SPSO Individual Decisions

Miss C complained that she was misdiagnosed in 2010 with ulcerative colitis (where ulcers form in the large intestine and rectum (the terminal part of the large intestine). She said that when she was offered a surgical procedure in 2012 this was inappropriate as her actual diagnosis was of Crohn's Disease (where the small intestine becomes inflamed, thickened and ulcerated). Ulcerative colitis is one of a range of conditions known as Inflammatory Bowel Disease (IBD). Miss C had undergone an emergency ileostomy (where the damaged portion of the small intestine is removed and the remainder directed to an opening created in the stomach wall. The contents of the intestine are then emptied into a collection bag which remains in place for life unless the ileostomy is reversed.) In 2012 she was offered a reversal of the ileostomy as her condition had been stable for some time. After the reversal procedure Miss C experienced an increase in her symptoms and was admitted to hospital four times in the next few months. Her diagnosis was eventually changed to Crohn's Disease and she was advised to have her ileostomy reinstated. Miss C complained that as a result of her misdiagnosis she underwent two major but unnecessary surgical procedures as she had been told that Crohn's sufferers are 'never' offered reversal surgery. After taking independent advice from one of our medical advisers, we did not uphold Miss C's complaints. We found that the original diagnosis of ulcerative colitis given to Miss C was not unreasonable. The adviser said that the conditions have similar symptoms but that Crohn's Disease classically involves the small intestine. In 2010 an internal examination had shown that Miss C had ulcers only in her large intestine. The adviser also said that the offer of reversal surgery was reasonable, on the basis of the diagnosis of ulcerative colitis and in view of her condition being well managed at the time. The adviser also said that even had the original dia

Mr C, who was a prisoner, complained to us that the health board unreasonably stopped his medication. However, he was released from prison during our investigation and did not tell us his new address. As we were unable to contact Mr C, we closed the case. Related reading View Decision Report 201204591 as a PDF (10.74 KB) Updated: March 13, 2018

Ms C complained about the care and treatment that her father (Mr A) received from the medical practice during the weeks leading up to his admission to hospital with a chest infection and kidney failure. Mr A saw doctors from the practice several times in the four weeks before he was admitted. Ms C was concerned that an earlier diagnosis of chest infection could have improved his care at home, and reduced the need for hospital intervention. Mr A died three days after he was admitted to hospital. Mr A had seen doctors from the practice five times - in relation to fluid on his lungs, an ongoing urine infection and unsteadiness with walking. In addition, he saw a physiotherapist twice, had a chest x-ray and a chest scan. The final consultation was during a home visit, when signs of a chest infection were apparent. At first, the GP had assessed that Mr A could stay at home, and take antibiotics. However, when blood tests showed that his kidney function was poor, she decided that he needed admission to hospital for closer monitoring. We obtained independent advice on this complaint from one of our medical advisers, but did not uphold the complaint. The advice indicated that the chest infection was not apparent until the day Mr A was admitted to hospital, and was not evident on the chest scan. Our adviser considered that the care and treatment provided by the practice were of a good standard and that there was no delay in diagnosing the chest infection. We also found that the practice had acted promptly to secure Mr A's admission to hospital when the infection was identified. Related reading View Decision Report 201204850 as a PDF (11.43 KB) Updated: March 13, 2018

Mr C complained about the care given to his wife (Mrs C) in an accident and emergency department on two occasions, and said that she was displaying clear symptoms of stroke on both. He also complained that Mrs C was discharged from hospital on her second visit, even though she was unable to speak without slurring. He told us he pointed this out to the doctors, but was ignored. Mrs C's GP referred her urgently to the hospital the following day, where she was found to have suffered a stroke. We took independent advice on this case from one of our medical advisers. Our investigation found that on the first occasion Mrs C was diagnosed as suffering from migraine (an extreme type of headache which can cause disturbances to speech and vision). We found that it was reasonable to attribute Mrs C's symptoms on this occasion to migraine, but that her case should have been discussed with the on-call neurologist (a specialist in diseases of the nerves and the nervous system) and a management plan agreed. We, therefore, upheld the complaint that her treatment and diagnosis was not reasonable and made a recommendation referring to the relevant guidelines from the Scottish Intercollegiate Guidelines Network (SIGN). We also found that on her second visit to hospital, it was unreasonable for Mrs C to have been diagnosed as suffering from migraine. There was no record of either a FAST (Face, Arm, Speech, Time of Event) assessment, or of a ROSIER (Record of Stroke in Emergency Room) review. Our adviser said that had either of these been carried out, then the result would have been positive. There was no record of discussion between emergency department doctors about Mrs C's unusual symptoms, and her case should have been discussed with a neurologist or stroke physician and a CT scan (a type of scan using x-rays to create a detailed picture of the inside of the human body), should have been requested. The board had not recognised this failing in their response to Mr C’s compl

