SPSO Individual Decisions

Ms C complained about the actions of staff at the GP practice when she had a seizure in the reception area. Ms C has a medical condition in which she experiences seizures. During seizures she is unable to move or speak, however, is aware of what is happening and can feel pain. Ms C complained that when she had a seizure at the GP practice, her dignity and privacy was not maintained. We took independent advice from a GP. We found that Ms C was not given appropriate privacy when she had the seizure, and this was unreasonable. We also found that Ms C's son was called to take her home in a wheelchair, before she had recovered from the seizure. Staff at the practice should have waited until Ms C had recovered in order to assess her clinically when she was fully conscious and allow her to coordinate her own transfer home as appropriate. We upheld Ms C's complaint.

Ms C complained about the treatment she received from the practice in response to her symptoms of oedema (swollen tissue from retained fluid). Ms C said that she had reported symptoms to the practice on numerous occasions. Ms C said there was an unreasonable delay in responding to her symptoms. During an appointment with a GP Ms C was told to stop a certain medication. Ms C said that during the appointment she was not given proper instructions or after care, i.e. to get her blood pressure checked. A few weeks later, after a severe headache, it was found that Ms C's blood pressure was too high and she required hospital admission. We took independent medical advice from a GP. We found that Ms C's treatment by the practice was reasonable and found no failings in the treatment offered. The practice considered Ms C's symptoms, taking into account her overall medical hisotry and chronic illnesses when considering appropriate action to respond to Ms C's reports of oedema. Therefore, we did not uphold this part of Ms C's complaint. Ms C also complained that the board failed to provide reasonable after care, specifically that her blood pressure should be checked. There was no written record or evidence to support the practice's view that appropriate information was provided to Ms C regarding having her blood pressure checked. Therefore, we upheld this part of Ms C's complaint.

Mr C complained that the practice had unreasonably stopped prescribing his Capasal (medicated shampoo) medication on NHS prescription. Mr C said that he had psoriasis (a skin condition) and had been prescribed Capasal for many years. He was suddenly told by the practice that in accordance with health board guidance, he would have to purchase Capasal over the counter at a chemist. We took independent advice from a general practitioner. We found that Mr C's medical records contained information that Mr C had been diagnosed with psoriasis in the past and as such he did satisfy the health board criteria which would allow the practice to prescribe the medication on NHS prescription. We upheld the complaint.

Mr C complained to the practice about the lack of care provided to his late partner (Ms A). Ms A had attended the practice on numerous occasions over a four  month period reporting continuing neck pain. The practice had diagnosed that Ms A was suffering from Polymyalgia Rheumatica (inflammation of the muscles in the neck, shoulder or hip) and prescribed painkillers. Ms A subsequently attended hospital due to the pain and a x-ray revealed she had neck fractures caused by lung cancer spreading through her body. Mr C felt there had been a delay in carrying out investigations which would have identified the cancer at an earlier time. We took independent advice from a GP adviser. We found that, based on Ms A's presenting symptoms, it was not unreasonable that the practice followed a working diagnosis of Polymyalgia Rheumatica. They prescribed appropriate medication which was changed to an alternative when it did not alleviate the symptoms. There were no red flag signs which would have indicated the possibility of cancer or symptoms which warranted either a hospital admission or an urgent hospital referral for a specialist opinion from a respiratory clinician. We found that Ms A's cancer presented in an unusual manner and that the cancer could not have reasonably been diagnosed earlier. We did not uphold the complaint. Related reading View Decision Report 201800795 as a PDF (11.3 KB) Updated: December 2, 2018

Mrs C complained to us that the medical practice had failed to provide appropriate care and treatment to her mother (Mrs A) at a home visit. She said that her mother had been dizzy, light-headed and off her feet and that she suffered from high blood pressure. Mrs C said that the GP recognised her mother's high blood pressure but did not take any further action and told her to wait for the district nurses, who were scheduled to visit in three days time, and that they would take further blood pressure readings, which Mrs C considered to be unreasonable. Mrs C called out the out-of-hours GP later that evening as her mother's blood pressure was still high. The offer of a hospital referral was made but Mrs A declined the offer. Mrs A was admitted to hospital two days later for a suspected heart attack and remained a patient for nearly two weeks. We took independent advice from a GP adviser and concluded that the practice had provided a reasonable level of care. We found that the GP had carried out a reasonable examination and had concluded that there was no indication of an acute illness. The GP felt that the cause of the high blood pressure was caused by Mrs A's anxiety. It was appropriate to check the blood pressure readings and we considered that, as the district nurses were scheduled to visit a couple of days later, the matter would receive appropriate follow-up at that time. We did not uphold the complaint. Related reading View Decision Report 201800348 as a PDF (11.28 KB) Updated: December 2, 2018

