SPSO Individual Decisions

C complained on behalf of their client (B) about the care and treatment given to B's late parent (A). A was admitted to hospital and discharged a few days later. A was readmitted the next day and died the following week. B had concerns around A's diagnosis and said that they should have been consulted given that they held Welfare Power of Attorney (Welfare POA). C also complained that the board's communication with B was unreasonable. The board said that A was treated for infection with broad spectrum antibiotics. A was discharged after their first admission as it was deemed appropriate and clinically safe to do. The board said that during A’s second admission a lumbar puncture procedure was indicated. They acknowledged that an Adults with Incapacity (AWI) certificate was in place and that during that time, Welfare POA rights were in effect. However, the board said that when the AWI certificate was revoked, the Welfare POA did not maintain the ability to make decisions on the patient’s behalf. In relation to communication, the board apologised that B found the manner of staff to be abrupt and explained that the situation was urgent. We took independent advice from a consultant physician in medicine for the elderly. We found that A received appropriate care and treatment. Appropriate investigations were carried out and various diagnoses were considered during A’s treatment. However, the board did not seek appropriate informed consent from B for a medical procedure when the AWI certificate was in place which was unreasonable. We found that the content of the communication recorded in the medical notes was reasonable. However, the tone of communication lacked sensitivity and respect of B and their role as the Welfare POA. Therefore, we upheld C's complaints.

C complained that the practice failed to adequately investigate and/or diagnose the cause of their persistent cough. C was subsequently hospitalised and diagnosed with pneumonia while on holiday. The practice did not uphold C’s complaint. They said that they had taken reasonable action in light of C’s presenting symptoms and that C’s cough had been reasonably treated. They said that C’s final examination was normal and not in keeping with a diagnosis of pneumonia and that, therefore, there was no missed diagnosis. C remained unhappy and asked us to investigate. We took independent advice from a GP. We found that there had been a failure to adequately investigate the cause of C’s cough. In light of C’s presenting symptoms, a persistent cough and infection, we found that an in person appointment and an urgent referral for a chest x-ray should have been considered after their initial telephone presentation. We also considered that C should have been referred for an urgent chest x-ray following a second presentation, in accordance with the Scottish Referral Guidelines for Suspected Cancer. Therefore, we upheld C’s complaint.

C complained about the care and treatment given to their late sibling (A) by the board. A, who had a history of addiction issues and Chronic Obstructive Pulmonary Disease (COPD, a group of lung conditions that cause breathing difficulties), was admitted to A&E after overdosing on non-prescription drugs. A was treated for the overdose and was discharged to C’s care. A died the following day. C complained that the board inappropriately discharged A and that the treating doctor had failed to communicate adequately with them. The board did not identify any failings in A’s care, but did apologise that A was discharged with a cannula in place. The board also apologised for communication failures with C. C remained unhappy and brought their complaint to us. We took independent advice from a consultant in emergency medicine. We found that A was monitored for approximately 12 hours before discharge. This is the minimum period recommended by Toxbase (the primary clinical toxicology database of the National Poisons Information Service). However, we found that A would have required observation over and above this minimum period. This was because of A’s history of acute seizures, intoxication with opiate drugs and their complex medical history. In the circumstances, we found that it would have been reasonable for A to have remained as an in-patient to enable a greater period of medical observation. Therefore, we considered that the decision to discharge A was unreasonable. We upheld C's complaint.

C complained on behalf of their partner (A) about the care and treatment provided to A by the board when they presented to the obstetric triage department 25 weeks’ gestation with pain and abdominal tightening. A was assessed as having Braxton Hicks (when the womb contracts and relaxes during pregnancy, also known as ‘false labour’) given advice on what to do if their condition worsened, and discharged. Four weeks’ later A suffered preterm prelabour rupture of the membranes (PPROM) and their child was delivered prematurely. C complained about the care and treatment provided to A as they considered the assessment at 25 weeks’ gestation was a missed opportunity for further investigation or follow-up. The board’s complaint investigation identified that according to local guidelines, A should have been reviewed by a more senior doctor. However, they were of the view that it was unlikely that this would have led to a different outcome. We took independent advice from a medical adviser. We found that while there were some areas for potential improvement, overall the care and treatment provided to A was reasonable. We therefore did not uphold C's complaint, though we did provide feedback to the board according to the adviser’s comments. Related reading View Decision Report 202400979 as a PDF (24.45 KB) Updated: June 18, 2025