Mr C complained about the care and treatment provided to him by the medical practice. We started our investigation, but Mr C died before it was completed. As we had no contact details for Mr C's next of kin or executor/executrix, we were unable to take this complaint further, and closed our file. Related reading View Decision Report 201204712 as a PDF (10.78 KB) Updated: March 13, 2018

Mr C complained to us about advice given to him by the board's out-of-hours service. We started our investigation, but Mr C died before it was completed. As we had no contact details for Mr C's next of kin or executor/executrix we were unable to take this complaint further and closed our file. Related reading View Decision Report 201203096 as a PDF (10.77 KB) Updated: March 13, 2018

Mr C, who is a prisoner, complained about the prison health centre's complaints handling. Mr C had submitted a formal complaint about the health care and treatment he had received. However, the health centre responded to the complaint under the feedback procedure, not the complaints procedure. The board said that this was in accordance with the approach for all informal complaints, which should be dealt with by local response. They said that any further complaints or feedback forms would be dealt with through the formal complaints procedure. They also commented that, where possible, complaints are addressed at the point of contact, unless the complainant wished to pursue their complaint through the formal complaints procedure. We considered that as Mr C had submitted a formal complaint, it should have dealt with as such. We were concerned that the board were using the feedback procedure as an additional level to the NHS complaints procedure. This is restricting, and over-complicates prisoners' access to the NHS complaints procedure. It is clear that Scottish Government guidance does not require NHS users to complete the feedback procedure before accessing the complaints procedure. This should also apply to people receiving NHS care and treatment whilst in prison. Mr C went on to make a further formal complaint to the health centre. However, he said that they returned the complaint form to him, and explained that it was not answered, along with several others, due to the fact that they met him to see if the issues could be dealt with. They said that during the meeting, Mr C withdrew the complaint after agreeing that the problems were resolved. However, we found no records to support this in the evidence we received from the board. Mr C then submitted a further complaint to the health centre, but did not receive a response. The health centre should have sent this complaint to the board for response. Mr C contacted the board, who advised that they had not received it f

Mr C complained about the care and treatment provided to him by the medical practice. We started our investigation, but Mr C died before it was completed. As we had no contact details for Mr C's next of kin or executor/executrix, we were unable to take this complaint further, and closed our file. Related reading View Decision Report 201204718 as a PDF (10.78 KB) Updated: March 13, 2018

Mrs C's GP referred her to hospital because she suddenly lost the vision in her left eye. She was diagnosed with a blockage of the main artery supplying the retina (the inside lining of the eye), and her loss of vision was severe and permanent. Mrs C attended the hospital again a few days later with similar symptoms affecting her right eye. She was then given a high dose of steroids, as it was suspected she had giant cell arteritis (GCA - inflammation of the blood vessels, usually in the head, which can cause blindness). Mrs C's husband (Mr C) complained to the board that Mrs C was not closely monitored after being prescribed such a large dose of steroids, but we did not uphold his complaints. After taking independent advice from one of our medical advisers, we found that the relevant consultant kept Mrs C under appropriate review, and there was a clear plan for the management of her steroids. We concluded that although Mrs C did suffer side effects, which were very distressing for her, these were properly assessed against the risk of her losing her eyesight permanently and having a stroke. Related reading View Decision Report 201104850 as a PDF (11.26 KB) Updated: March 13, 2018