Mr C complained about the care and treatment provide to his late father (Mr A) by the practice. Mr A was referred to a cardiology consultant (a doctor who specialises in the heart and blood vessels) by his GP following complaints of breathlessness. The consultant gave the practice some guidance about future treatment, and Mr A visited the practice a number of times over the next few weeks. Some changes to his medication were made and he was again referred to cardiology. Following this, Mr A was diagnosed with pulmonary fibrosis (a rare condition causing scarring of the lungs) and he died a few weeks later. Mr C complained that the practice had not followed the guidance of the consultant. We took independent advice from a GP adviser. We found that the practice did follow the advice of the consultant, and that the eventual diagnosis of pulmonary fibrosis could not have been foreseen during the period when the practice was responsible for Mr A's care. We did not uphold the complaint. Related reading View Decision Report 201708396 as a PDF (11.08 KB) Updated: December 2, 2018

Ms C complained about the care and treatment provided to her late sister (Miss  A). Miss A had attended a routine appointment with a practice nurse for her asthma, and had reported symptoms of a urinary tract infection. The nurse had taken a urine sample and had the on-call GP prescribe antibiotics. Several days later Miss A's condition deteriorated and she was admitted to hospital with sepsis (a blood infection), where she then died. Ms C complained that the practice nurse should have realised how unwell Miss A was and carried out further checks such as heart rate, temperature and blood pressure. Ms C felt that if these had been carried out Miss A would have had appropriate treatment sooner. We took independent advice from a practice nurse and a GP. We found that there was nothing in the medical record to note what symptoms Miss A presented with or any assessment undertaken, and we considered this to be unreasonable. We found that based on the symptoms described by the practice nurse in her complaint investigation statements, the practice nurse should have undertaken a thorough history of Miss A's symptoms, checked her temperature, pulse and blood pressure, and checked for signs of pain. We upheld this aspect of Ms C's complaint. Ms C also raised concerns that Miss A's blood test results were not acted upon in the weeks leading up to her death. We found that the blood tests that were being monitored were part of the practice's routine screening for chronic disease, and that any abnormal results were followed up appropriately and were not related to Miss A's later diagnosis of sepsis. We did not uphold this aspect of Ms  C's complaint. Finally, Ms C complained about the practice's handling of her complaint. We found that the practice failed to handle Ms C's complaint reasonably and that it did not meet the complaints handling guidance in place at the time. We upheld this aspect of Ms C's complaint.

Mrs C attended the practice with symptoms of a hoarse voice, burning and tightness in her chest, decreasing over five days. Mrs C explained to the practice that she was due to go on holiday in three days and queried whether she was fit for travel. The doctor considered that she was suffering from a viral infection, recommended fluids and paracetamol and considered her to be fit for travel. However, in the following days her condition worsened, causing her to attend a hospital's emergency department who prescribed antibiotics. Mrs C was still unwell when her holiday commenced. Mrs C complained that the practice had not provided her with reasonable treatment, which caused her to be unwell on her holiday. We took independent advice from a GP. Based on the information available at the time, we considered that the practice provided a reasonable standard of medical treatment and that the practice could not have foreseen that Mrs C's condition would worsen, impacting on her holiday. Therefore, we did not uphold the complaint. Related reading View Decision Report 201708674 as a PDF (11.09 KB) Updated: December 2, 2018

Mr C complained on behalf of his late wife (Mrs A) that the practice failed to provide a reasonable standard of care and treatment. Mrs A attended the practice with pain in her right chest wall which was thought to be related to an injury. The practice noticed a small lump over her clavicle (collar bone) and requested an x-ray, which showed no significant abnormality. Mrs A attended the practice again with worsening shoulder pain and was referred to orthopaedics (the branch of medicine involving the musculoskeletal system). Mrs A was later diagnosed with bone and liver cancer. Mr C complained that the practice failed to note Mrs A's history of breast cancer on the x-ray request form and that they had not chased up the orthopaedic referral. We took independent advice from a general practitioner. We found that there was no indication for the practice to consider cancer as a possible diagnosis. The practice had been investigating Mrs A's shoulder pain and lump as an injury and we considered that the practice's diagnosis was reasonable. We did not uphold Mr C's complaint. However, we identified failings in the way the practice handled his complaint and made recommendations in light of this.