C complained about the nursing and medical care and treatment provided to their parent (A) when A was in hospital following a hip fracture. A had surgery for the fracture but was diagnosed with a number of illnesses while in hospital and died. We took independent advice from a nursing adviser and consultant geriatrician (specialist in medicine of the elderly). In relation to nursing care, we found failings with A's nutrition, pressure care, person centred care planning, and documentation. We upheld this part of C's complaint. In relation to medical care and treatment, we generally found this to have been reasonable and did not uphold this part of C’s complaint. However, we provided feedback to the board regarding starting oral nutrition supplements in line with Scottish Hip Fracture Guidance. Finally, we found that there were delays in the handling of C's complaint and the board failed to fully address of all C's concerns. The board had acknowledged these failings and taken action to address them. Therefore, we upheld this part of C's complaint but made no further recommendations in this regard.

C complained about the decision to stop the anticoagulant (blood thinning) medication given to their late parent (A) and a lack of communication with the family around this decision. The practice instructed to stop the medication due to an unexplained bleed. Following this stoppage, A died from a stroke. A’s family contacted the practice to discuss their concerns about the medication but they were unable to speak to a clinician in a timely manner. We took independent advice from a GP adviser. We found that there were clear indications for A to be on anticoagulant medication and that it was unreasonable that the medication was stopped without a replacement in place. The decision to stop the medication was not fully informed. We noted that the practice did not undertake timely blood tests or communicate with A’s family and the relevant specialists. We also found failings around the administration of blood tests. The practice carried out a Significant Adverse Event Review (SAER), which we found was not in line with relevant national guidance. We upheld C’s complaint

C complained that the board failed to provide their parent (A) with reasonable care and treatment when they attended the A&E with symptoms including a loss of sight in one eye. C raised concerns about the delay in assessing A and failures by staff to reasonably diagnose and treat A. C also said that the board failed to reasonably communicate and provide A and C with sufficient information after A was taken to a cubicle, to provide A with appropriate personal care, to adequately record information about A’s care and treatment and to follow the relevant policies and procedures in providing care and treatment to A. We took independent advice from a consultant neurologist and a nurse. We found that there was an unreasonable delay in A being assessed by a doctor. We also found that there was poor record keeping in A’s medical and nursing records, which showed the level of care and observation A had received was unreasonable. We found that, had A’s observations been recorded as required, it was possible that a deterioration in A’s condition would have been picked up sooner. Consequently, we found that the care and treatment provided to A in the A&E was unreasonable. We, therefore, upheld this part of C’s complaint. C also complained that, after A was transferred to the high dependency unit, a consultant neurologist failed to sensitively explain to them about A’s diagnosis and prognosis. We found that adequate and appropriate information was conveyed to C by the consultant neurologist and the communication between them had been clinically appropriate and satisfactory. It was not possible to determine whether or not the consultant neurologist had failed to explain this sensitively. We did not, therefore, uphold this part of C’s complaint. C further complained that a senior research nurse failed to take reasonable steps to contact them regarding a stroke research study. We found that there was a failure to take reasonable steps to contact C regarding the stroke research stud

C complained that the board failed to provide reasonable personal care and treatment to their sibling (A). A was admitted to hospital to initiate and titrate Clozapine (an antipsychotic drug used to treat schizophrenia and other psychotic disorders). A had a history of diabetes and experienced episodes of incontinence which placed A at greater risk of infection. C complained that the discharge letter did not mention a pressure sore which was treated by A's GP upon discharge. This could have resulted in A’s Clozapine treatment being temporarily suspended. We took independent advice from a mental health nurse and from a wound-care specialist nurse. We found that A’s feet were examined following concerns raised by C. However, no treatment was prescribed and the doctor's advice about caring for A’s feet was not passed on to C. We found that there was no conclusive evidence to determine whether A had a pressure sore or an ulcer which might have impacted on A’s Clozapine treatment. We also found that it was reasonable for the board to conclude that the wound A had was not a pressure ulcer. However, the board failed to evidence that relevant assessments relating to pressure ulcer risk and skin inspections were carried out. We also found that there was no person centred care plan in place to identify A’s needs in relation to activities of daily living, including personal hygiene. We found that the immediate discharge letter was dated the day after discharge which suggests it was not available to C at the point of discharge, or on the same day, when it should have been. Therefore, we upheld C’s complaint.