Mrs C attended the board's dental service, as her dentures were loose and uncomfortable. She had a new lower denture fitted and her top denture relined. However, she found the new dentures uncomfortable from the outset and returned to the service. The dentist made her a new lower denture based on her original dentures. Mrs C was unable to eat with these dentures and they caused her pain. She went back to the dental service again and was referred to the dental hospital. She was told to wear her old dentures in the meantime, as they fitted better. Mrs C saw a consultant at the hospital. He suggested replicating her old dentures, and adding a permanent soft lining material. He placed her on the waiting list for treatment by postgraduates at the hospital. However, at that time, they were reaching the end of their placements and were unable to offer treatment to new patients. Mrs C told us that due to the delay, she decided to get private treatment. She said that the dentist she saw privately was able to make her dentures without any difficulty. Our investigation found that the board had failed to let Mrs C know that there would be a delay in her treatment because the postgraduates were unable to offer treatment to new patients at that time. Due to the delay that occurred as a result of this, the board failed to meet the 18 weeks referral to treatment target. Although the board's view was that the dentures made by the dental service were not defective, we found that they had accepted that the dentures were not fit for purpose by agreeing to make new ones.

Mr C complained that, when he attended a hospital clinic appointment, the doctor carried out a procedure without Mr C's consent. He said that he told the doctor that he could look at the problem only, but not take any action. He said that the doctor ignored his wishes. When we investigated this, the board explained that the doctor and the health care assistant who were present were of the opinion that Mr C had agreed to the procedure. We found, however, that the doctor had not strictly adhered to the board's informed consent policy and had not explained what the procedure entailed, or recorded that Mr C had agreed to the procedure. We upheld Mr C's complaint and made a recommendation about this.

Mr C is unable to cut his own toenails, and complained that the board failed to provide him with an appropriate regular service for this. He explained that delays in having his toenails cut impacted on his mobility and caused him discomfort. Our independent medical adviser noted that it was reasonable that times between appointments may be affected by staff resource and demand. As Mr C’s complaint was very similar to one that he had made before and the board had already explained the appointment system to him at that time, we did not uphold his complaint. Related reading View Decision Report 201204154 as a PDF (10.94 KB) Updated: March 13, 2018

Ms C complained that doctors at the practice failed to manage her medication regime appropriately. Ms C was suffering from bi-polar disorder (a condition that affects a person's mood). She was prescribed medication, including lithium (a medicine used to treat mood disorders) and quetiapine (a drug used to treat bi-polar disorder). Her lithium levels were monitored every three months at a special clinic as lithium may interact with other drugs and can cause toxicity (a poisonous effect on the body). She was also monitored by a community psychiatric nurse (CPN) and a consultant psychiatrist every four to six weeks. On one occasion Ms C went to the practice as she felt she was suffering from toxicity. She saw a locum GP (a doctor in a temporary position at the practice), who did not think that she was but asked her to speak to her CPN to organise a blood test. The CPN told her to go back to the practice, and another doctor did the blood test. The results showed that she was not suffering from toxicity. After investigating, we did not uphold Ms C's complaint. We took advice from as independent medical adviser, who said that the evidence in the clinical notes showed that it was unlikely Ms C was suffering from toxicity when she saw the locum GP. Although the adviser was concerned that the locum GP asked Ms C to arrange her own blood tests, she considered this to be a misunderstanding about the resources available. In light of this, although we did not uphold Ms C's complaints, we drew to the practice's attention that the adviser had suggested they might wish to consider placing an alert on the notes of patients prescribed lithium, with information on how to obtain urgent blood tests where there is a suspicion of possible lithium toxicity. Ms C also complained that the practice would not prescribe her extra quetiapine. She was under the impression that her psychiatrist had increased the dose. Having looked at Ms C's clinical notes and the communication between

Miss C raised a concern about the treatment she received from a hospital dermatology department (a department dealing with skin conditions and problems). In particular, she said that there was an unreasonable delay in diagnosing her condition and in progressing treatment. After taking independent advice from one of our medical advisers, a senior consultant dermatologist, we did not uphold her complaint about diagnosis. We recognised that this was a difficult and stressful time for Miss C, but we found no evidence that the treatment was not of a reasonable standard in the face of what had been an unusual problem. We did, however, uphold her complaint that there was a delay in progressing treatment. Before we investigated, the board had accepted that Miss C's referral to the plastic surgery team had, in error, not been marked as urgent. As a result, it had been treated as a routine referral and this had resulted in a delay before Miss C was seen by the team. As, however, the board had already recognised this and apologised to Miss C, we did not make a recommendation about this. Related reading View Decision Report 201201868 as a PDF (11.19 KB) Updated: March 13, 2018

