not have changed the outcome, there were some things that could have been done better, including the use of ICD10 (a classification of mental and behavioural disorders - clinical descriptions and diagnostic guidelines) we made some related recommendations.

Mr C complained that a GP provided him with inadequate care and treatment. Mr C visited the GP because he had pain on the left side of his head. He said the GP diagnosed shingles and prescribed inappropriate medication, an antidepressant. We looked at Mr C's medical records and took independent advice from one of our medical advisers. In the absence of any independent evidence from the consultation, however, we could not reach a definitive finding on exactly what was said there. We found that the medical records showed that the GP had noted that there was no shingles rash present, and had treated Mr C for nerve pain. We also found that the medication prescribed was appropriate for this, as although it is an antidepressant, it is also frequently used to treat nerve pain. We concluded that the GP provided a reasonable level of care and treatment in the circumstances. Related reading View Decision Report 201301600 as a PDF (11.02 KB) Updated: March 13, 2018

Mr C complained about a surgical procedure that was carried out in hospital. He said a biopsy was taken, and although he had understood that three sebaceous spots would be removed from his groin/penis area, they were still there. In addition, he now had seven stitches on his penis. He was discharged from hospital the same day, and was told the stitches would dissolve naturally. However, the wound opened the next day, and he self-cared for it. He questioned why no follow-up treatment was planned for him and why nobody explained what the procedure would entail. He said that he did not give consent for anything other than the removal of the cysts. The board explained that the proper procedure was carried out, to which Mr C had consented. In addition, staff had explained the procedure along with any potential risks of the surgery and an advice leaflet was provided on discharge from hospital. Before we finished our investigation, however, the board told us that Mr C had instructed legal action against them. As a result we discontinued our investigation, as we are unable to look at a complaint where the matter complained about is being determined in court. Related reading View Decision Report 201204143 as a PDF (11.17 KB) Updated: March 13, 2018

Mr C complained about the care and treatment the board provided after he went to their accident and emergency department (A&E). He said that they failed to appropriately examine and assess his symptoms of severe abdominal pain with urinary and bowel problems. He also said that they inappropriately discharged him at 05:30 in the morning without considering whether he had the means or ability to return safely home. Mr C said that after seeking further medical assistance elsewhere, he was admitted to hospital the next day with an obstructed bowel and was kept in for assessment and treatment. We took independent advice on this case from one of our medical advisers. The adviser said that the assessment and examination in A&E were of a reasonable standard and that the treatment Mr C received elsewhere the next day did not indicate otherwise, so we did not uphold his complaint about care and treatment. However, the adviser was critical of the board for failing to have adequate discussions with Mr C about treatment for constipation and failing to give him laxatives to take home with him. The adviser also said that they failed to discuss practical arrangements for Mr C's discharge to ensure that he could return home safely. We upheld the complaint about discharge and made recommendations accordingly.

Ms C, who is an advice worker, complained on behalf of Ms A about the care and treatment that her late father (Mr A) received during the last three days of his life, and about how her complaint about this was handled. Mr A's GP referred him to a medical admissions ward. Mr A went straight to the ward, and was asked to wait in the day room. He remained there for four hours before he was seen by a doctor, given a bed, and treatment was started. Information on his referral showed he was very unwell, indicating that he had pneumonia and kidney failure. Mr A was treated with antibiotics, and was transferred to a different ward the next day. For the next two days Mr A’s condition remained stable and his vital signs (pulse, blood pressure, temperature and oxygen levels) were taken roughly every four hours. In the evening of the second day Mr A became increasingly unwell. This was noted by staff, who increased the frequency of checks on his condition to hourly. A doctor reviewed Mr A and identified that he needed more oxygen. He arranged for a special blood test to check oxygen levels in Mr A’s blood, and asked for a repeat of this test two hours later. There are references to the results of both these tests in the clinical notes, but only the first test was noted in detail, and the second set of results were not identified by the board in their response to Ms C’s first complaint. As a result, Ms C was mis-informed about these tests. This was because the test results were held on record electronically, and were not added to the clinical file. Despite further assistance with his breathing, Mr A died the following day. We obtained independent advice on this complaint from one of our medical advisers. We upheld the complaint about the delay in getting a bed, as his advice indicated that Mr A should not have been kept waiting in the day room of the admissions ward for such a long time, and that this created risks for patient care. We did not uphold Ms C's complaints about vital