C complained about the care and treatment provided to their parent (A) during an admission to hospital. C complained that the board had failed to manage placement of a nasogastric tube (NG) correctly and did not act timeously on signs of a complication. C said that the board failed to carry out an adverse event review of this event. C complained that the board dismissed A’s known diagnosis of myasthenia gravis (a rare long-term condition that causes muscle weakness) too quickly and failed to arrange a neurology (speicalism concerned with the diagnosis and treatment of disorders of the nervous system) review. Finally, C said that the board did not maintain A's privacy or dignity when providing end of life care and communication with the family was poor. The board apologised for failures in A’s care in respect of the NG tube insertion and for aspects of their communication. The complication which occurred with the NG tube was a rare but known complication of the procedure. The board said that A’s case had been reviewed at a Mortality and Morbidity (M&M) meeting and points of learning had been identified. We took independent advice from a consultant neurologist (specialist in the diagnosis and treatment of disorders of the nervous system), a consultant gastroenterologist (specialist in the diagnosis and treatment of disorders of the stomach and intestines) and a consultant respiratory physician (specialist in conditions affecting the lungs). We found that there were aspects of A’s care which were reasonably managed including the review by neurology, the decision to site the NG tube, the end of life care provided to A and the review of the admission undertaken by the M&M meeting. However, we found that the chest x-ray undertaken after insertion of the NG tube was unreasonably delayed. Therefore, we upheld this part of C’s complaint. However, we noted that the board had recognised this failure as part of their own review of C’s complaint. C complained that the board fai

C complained about the care and treatment provided to their parent (A) during two admissions to hospital. Both admissions were due to concerns about A's lungs. A was admitted to hospital for a third time and was diagnosed with empyema (pockets of pus) in their left lung. C complained that this was missed during A's first two admissions and that A was unreasonably discharged from hospital on both occasions. We took independent advice from a consultant who specialises in both respiratory and general medicine. We found that there was no evidence that empyema was present during the two admissions. However, there were missed signs that indicated the potential for empyema to develop. In particular, the presence of high C-reactive protein (CRP, an indicator of inflammation in the body) during the first admission and the recent history of pulmonary and pleural infection at the time of the second admission. We considered that it would have been reasonable for the board to carry out further investigation during A's admissions to hospital. We concluded that the board did not take reasonable steps to establish whether there was an evolving infection or potential for empyema to develop. Therefore, we upheld this part of C's complaint. In respect of A's first admission, we found that A was clinically well enough to be discharged. However, there was a failure to recognise the significance of the raised CRP in the context of A's presentation, and to consider further assessment on this basis. Therefore, we upheld this part of C's complaint. In respect of A's second admission, we found that A was clinically well enough to be discharged. In contrast to the first discharge, A's CRP was not as significantly high and was shown to be declining. As such, there was less indication that A would benefit from remaining in hospital. Therefore, we did not uphold this part of C's complaint.

C complained about the process followed by the board in commissioning and completing a Level 1 Significant Adverse Event Review (SAER) with respect to the care provided to their partner (A), after they had been diagnosed with Barrett’s oesophagus (a condition where some of the cells in the oesophagus grow abnormally). The SAER was commissioned following the death of A. C complained to the board about their lack of inclusion and involvement in the SAER process. In response to the complaint, the board concluded that whilst the SAER was carried out appropriately and C had been involved in the process, they failed to adhere to their own and published national guidelines in a number of ways. The lack of an appropriate Family Liaison contact had negatively impacted communication with C during the process. C was dissatisfied with the board’s complaints response and brought their complaint to our office. We took independent advice from a consultant hepatologist (medical doctor who specialises in diagnosing and treating liver disease) and gastroenterologist (a medical doctor who specialises in conditions affecting your digestive system) We found that in conducting the SAER, the board had acted in the spirt of national policy and guidance with respect to including C in the SAER process. However, the board’s own policy sets more concrete standards about how communication should be managed. We found that overall C’s level of involvement with the SAER process was reasonable, but that there was issues with respect to miscommunication and managing C’s expectations in this regard. Whilst the board responded to C’s requests to meet relevant members of the SAER team, again the communications were not always consistently responded to by the board. Issues with communication were impacted by the board’s failure to follow process and appoint an appropriate point of contact to assist C and provide them with support. Given the failure to follow process, and issues with respect to communica