Mr C complained to us that the practice had failed to provide appropriate treatment to his late wife (Mrs A). Mrs A had been attending a hospital out-patient department for a separate matter and had been advised to make an emergency GP appointment as she was showing symptoms of a cough and breathlessness. Mrs A developed deep vein thrombosis (DVT, blood clot in a large vein) four days after the consultation and later died. Mr C believed that the practice should have referred his wife to hospital at the time of the appointment. The practice responded that Mrs A was given an emergency appointment following her attendance at the out-patient clinic. However, the reason for the appointment was for anxiety problems and Mrs A only reported symptoms of low mood and that her heart was racing. Mrs A did not report symptoms of having a cough, chest pain, shortness of breath, or pain or swelling in her leg. The practice prescribed anti-depressant medication and diagnosed anxiety problems. We took independent advice from an adviser in general practice medicine and concluded that, from the entries in Mrs A's medical records, the practice had provided a reasonable level of care. There was no indication that Mrs A had reported symptoms suggestive of DVT and the medication prescribed by the practice was appropriate for symptoms of anxiety and low mood. There was also no indication that a hospital referral was required at that time. We did not uphold the complaint. Related reading View Decision Report 201704181 as a PDF (11.31 KB) Updated: December 2, 2018

Ms C complained on behalf of her late father (Mr A) about the care and treatment he received from the practice prior to his diagnosis of cancer. Mr A presented at the practice with a swollen jaw and neck and was advised to visit his dentist immediately. Mr A later attended the out-of-hours GP service. The practice received the out-of-hours report that stated Mr A had an upcoming appointment at hospital and that he had been referred to an ear, nose and throat specialist. Ms C later contacted the practice as Mr A had become more unwell and an admission to hospital was agreed. Mr A was diagnosed with cancer and died not long after his diagnosis. Ms C complained that more could have been done by the practice to speed up the diagnosis. We took independent advice from a medical adviser. They reviewed the records and were satisfied that the practice had provided reasonable care at each point of contact. Mr A had been seen by his dentist and out-of-hours services and was soon under the care of a consultant. Therefore, we did not uphold the complaint. Related reading View Decision Report 201703294 as a PDF (11.11 KB) Updated: December 2, 2018

Mrs C, an advocacy and support worker, complained on behalf of her client (Mr B) who had concerns about the way the medical practice had managed his mother (Mrs A)'s oxazepam medication (for anxiety and to be taken for short periods only). He said that Mrs A had been taking the medication for a number of years and that the practice had recently reduced the medication and, as a result, Mrs A suffered a stroke. She was taken to hospital and died of a further stroke a number of days later. Mr B felt that the stress of the medication reduction caused Mrs A to suffer a stroke. We took independent advice from an adviser in general practice medicine and found that the practice had managed Mrs A's medication regime in an appropriate manner. Care has to be taken with oxazepam medication as it can cause both psychological and physical addiction. Practices have a responsibility to keep medication under review to ensure that it is still required and if it is not, they must reduce it or stop the medication completely. We found that there was evidence from the records that Mrs A was initially not requesting the medication on a regular basis but recently had made increased requests. This made it necessary to review and reduce the medication to an appropriate level. There was also no evidence that the reduction in medication led to Mrs A suffering a stroke. Therefore, we did not uphold the complaint. Related reading View Decision Report 201704238 as a PDF (11.29 KB) Updated: December 2, 2018