Mrs C had concerns that in 2011 the board had sent us a complaints file which was incomplete and contained inaccurate information about previous complaints that she had raised. We had asked for this file when looking at a previous complaint from Mrs C. (We had decided that complaint was too old for us to look at, so the information from the complaint file did not, therefore, affect that decision.) Mrs C formally complained to the board about the file and, when she received their response, she felt her concerns had not been addressed. Our investigation found that the board had taken Mrs C's concerns seriously and had conducted a thorough investigation. They provided a comprehensive response about the contacts that Mrs C had made with their complaints team as far back as 2007. They also explained the difference between enquiries, informal complaints and formal complaints, and how they deal with these. We, therefore, did not uphold Mrs C's complaint. However, we found that Mrs C had raised a couple of concerns that would have benefitted from a more detailed response and made a recommendation about this.

Mrs C made a number of complaints about the board's care and treatment of her husband (Mr C). Mr C had been diagnosed with rectal cancer (cancer of the lower part of the large bowel) and liver metastasis (cancer that spreads to other parts of the body). Mrs C said that her husband had cognitive defects (his understanding was limited) and the board did not take this into account when obtaining consent for surgical procedures carried out on him. She said that Mr C was not competent to give informed consent (consent for medical procedures to take place, with a proper understanding of what these involve) and that she stressed this to every health professional she came in contact with. Mrs C was both financial and welfare power of attorney for her husband (ie she could control decisions about most aspects of his life). However, when responding to her complaint, the board said that Mr C was not at any point considered to have been incapacitated to an extent where he could not sign his own consent forms. We upheld Mrs C's complaints about Mr C's care and treatment and about the board's complaints handling, but not her other complaints. Our investigation found that, on balance, there was evidence in the case notes to show that Mr C had cognitive impairment that compromised his capacity to provide informed consent. The clinicians involved should have documented their own assessment of his capacity, but failed to do so. We, therefore, did not know what their views on this were, or how, if at all, they had assessed Mr C's capacity to consent to medical procedures. If they believed that Mr C lacked capacity, then the provisions of the Adults with Incapacity Act should have been used, which would have ensured Mrs C's involvement as power of attorney. Mrs C's involvement in major decisions relating to Mr C's care, including consent to undergo surgery, would also have been documented. On the other hand, had the clinicians believed that Mr C did have capacity for such decision maki

Mrs C said that her husband (Mr C), who had terminal cancer, had fallen from his bed which was in a side room in the hospital, and died later that day. Mrs C felt that staff should have kept a better watch on her husband as he had lain on the floor for some time. She felt that the level of investigation of her complaint was inadequate. In response to Mrs C's complaint, the board had apologised that the level of observation carried out on Mr C overnight was inadequate, and said that they had reminded staff of their responsibilities. They also explained that Mr C was assessed as at low risk of falling and when he was discovered on the floor he was examined by a doctor and put back to bed. Mr C had been placed in the side room for privacy, and to allow the family flexibility in visiting. Our investigation noted that it was good practice for the board to have placed Mr C in the side room for privacy reasons. We did not uphold the complaint, as we found that the board had properly investigated Mrs C's concerns. Related reading View Decision Report 201202867 as a PDF (11.15 KB) Updated: March 13, 2018

Mr C and his partner sought in vitro fertilisation (IVF) treatment on the NHS. The board, however, said that because Mr C's partner's child from a previous relationship lives with them, they were not eligible for treatment. Mr C said that this decision was unreasonable because the board's policy on assisted conception discriminates against him and other men who have no biological children. He also said that the board did not deal with his complaint properly in that there were inaccuracies and delays in their responses and that they failed to address his complaint. We explained to Mr C that it was not for us to determine whether the board's policy was discriminatory, but that we would consider whether their actions were reasonable. We found that their decision was reasonable in light of the framework for infertility services accepted by the Scottish Government and that, in taking legal advice and ensuring compliance with Scottish Government guidelines, they had acted in line with legislation and guidance. We did find that the board delayed in responding to the complaint and that their responses should have provided a clearer explanation about the framework for infertility services from the outset. However, we made no recommendations about this, in light of the fact that the board reviewed their complaints management system earlier this year. Related reading View Decision Report 201103655 as a PDF (11.31 KB) Updated: March 13, 2018