C complained about the care and treatment that their child (A) received from a dentist. A injured their front tooth and attended their dental practice for an emergency appointment. The dentist noted there was a 1mm extrusion (tooth displacement) but decided that no treatment was needed. C complained that the tooth wasn’t treated with a splint. The dentist said that dentists are able to use their own clinical judgement to decide whether or not to follow the guidelines in each case. In this case, the dentist decided that the tooth would recover on its own and made the decision not to splint the tooth. We took independent advice from a dentist. We noted that there are standards a dentist should follow. This includes providing patients with treatment that is in their best interests and keeping up-to-date with current evidence and best practices. If a dentist chooses to deviate from established practice and guidance, the reason why should be recorded. We found that the dentist did not record the reasons why they decided not to follow the guidelines and they did not inform C that there were guidelines that applied in this case. We also considered that the decision not to follow the guidelines in this case was unreasonable. Therefore, we upheld C’s complaint.

C complained on behalf of their elderly parent (A). A had a known history of high blood pressure and white coat syndrome (when a patient’s blood pressure rises in response to a stressful situation, such as, a doctor’s appointment or visit to the hospital). A had been prescribed a combination of two diuretic medications (types of drug that cause the kidneys to make more urine) to treat this. During an appointment with a locum GP, it was noted that A’s blood pressure was high so they prescribed a third diuretic medication. A became unwell and attended the practice a few days later. They were then admitted to hospital and diagnosed with hyponatraemia (a lower than normal level of sodium in the blood). C was concerned that the practice prescribed an unnecessary third diuretic that led to A’s admission to hospital and that they did not perform checks on A’s bloods before prescribing this medication. The practice said that the medications were safe to be prescribed together with close blood monitoring. They explained that they have a system in place to monitor patients who are prescribed ‘triple whammy’ drugs (a combination of drugs of different types: non-steriodal inflammatories, diuretic, and ACE inhibitors). They also highlighted that they took bloods during the consultation before A’s admission to hospital. We took independent advice from a GP. We found that the decision to prescribe the third diuretic was unreasonable and unsafe. The consultation that took place before the admission to hospital was reasonable and bloods were gathered. However, the practice’s procedure to monitor triple whammy drugs does not apply in this case as A was prescribed three diuretics and none of the other drug types. Therefore, A’s case would not be picked up by this monitoring programme. We found that the practice should have carried out a Significant Adverse Event Review and did not acknowledge any failings in their complaint response. Therefore, we upheld C’s complaint.

C complained that Lothian NHS Board (Board 1) unreasonably failed to maintain records of specialist advice they provided to another board (Board 2). C attended A&E at Board 2 with symptoms of significant pain, problems passing urine and lack of sensation. On the specialist advice of neurosurgery at Board 1, C was admitted to the Orthopaedics department of Board 2’s hospital and an MRI was carried out the following day. The MRI scan results were discussed with the Board 1's neurosurgery team, following which C was discharged. C later required emergency surgery and considers the outcome would have been better if they had undergone surgery when they originally attended hospital. When C complained to Board 2, they confirmed that they had relied on the Board 1’s specialist advice but Board 1 had failed to keep a record of the referral. C complained that Board 1 unreasonably failed to maintain records of the specialist advice provided to Board 2. C also complained about the neurosurgery advice provided by Board 1 to Board 2. We took independent advice from a consultant orthopaedic surgeon in relation to the complaint about maintaining accurate records. We found that Board 1 unreasonably failed to maintain records of the specialist advice provided to Board 2. We upheld the complaint. We took independent advice from a consultant neurosurgeon in relation to the complaint about neurosurgery advice. We found that C had been appropriately assessed with a thorough examination. As such, we did not uphold this complaint.