Ms C complained about the medical practice on behalf of her five-year-old son. Ms C complained that the GP failed to diagnose her son's tonsillitis over the course of two appointments. Ms C told us that the GP should have diagnosed tonsillitis rather than referring her son to the paediatric team at a hospital in the board's area. The practice advised that, at the first appointment, the GP had been able to examine Ms C's son, despite him being upset. The GP did not observe any infection, and based on his symptoms, diagnosed Ms C's son with hand and mouth disease. At a second appointment, the GP examined Ms C's son. At this appointment the GP had not been able to take all of the measurements they had wanted to during the consultation. As a result, the GP felt that the diagnosis was unclear and referred Ms C's son to the paediatric team at the hospital. Ms C also complained that the GP refused to arrange an ambulance to transport her son to the hospital. The GP offered patient transport, however Ms C felt that this was not suitable as it would have taken too long. We took independent GP advice. The adviser examined the records and confirmed that the GP examined Ms C's son in line with General Medical Council (GMC) guidance. The adviser confirmed that it was appropriate for the GP to refer Ms C's son to the hospital given that he was presenting with persistent symptoms. The adviser also confirmed that the GP's actions regarding transport to the hospital were appropriate as ambulances should only be used in an emergency. We found no evidence that the GP had failed to provide the appropriate clinical treatment. We did not uphold this complaint. Related reading View Decision Report 201609426 as a PDF (11.36 KB) Updated: March 13, 2018

Mrs C complained about the practice after she required a CT scan to be diagnosed with pneumonia. She told us that she felt an earlier diagnosis should have been possible, based on her medical history and presenting symptoms. We took independent advice from a GP adviser. We found that the practice did not fail to identify any signs or symptoms that would have led a GP to reach a diagnosis of pneumonia. The adviser considered that the practice carried out reasonable examinations and, when these failed to provide a diagnosis, took prompt and reasonable steps to arrange appropriate tests to investigate further. This involved arranging for an x-ray and then a CT scan, which provided the eventual diagnosis. For these reasons, we did not uphold the complaint. Related reading View Decision Report 201607870 as a PDF (10.97 KB) Updated: March 13, 2018

Miss C complained to us that the medical practice had unreasonably notified the Driver and Vehicle Licensing Agency (DVLA) that she had alcohol issues. She said that she had to surrender her driving licence for a period and that she had suffered financially as a result. The practice explained that they had acted in accordance with their policy about advising patients to inform DVLA about alcohol problems and the circumstances where the practice could contact DVLA themselves. We took independent advice from an a GP adviser and concluded that the practice policy in force was reasonable and that the practice were entitled to notify DVLA in this instance. We did not uphold the complaint. Related reading View Decision Report 201607644 as a PDF (10.93 KB) Updated: March 13, 2018

Mrs C complained that her late mother (Mrs A)'s medical practice did not take urgent action and advise Mrs A to attend hospital after she reported symptoms related to deep vein thrombosis (DVT, a blood clot). Mrs A collapsed at the entrance of the main health centre at the practice and was taken to hospital. She died shortly after of a pulmonary embolus (a blockage of an artery in the lungs), which is a side effect of DVT. Mrs C was also unhappy that the medical practice had not told her about the incident. We took independent medical advice and found that the practice acted reasonably in advising Mrs A to attend the practice for assessment rather than going immediately to her local emergency department. We considered that the practice provided a timely appointment for Mrs A to be reviewed. In addition, we considered it was reasonable that practice staff had not contacted Mrs C regarding the incident because Mrs A had collapsed outwith the premises of the medical practice and staff there were unaware of what had happened. In view of these findings, we did not uphold the complaint. Related reading View Decision Report 201606368 as a PDF (11.15 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment provided to her late father (Mr A) by his medical practice. Mr A suffered from advanced dementia and was cared for at home by his daughters. Mrs C was concerned that a GP from the practice prescribed Mr A pain relief without consulting his welfare power of attorney (Mrs C’s sister), even though they had agreed to consult her on any medication decisions. Mrs C also felt the medication prescribed resulted in Mr A being over-sedated and contributed to his deterioration in health. The practice acknowledged that the GP had prescribed some medication without consulting the welfare power of attorney. The GP apologised for this and the practice said that the GP had reflected on the case and had undertaken reading on the Adult with Incapacity (Scotland) Act. The practice said the GP understood that the role of the welfare power of attorney is to act in the best interests of the patient and that they can consent to or decline any treatment, and must be involved in decisions. However, the practice considered the medication prescribed was appropriate. After taking independent medical advice, we did not uphold Mrs C’s complaints. We found that the medications prescribed by the GP were reasonable and the effects of the medication were appropriately monitored with regular visits and feedback from carers and district nurses. In relation to the GP’s failure to consult the welfare power of attorney, we noted that the GP had apologised for this and had taken appropriate steps to improve. Related reading View Decision Report 201602925 as a PDF (11.32 KB) Updated: March 13, 2018

