SPSO Individual Decisions

Mrs C complained to the board about the treatment her late husband (Mr C) received at Ninewells Hospital in January and February 2011. Mr C had been attending his GP surgery since November 2010 with breathlessness, cough and weight loss. Mr C attended the hospital's A&E department in late January 2011 and after seeing a nurse and a doctor he was sent home and told to wait until the GP referred him to hospital. No medical assistance was given. Mr C attended the respiratory clinic ten days later where he was x-rayed, weighed and had bloods taken. He was told he did not have cancer. Eight days later, the GP arranged for Mr C to be admitted to hospital that day and a CT scan was carried out two days later. The scan showed evidence of widespread infiltration of the lung, suggestive of malignant disease or infection. As the scan was inconclusive a biopsy of the lung was carried out the following day. The result indicated that Mr C had lung cancer which was rapidly progressing and which was unusual for a non-smoker. It was decided that Mr C should be transferred to a community hospital, where he died two weeks later. We upheld Mrs C's complaint that her husband was unreasonably turned away from the A&E department when she brought him there when she was concerned at his condition and the lack of urgency shown by his GPs. We also upheld the complaint that when Mr C attended an outpatient appointment he was incorrectly told he 'definitely did not have cancer'.

Mr C complained that his dental practice had given him inaccurate information in telling him that work he needed done (template and crown work in preparation for implants) could not be provided on the NHS. Our dental adviser confirmed that the required work would not have been covered by the NHS and so would have to have been done on a private basis. We, therefore, concluded that the practice's response was reasonable. Related reading View Decision Report 201102219 as a PDF (13.4 KB) Updated: March 13, 2018

Mr C complained to us about the board's care and treatment of his late brother (Mr A) prior to his death. Mr A, who was elderly, was due to be admitted to hospital for an endoscopic examination. In anticipation of this, he was given medication the day before, but became very ill and was instead admitted to hospital on the day of the planned procedure, as an emergency. The next day, a Tuesday, Mr A had a colonoscopy and he was then considered ready for discharge in a few days. It was proposed he would be discharged on Friday or Monday, subject to the availability of an ambulance. However, he was returned to his care home by ambulance on the Saturday. Unfortunately, he was returned back to the hospital later that day in a very poor state, and died the next day. Mr C was of the view that his brother was unreasonably discharged from hospital. He also complained that the board's communication with his family was inadequate. We fully upheld Mr C's complaints. Our investigation showed that there was little information in Mr A's clinical notes and our medical adviser pointed out that nothing at all was noted about his condition on the day that he was discharged. Accordingly, Mr A may well have not been ready and fit for discharge. Similarly, there was very little record of any discussion with Mr A and his family about his care and treatment.

Mrs C said that for eleven years she had been prescribed MST (morphine sulphate based medication) but had received a letter from her medical practice saying that the drug would no longer be prescribed. Mrs C complained that she had asked for the decision to be reconsidered but was told it was final. Mrs C said that because of the decision to stop her prescription she suffered very badly from withdrawal symptoms. As part of our investigation, we discovered that the medical practice had received anonymous information alleging that Mrs C was selling her MST tablets. Because of this the practice requested a toxicology report on a urine sample. This did not show the presence of opiates and so the medical practice considered that it was reasonable to stop prescribing them. As it appeared that Mrs C was not taking the MST prescribed to her, the practice also considered it unlikely that she would have suffered withdrawal symptoms. We did not uphold the complaint but we made a recommendation to the practice. Recommendation We recommended that GPs at the practice: • in future similar cases should seek patient consent before a toxicology screen is requested. Related reading View Decision Report 201100446 as a PDF (18.62 KB) Updated: March 13, 2018

Mrs C complained that a nurse had inappropriately discussed social work matters in front of her and her son, Master A, during a 1-2-1 meeting that resulted in Master A becoming upset and distressed. Mrs C also complained about the board's handling of her complaint about the discussion and that her complaint against the nurse had not been addressed. The board had investigated Mrs C’s complaint and met with her, however, this had not resolved matters and Mrs C brought her complaint to the SPSO. We did not uphold the complaint against the nurse as there was no evidence to substantiate the allegations. We did not uphold the complaint that the board’s handling of the investigation into the alleged discussion that took place at the 1-2-1 was inadequate. We noted that before Mrs C brought the complaint to us the board had apologised for a delay in their final response being sent to her. Related reading View Decision Report 201005281 as a PDF (13.71 KB) Updated: March 13, 2018

Mr C had requested a home visit early in 2010 which was refused. In December 2010 he contacted the practice by email to ask why the visit had been refused and to ask for a copy of the practice policy on home visits. The practice manager responded five days later by email explaining the policy on home visits. The final paragraph of the emailed letter stated that Mr C's previous email had 'sullied' the patient / doctor relationship and Mr C was to be removed from the list. Mr C complained that the decision to remove him from the GP list without prior warning was unreasonable. We found that it was not appropriate for the practice to have taken the action they did without first giving Mr C a warning and we, therefore, upheld his complaint.