C complained on behalf of their spouse (A) about the standard of care and treatment received in the months before A died. The board partially upheld the complaint, including failings in communication and a lack of privacy and dignity shown to A. We took independent advice from a registered nurse. We found that while the board had acknowledged some failings, they had not identified other issues with person-centred care planning, care delivery and documentation. We therefore upheld this part of the complaint. C complained that the board had failed to communicate with A and their family to a reasonable standard. The board acknowledged that despite C being A’s carer, and it having been agreed to utilise email communication, information was not always shared with the wider team, which may have contributed to C’s perception that communication was lacking. We found that the board’s position that there was no record of any upset between A and individual staff members was factually incorrect. We thereby upheld this part of the complaint. C complained that there was no record of a care plan, and that the package of care was not adequate for A’s needs. The board acknowledged the lack of a suitable care package had an impact on discharge planning, and that they had failed to establish a more detailed person-centred care plan once A was discharged. We found that there was detailed planning and discussion around discharge involving C and A. We did not uphold this element of the complaint because, on balance, while the delivery of care did not match C and A’s expectations, this did not make the plan unreasonable in the circumstances. C also complained that the board’s response to their complaint was unreasonable and delayed. We found that C’s complaint was complex and multi-faceted accounting to some extent for the delay. However, the response had inaccuracies and failed to identify all the failings in care. For that reason, on balance, we upheld this aspect of the complaint.

C complained that the board failed to provide them with appropriate orthopaedic (specialists in the treatment of diseases and injuries of the musculoskeletal system) care and treatment following a fall. The board operated on C’s left wrist the day after the fall. Two days later, they performed revision surgery on C’s wrist and operated on their left elbow. C said that they had been advised by an orthopaedic surgeon at the board that their initial wrist surgery had not been done correctly. C said they had developed nerve compression pain issues and would require further surgery. We took independent advice from an orthopaedic consultant. We found that C’s initial wrist surgery was reasonable. However, the tilt of the radius was slightly beyond the normal range, which carried a minor increased risk of longer term functional impairment in the wrist. We considered that, if C had not required additional surgery for the elbow, the initial wrist fixation might have been left unchanged, as any potential long-term dysfunction could still have been treated later if necessary. However, given that C was already scheduled for elbow surgery, the decision to proceed with revision surgery on the wrist was considered reasonable. We also noted that key indicators related to pain were appropriately assessed in C’s case, and there was no indication that the surgery had been performed in a manner likely to cause excessive pain. Therefore, we did not uphold C’s complaint. Related reading View Decision Report 202301420 as a PDF (24.53 KB) Updated: November 20, 2024

C complained about the care and treatment that their late parent (A) received while in hospital. A suffered a fall and broke their hip. C complained that A was never provided with a falls monitor despite being assessed as a falls risk. C also said that there was a delay in reporting the fall and having A assessed. The board apologised to C for the fact that, due to a lack of falls alarms, A had not received one. They explained that additional alarms had been obtained to ensure a sufficient supply on the ward. They also accepted that a ‘top to toe’ examination should have been carried out following A’s fall and that there was a delay in identifying that A had a broken hip. They explained that a full review of A’s fall was underway, and if any learning points were identified, they would be acted upon. In addition, a teaching session had been carried out to ensure best practice was followed at all times. The board provided us with details of the learning points that had been identified as a result of the complaint. We took independent advice from a registered nurse. We found that there was no evidence that A received timely risk assessments or person-centred care. Although a fall with harm was apparent from A’s misaligned leg, this went unnoticed. Basic assessments, including pain assessment, were not conducted, resulting in a delay in recognising A’s pain. Additionally, wound charts were not completed, and there was a failure to follow policy regarding pressure ulcer prevention, malnutrition, and wound assessment and management. While the board had taken action in response to the complaint, we considered that there were still areas for learning and improvement. Therefore, we upheld C’s complaint. We also found that the board’s complaint response had not been open, transparent, and accurate. The board had failed to identify a number of failings in A’s care and treatment. Additionally, the board had not provided this office with all relevant information in response to o