Mr and Mrs C complained about the care and treatment the practice provided to their late son (Mr A). Mr A had a background of autism and other additional needs. He attended the practice with problems including diarrhoea, sickness and weight loss. The practice initially considered Mr A’s bowel upset was caused by antibiotics. After approximately three months, the practice referred Mr A to gastroenterology for investigations. However, his background health problems made these investigations difficult. Mr A’s condition continued to deteriorate and he was taken into hospital approximately four months later. Mr A was diagnosed with Crohn’s disease (a long-term condition that causes inflammation of the lining of the digestive system), and died despite surgical management. Mr and Mrs C complained that the practice failed to provide Mr A with appropriate clinical treatment. They said his condition deteriorated considerably, and that his family and carers specifically raised concerns that he was suffering from Crohn’s disease. They also raised concerns that the practice did not appropriately take into account Mr A’s additional needs. Mr and Mrs C also complained that the practice unreasonably delayed in referring Mr A for a gastroenterology opinion. Related reading View Decision Report 201608767 as a PDF (11.2 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment provided to her late niece (Miss A) by the practice. Miss A had reported gynaecological symptoms and after examinations and tests, she was diagnosed with an infection. Miss A received treatment for this, however, a few months later, she reported similar symptoms. She was seen on a number of occasions and provided with treatment. When her symptoms persisted, a referral was made to the local gynaecology department and a scan was arranged. Miss A was later diagnosed with cervical cancer following an emergency hospital admission. Mrs C complained that, given the level of contact Miss A had with the practice, she had not received appropriate care for her reported symptoms. After taking independent advice from a general practitioner, we did not uphold Mrs C's complaint. We found that Miss A had had an infection and that the symptoms she reported later were consistent with infection or complications of an infection. The advice we received was that it was reasonable to consider that her symptoms were due to infection and that the practice had arranged appropriate tests and referrals for Miss A. Related reading View Decision Report 201601598 as a PDF (11.13 KB) Updated: March 13, 2018

Mr C complained to us that the medical practice had failed to provide appropriate care and treatment to his late wife (Mrs A). He said that Mrs A died from cancer and that he requested a copy of her medical records from the practice. He noted that two years prior to his wife's death she had attended the practice with an eight week history of abdominal pain. He had checked the National Institute for Health and Care Excellence (NICE) guidance and this said that a CA125 blood test (a test used to diagnose ovarian cancer) should have been carried out. The blood test was not performed at the first consultation. Mr C felt that his wife had met the criteria for the test and had it been carried out, it may have identified her cancer earlier. He also said that his wife attended the practice 12 months later and again the CA125 blood test was not taken. The guidance states that clinicians should carry out tests if a woman (especially if 50 or over) reports having any of a number of symptoms on a persistent or frequent basis (particularly more than 12 times per month). Abdominal pain is one of the stated symptoms. We took independent GP advice and found that at the first consultation, the practice had provided a reasonable level of care. It was recorded that Mrs A had reported an eight week history of right sided abdominal pain and tiredness with no change in bowel habit. Antibiotics were prescribed along with blood tests (not including CA125) with a further review. The adviser said that it was not a failing in care not to have requested a CA125 blood test as the guidance does not define 'persistent or frequent basis' in terms of length of time of having symptoms. Although Mrs A was over 50 and had symptoms for eight weeks, the guidance does not specifically state that a CA125 blood test is required in such a situation. We did not uphold the complaint, but highlighted that it would have been best practice for Mrs A to have been asked to return if her symptoms persisted followin

Ms C complained about the care and treatment provided to her brother (Mr A) for pain and other symptoms he reported in his legs. Mr A had been attending the practice about these issues. The practice referred him to a community clinic and deep vein thrombosis (DVT) service at the local NHS board during the period covered by this complaint. He was diagnosed with severe critical limb ischemia (obstruction of the arteries that reduces blood flow to the extremities) and later required amputation of his leg above the knee. Ms C was concerned that there was an opportunity to diagnose Mr A's condition earlier and that this could have resulted in a different outcome. After taking independent medical advice from a general practitioner, we did not uphold Ms C's complaint. The advice we received was that appropriate timely referrals had been made for Mr A and that the practice had reasonably explored potential causes of his symptoms. We found that there could have been more information included in one of the referrals that had been made for Mr A, however, the advice we received was that this did not have any impact on Mr A's case. We made a recommendation in connection with this for learning purposes.