Mrs C complained that she received poor care in hospital after undergoing a procedure to remove a gallstone from her bile duct, which resulted in her bowel being perforated. Mrs C also raised specific concerns that the risk of perforation was not explained to her; there was a lack of information given to her about what happened during the procedure, and she had not been aware of a tube having being inserted during the procedure. The board said that the procedure was appropriate as not removing the gallstone could have led to recurrent inflammation of the pancreas (pancreatitis), inflammation of the bile ducts and jaundice (yellowing of the skin or eyes). In addition, the procedure carried a lower risk than open surgery. We considered this response reasonable as earlier investigations had showed a small stone blocking the bile duct. However, we upheld Mrs C's complaint. Our medical adviser said that, while junior medical staff did consider at an early stage the possibility that there had been a perforation, aspects of Mrs C's after-care fell below a reasonable standard. This was because there was no senior doctor accountable for Mrs C's care after the procedure, and no clear supervision of the junior medical staff who were reviewing her. Our adviser considered that there should have been a clear and consistent action plan from the time the perforation was identified to the time Mrs C was transferred to another hospital (five days later) for surgical review. In addition, there did not appear to be any clear instructions by medical staff about feeding or fluids. Therefore, five days were lost in getting the perforation effectively healed, due to poor nutrition and the likelihood that Mrs C's immune system was weakened. The board said that Mrs C had been sent a leaflet on the procedure which included information on the risk of perforation. Our investigation, however, identified that Mrs C was given a different leaflet that did not explain any of the specific risks. Gene

Miss C's medical practice were concerned about her compliance with her medication. They had, therefore, previously decided, with Miss C's agreement, to dispense her medication on a daily basis. However, Miss C requested that this be returned to weekly or monthly prescriptions, and she complained when this request was refused. The practice told us that, as they continued to have safety concerns about Miss C's compliance with her medication, they had decided that daily prescribing would remain in place. Having taken independent advice from our medical adviser, we considered this to be a reasonable decision in the circumstances. Miss C also complained that her medication was no longer being prescribed to her in tablet form. She was receiving a liquid alternative and did not feel it was working as well for her. Although the practice had advised her that the tablet form was no longer available in this country, Miss C identified a drug company who could still supply this. However, the practice noted that this was imported and unlicensed and, therefore, did not agree to prescribe it. Our medical adviser took the view that this was reasonable and said that doctors are discouraged from prescribing unlicensed medication when licensed alternatives are available. In addition, he noted that the medication was very expensive and he did not consider that it would be prudent for the practice to prescribe overly expensive drugs that were not clinically necessary. Related reading View Decision Report 201200850 as a PDF (11.34 KB) Updated: March 13, 2018

Mr C complained on behalf of a constituent (Mr A). He complained about the board's decision to refuse funding for Mr A's weight-loss surgery to be carried out by another health board. Mr A had serious concerns about the care and treatment he received from the board, when he was admitted to hospital previously. As a result, during the past few years, his GP had referred him for treatment, including weight-loss surgery, to a hospital in another health board area. The hospital offered Mr A weight-loss surgery but said that it would have to be funded by his local health board. The local board decided not to approve Mr A's application for funding and instead offered him the weight-loss surgery service that they provided. Mr A, however, believed it would be in his best medical interests for the surgery to be performed outwith his local health board area. Our investigation found that the board's decision to refuse the funding of Mr A's treatment at another health board was a discretionary decision that they were entitled to take. We cannot look at such a decision unless we find evidence that something went wrong in the way it was taken. We did not uphold Mr C's complaint, as we found that the board followed their procedures and took all relevant factors into account in reaching their decision. Related reading View Decision Report 201104984 as a PDF (11.27 KB) Updated: March 13, 2018

Ms C complained about the care and treatment she received from a hospital. She outlined eight specific areas of concern, including communication, standard of care, waiting times, lack of after care and competence of staff. She said that she initially went to the hospital with symptoms of bowel disease, but her worsening symptoms suggested a gynaecological problem. She said that after that she experienced other health issues. She underwent an operation and was referred for treatment to another health board. Ms C’s complaint to us also included other issues of concern including misdiagnosis, inappropriate administration of medication and poor complaints handling. Our medical adviser considered all aspects of Ms C’s complaints and said that she displayed complex symptoms and had had a thorough investigation of her gastro-intestinal tract. She had an ovarian cyst (a sac filled with fluid that forms on or inside an ovary) removed promptly and an area of endometriosis (small pieces of womb lining found outside of the womb) destroyed. We found that medication was appropriately used, communication was effective and Ms C received timely inpatient attention and after care. Having taken account of all the evidence and the advice received, we considered that the board appropriately addressed and responded to all Ms C’s complaints. Although we did not uphold her complaints, we found some delay in advising Ms C's GP of a test result.