C complained about the care and treatment that they received from the dentist during a period of eight months. C is a bariatric patient and is unable to recline due to their medical condition. C attended for an examination with the dentist and complained of a broken front tooth and decay on the upper left second molar. Treatment options were discussed and it was agreed that at the next visit, the dentist would apply fillings to both teeth. C attended for treatment to both teeth 11 weeks later. The dentist explained to C that a referral to the Public Dental Service (for individuals who cannot access an independent dentist) would likely be the best option going forward as they were unable to gain proper access to treat C. C agreed to a referral and the next examination was scheduled for six months’ time. C attended for an emergency appointment six weeks later, complaining of pain. The tooth was filled and the dentist made a referral to the Public Dental Service, resending it six weeks later. C emailed complaints to the practice on two occasions but did not receive a response to either. C attended for a further examination complaining of ongoing pain. Treatment options were discussed and the dentist booked C in for an appointment for treatment. C emailed the practice to ask for a response to their previous two complaint emails. C was advised by the practice to speak with the dentist during their appointment the following day. However, C decided to cancel future treatment as they had lost faith in the dentist. C received a complaint response from the dentist and contacted the practice the following day to express their dissatisfaction with the response. The dentist issued a further response in an undated letter. C wrote to the practice again and the dentist subsequently issued a further letter to C saying that they believed they had already addressed all of C’s concerns. In considering C’s complaint, we took independent advice from a dentist. We found that overall, the

C complained about the care and treatment provided to their parent (A) when A was admitted to hospital with ongoing pain and mobility issues following a fall. A suffered from significant leg ulcers and had received a package of care while at home. While in hospital, A developed sepsis and did not respond to treatment. A died a few months after admission. C complained of failings in how A’s leg ulcers had been managed, stating that A’s dressings were being changed less frequently than when A was in the community. C highlighted times when family members had raised the need for A’s wounds to be dressed with nursing staff who repeatedly failed to respond to these requests. C also complained of similar failures to provide catheter care and stated their belief that these were contributing factors in A’s deterioration. We took independent advice from a nurse. We found significant failings had occurred with regards to washing and dressing the wounds, and a failure to adhere to the standard of monitoring, risk assessment and record keeping as per the relevant professional Nursing and Midwifery Council (NMC) code. We considered that the nursing care provided was unreasonable and upheld this part of C's complaint. The adviser also highlighted concerns about the medical care and treatment provided and on this basis we took additional advice from a geriatrician (specialist in medicine of the elderly). We found that the wound care provided lacked a coherent and consistent approach, and in particular, that A’s legs were not examined until a number weeks after admission. We also found insufficient attention was given to wound swab results and blood tests, as well as A’s level of pain and overall condition. We found that the medical care and treatment provided to A was unreasonable and upheld this part of C's complaint.

C complained about the care and treatment that they received from the board. C underwent a left total hip replacement but returned to the consultant orthopaedic surgeon for follow-up three months later as they were continuing to experience pain and mobility problems. C complained that they were told there was nothing the surgeon could do for them. C sought a second opinion and learned that they had impingement (pinching or rubbing together inside a joint) which would require further surgery. C said that they had been significantly impacted by the initial surgery, both mentally and physically. In their original complaint response, the board acknowledged the poor outcome of the surgery. Following our formal enquiry the board acknowledged that a different choice of acetabular (socket) implant would have been appropriate. The surgeon acknowledged that this case was one where they would have benefited from advice from a more experienced surgeon. They accepted that they had failed to discuss with C that a poor outcome from surgery was a risk, and failed to document decision making and consent discussions in C’s clinical records. They apologised for failings in communication with C during their post-operative consultation. They also apologised for record-keeping failings. The board said they should have discussed this case at a departmental Morbidity and Mortality meeting once it became clear that there were ongoing problems requiring further surgery. They considered that not doing so represented a failure of process, prompting them to review their relevant structures and processes. The board confirmed comprehensive measures to address what had gone wrong in C's case. We took independent advice from a consultant orthopaedic surgeon (specialists in the musculoskeletal system). We concluded that the board had now appropriately acknowledged the multiple failings in this case, apologising and confirming extensive learning and improvement. Taking all of this into account, we up