Mrs C complained about the care and treatment provided to her late husband, Mr C, and about the way in which the board handled her complaint. Mrs C said that her husband was diagnosed as having prostate cancer in November 2006. She said that this was confirmed by a biopsy but that complications arose. She said that Mr C rang the hospital for advice about being unable to pass urine but he was wrongly referred back to his GP. As this was over the weekend, his GP was unavailable. Generally, things appeared to settle by mid 2007, but, Mrs C said, from April 2007 her husband was complainaning of rectal bleeding, which continued until his death. Mrs C said this was raised at every meeting with clinical staff but the cause was suggested to be haemorrhoids. In late 2008, Mr C was diagnosed with cancer of the liver and given hormone replacement therapy. Mrs C complained that by the end of 2009, he was suffering considerable pain and discomfort and that the quality of his life reduced significantly. She said that there was no coordinated plan for his treatment and that despite frequent requests for help there was no sense of urgency on the part of clinicians. She alleged that what action points there were, were not implemented. She complained that by 2010 there was a dramatic decline in her husband's condition and he was moved to Ninewells Hospital but again, she said that there was no coordinated plan and that Oncology and Urology failed to work together. She alleged that any treatment for Mr C was merely reactive. After her husband died, Mrs C raised these matters as a formal complaint. She said that the time taken to deal with the complaint was too long and that the responses she recieved failed to answer her concerns. We fully upheld these complaints and also those about the care and treatment of her husband.

Miss C complained that the board had deliberately, and inaccurately, diagnosed her with cancer and were pretending to give her medicine (so-called placebo injections and pills). Her medical records showed much evidence of testing and decision-making by a number of different healthcare professionals in order to reach a diagnosis of cancer. Likewise, the records indicated that actual medication was being administered. There was no evidence to support Miss C's views and we, therefore, did not uphold the complaint. Related reading View Decision Report 201001292 as a PDF (13.48 KB) Updated: March 13, 2018

Mr C, an advocate, complained that the board failed to provide reasonable care and treatment to Mr A from March until June 2009 and, as a result, Mr A became increasingly vulnerable and was forced to move to another health board for alternative treatment. Mr A accessed mental health services for treatment when he became mentally unwell in March 2009. Mr C said that the board had failed to diagnose Mr A's psychotic depression and provide appropriate treatment. He also complained about the board's decisions to discharge Mr A on four occasions and that the communication between the board and Mr A and his wife was inadequate. Finally, he complained about a psychiatrist's assessment of Mr A as fit to plead in court and the follow-up arrangements following his final discharge in June 2009. Mr A said that he had moved to another health board who diagnosed psychotic depression and treated him with electroconvulsive therapy. Mr A said the treatment was successful. We did not uphold the complaint because we found that all the board's actions in managing Mr A's mental illness were reasonable. Related reading View Decision Report 201003602 as a PDF (13.91 KB) Updated: March 13, 2018

Mr C complained that Tayside NHS Board's out-of-hours GP service refused to visit him when he had kidney stones, a very painful condition. Our investigation revealed that weather conditions at that time were such that police and weather forecasters were advising motorists not to travel unless absolutely necessary, and that the board's four-by-four out-of-hours vehicles were having great difficulty. The board said that, after careful thought, they had decided not to attempt home visits unless absolutely essential. As Mr C's own medical practice was due to open about half an hour after the call (when the out-of-hours GP service would, therefore, be closing for the day), it was also considered that someone from the medical practice would be able to reach Mr C earlier than the out-of-hours service. Given all the circumstances, including Mr C's medical condition, we considered the board's decision had been appropriate. Related reading View Decision Report 201005157 as a PDF (13.81 KB) Updated: March 13, 2018

Ms C, who is a telephonist, suffered an acoustic shock incident at work for which she needed medical treatment. She was unhappy with the care and treatment she received from the Board and the way they handled her complaint. During a consultation with a specialist, Ms C described the pain in her ear, head and neck. She also described how noise and/or examination made her symptoms worse. The specialist told Ms C's GP that Ms C had suffered an acoustic shock and that the description of the pain sounded like muscle tension. He also said that Ms C had tinnitus and that this was difficult to tie in with acoustic shock, although it was also difficult to say what else might have caused the problem. Ms C complained that this diagnosis was not reasonable and that the Board's subsequent investigation of her complaint was inadequate. After taking advice from one of the Ombudsman's professional medical advisers, we found that the specialist's conclusions were reasonable in the circumstances. We also found that the Board's investigation of the matter was appropriate. Ms C had said she felt that certain clinical aspects of the complaint should have been subject to independent review and that this was missing from the Board's investigation. We explained to Ms C that the second stage of the NHS Complaints Procedure (investigation by our office) provides the independent and impartial examination of the clinical information that she wanted.