Ms C complained about the care and treatment provided to her mother (Mrs A) by her GP practice. A GP visited Mrs A's home and following an examination, the GP considered that Mrs A had an upper respiratory tract infection. Her condition did not improve following the GP's visit and her family took her to hospital. Further examinations in hospital identified that Mrs A had pneumonia, and she died a number of days following admission. Ms C raised a number of concerns about the home visit carried out by the GP, and felt that an x-ray should have been arranged and antibiotics prescribed. We took independent GP advice and found that the GP's assessment was reasonable. We noted that the GP had documented a detailed history and examination of Mrs A, and that their observations were consistent with a viral infection such that antibiotics were not necessary at that time. The adviser also said that there was no clinical indication for a chest x-ray as Mrs A's symptoms and signs were not consistent with a likely diagnosis of pneumonia. The adviser noted that the GP had also provided advice on what to do if Mrs A's condition became worse. Overall, we found that the GP had provided reasonable care and treatment. We did not uphold this aspect of the complaint. Ms C also expressed concern that the GP failed to arrange hospital admission given Mrs A's symptoms. While we noted that Mrs A was subsequently admitted to hospital where she was diagnosed with pneumonia, the adviser did not consider that Mrs A's recorded symptoms at the time of the GP visit were consistent with pneumonia, and did not consider that there was an indication that Mrs A needed to be admitted to hospital at this time. We did not uphold this complaint. Related reading View Decision Report 201605105 as a PDF (11.39 KB) Updated: March 13, 2018

Mr C complained to us about a delay in the medical practice referring him for a scan. The scan showed a diagnosis of testicular cancer. He had attended the practice on three occasions and it was only on the last attendance that he was referred for the scan. Mr C believed that the scan should have been arranged at either the first or second consultation. We took independent GP advice. At the first consultation there was a report of a tender right testicle which had been present for two to three days. There was no lump and antibiotic medication was provided with a review the following week if the condition did not settle. A diagnosis of orchitis (inflammation of one or both testicles) was made. Mr C then reattended the practice some 12 weeks later with a report of right testicular discomfort again and repeat medication was provided. Mr C then attended again after a further five weeks and reported right testicular discomfort and a lump. The ultrasound referral was then made, in line with national guidance, which led to the diagnosis of testicular cancer. We found that the practice had provided a reasonable level of care and that the referral was made at an appropriate time in view of Mr C's reported symptoms. We therefore did not uphold Mr C's complaint. Related reading View Decision Report 201604033 as a PDF (11.21 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment given to her late husband (Mr A) by his medical practice. She said that despite his serious symptoms, the practice failed to ensure that appropriate tests were carried out. In particular, he was not referred for a scan. She maintained that he was misdiagnosed and not properly treated as a consequence. We took independent medical advice which confirmed that the practice had provided a reasonable standard of care. We found that doctors in general practice were unable to request scans and that once a referral had been made to hospital (as happened in Mr A's case), his treatment was determined by clinicians there. We did not uphold Mrs C's complaint. Related reading View Decision Report 201600070 as a PDF (10.96 KB) Updated: March 13, 2018

Mrs C, who works for an advocacy and support agency, complained on behalf of Ms A about a GP home visit when Ms A reported severe dizziness and staggering. Ms A was diagnosed with labyrinthitis (an inflammation of the inner ear), but it was later discovered that she had suffered two minor strokes. Mrs C said that the GP should have considered the possibility of a stroke and admitted Ms A to hospital by ambulance. Mrs C also said that it was unreasonable for the GPs at the practice to prescribe statins (medication used to lower cholesterol in the blood) to Ms A. We took independent advice and found that the care and treatment provided to Ms A at the home visit was reasonable. It was appropriate to diagnose labyrinthitis and there was no clinical evidence at this point to suggest that Ms A had had a stroke. However, there was an unreasonable delay in making a referral to a stroke unit, and there was a failure to carry out a particular examination which would have been reasonable in light of Ms A's symptoms, which included hypertension. In relation to the prescription of statins, we found that this was reasonable in the circumstances.