Mrs C was on medication for serious mental health problems. She registered with a new medical practice in 2011, having been stable for a number of years on an existing medication regime. However, the new practice did not obtain her medical records nor make contact with the psychiatrist who had been treating her previously. In March 2012, Mrs C attended the practice about a non-related medical issue and saw a doctor. During the appointment, the doctor questioned the medication regime and said that Mrs C should undergo a review, as the types of medication she was on could have serious cumulative side effects if taken long term. Mrs C was upset and anxious that the doctor proposed reviewing her medication, given that she had been stable on the regime for a number of years and had had serious difficulties in achieving this stability. She was also upset by the doctor's tone and a number of comments he made during the consultation which she felt were inappropriate when dealing with a patient with mental health problems. We found that the aims of the consultation were valid and constituted good practice. We were, however, critical that the practice failed to obtain Mrs C's medical records or to contact her psychiatrist, as she had registered with them nearly a year before. We noted that the doctor had written details of his comments in the consultation notes, and that he himself had since accepted that these may have added to her concerns. We were critical of this, and for the fact that he did not conduct an assessment of Mrs C's health at that time, although we recognised this could have been difficult given the nature of the consultation overall. On balance, however, we did not uphold the complaint as we found the aims of the consultation about which Mrs C had complained were reasonable and should have been undertaken earlier. We did, however, make recommendations to address the shortcomings we identified that took place before the consultation.

Mrs C suffered from lung cancer and chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed). She was receiving chemotherapy but after the second cycle her condition deteriorated and she was admitted to hospital, where she died a few days later. Her daughter, Miss C, was concerned that while her mother was in hospital one of her medications, which was given by injection, was not always administered. She said that at times the injections were prepared and then left by her mother's bedside if they were not given. Miss C also complained that a pain relieving patch was not administered. The board said that the patch had been administered but was later removed. There was conflicting information from the board and Miss C about when this happened. We investigated and took independent advice from one of our medical advisers, a senior and experienced nurse. She said that the Nursing and Midwifery Council (NMC) issue guidance on the preparation and administration of drugs and that the practices demonstrated in this case did not comply with that guidance. We upheld both complaints. Miss C said that there were inaccuracies in the fluid monitoring charts, but we could not establish the accuracy of these, given the time that has passed since. The board did say that Mrs C, who was a retired nurse, liked to maintain her independence where possible and preferred to go to the bathroom when she was able. They said that this may have introduced some inaccuracy to the charts. Our investigation found that it was reasonable to allow Mrs C to maintain her independence where possible. The nursing adviser reviewed the charts and had no concerns, and we did not uphold this complaint. Finally, we upheld Miss C's complaint about complaints handling. We found that there were unacceptable delays in responding to Miss C's complaints. The final response took four months rather than the 20 working days required by the NHS guidance on complaints

Ms C's late father (Mr A) was admitted to hospital with circulation problems in his legs. He was diagnosed as having compressed arteries causing reduced blood supply, and emergency surgery was arranged for that afternoon. This was carried out but there was no improvement and his condition deteriorated. Two days later, medical staff concluded that the outlook for Mr A was poor and agreed with his family to provide only palliative care (care to prevent or relieve suffering). Mr A passed away later that day. Ms C said that the day after Mr A's operation her mother (Mrs A) tried unsuccessfully to discuss his condition with a doctor. Ms C also told staff that she was going on holiday the next day, but said that nobody told her how serious her father's condition was. The next day, Mrs A went to hospital expecting an update and so did not bring any family members with her. Staff there told her that Mr A’s condition was terminal. Ms C was informed of this when she arrived at her holiday destination but could not get a flight back until the following day and so did not see her father before he died. We took advice from one of our medical advisers, and found that while Mr A was critically ill, he was stable on the day after his operation. We found no evidence that his death so soon afterwards could have been predicted, as his condition did not deteriorate significantly until shortly before his death. We also found that staff acted reasonably when they asked Mrs A to come into the hospital quickly and told her of her husband's terminal condition, as at that point Mr A was deteriorating rapidly. Related reading View Decision Report 201104041 as a PDF (11.55 KB) Updated: March 13, 2018