C complained about the care and treatment provided to their parent (A) over two admissions to hospital. A attended the emergency department following a fall at home and was treated with painkillers for a pain in their neck. They were admitted to the ward for further monitoring of their fast and irregular heartbeat. A was reviewed the next morning and discharged that day. However, A returned to hospital later that day after another fall. A was reviewed and admitted to the ward where they were later diagnosed with a fracture of a bone in their neck. C complained that the board failed to diagnose the fracture on the first admission to hospital and about the decision to discharge A. In response to the complaint, the board did not identify any failings with respect to assessment of A, but acknowledged that the communication of their diagnosis and discharge could have been better. With respect to the second admission, the board explained that symptoms of neck fracture are not straight forward and the examinations carried out within the emergency department were appropriate. C was dissatisfied with the response and brought their complaint to our office. We took independent advice from an emergency medicine consultant and a consultant geriatrician (specialist in medicine of the elderly). In relation to A’s first admission, we found that the initial assessment of A’s condition in the emergency department was reasonable, although there was a missed opportunity for further assessment before A went to the ward. However, the examination and assessment of A’s neck pain on the ward was unreasonable, as was the assessment of A’s suitability for discharge, given the failure to properly assess A’s neck injury, mobility, and cognitive function. We found that the board failed to provide A with appropriate care and treatment during their first admission and upheld this part of C's complaint. In relation to A's second admission, we found that A’s neurological examination did not include

C complained about the care and treatment provided to their late parent (A) during two admissions to hospital. C complained that during their first admission A was given insulin that was for another patient and C was not timeously informed. C complained that during the second admission, A was initially diagnosed and treated for sepsis but when a CT scan was later performed a major stroke was discovered. C considered that stroke should have been considered and a CT scan should have been carried out earlier. A was given an infusion of both insulin and glucose to manage diabetes. C complained that A was inappropriately given intravenous (IV) glucose for 38 hours after IV insulin had stopped, noting that A became hyperglycaemic (when the level of sugar in the blood is too high) and then developed seizures. C also complained that nursing records were incomplete and that the board’s incident management and review process did not go far enough to recognise or rectify failings. We took independent advice from a registered nurse and a consultant specialising in medicine of the elderly. We found that the insulin error should not have happened. In relation to sepsis treatment, it was reasonable to treat the infection in the first instance but when C informed medical staff of A slumping to one side a medical assessment for stroke should have been carried out and a CT scan should have been booked. We also found that it was unreasonable to continue IV glucose after insulin had been stopped, record keeping was inconsistent and incomplete such that it could not be said that nursing care was reasonable and that incident management and review was also unreasonable. Therefore, we upheld C's complaints.

C complained about the nursing care and treatment provided to their late parent (A). A had a fall during an admission to hospital. Their condition deteriorated and a large intracranial (brain) bleed was identified. A died shortly after. C complained that the nursing staff provided unreasonable care and treatment as they did not put the correct safety measures in place, given A's frailty and instability on their feet. The board said that A was reviewed by physiotherapy who assessed A as being safe and able to mobilise independently with a walking stick. The board said that nursing staff carried out care rounding and that A was checked 30 minutes prior to their fall. Following the fall, it was noted that A was able to get up with assistance and an assessment was completed by nursing staff. When checked later, it was found A had become unconscious. The board carried out a scan of A’s head and found a large intracranial bleed. We took independent advice from a registered nurse. We found that there was a lack of documentation and documented evidence of action taken by staff in response to cognition and mobility. Care rounding documentation was not completed to a reasonable standard or carried out to the prescribed frequency. When A’s needs changed, the care rounding was not increased. We found that the nursing staff failed to complete the mobility risk assessment, consider the use of bedrails and identify A required more help when their condition changed. We noted that the care provided by nursing staff when the fall happened and after the fall was reasonable. We also found that the Significant Adverse Event Review that was carried out after the fall was not carried out in line with national guidance. The Duty of Candour process should have been followed in this case and it was unclear from the documentation whether this had been activated or not. We upheld C's complaint.

C complained about the care and treatment that their spouse (A) received from the board whilst they were a patient of the cardiology ward. C complained that A collapsed on arriving home having been discharged after undergoing a coronary angiogram (a type of x-ray used to take pictures of the heart’s blood vessels, the coronary arteries) and stenting procedure. A was found to have experienced a vascular complication (a large haematoma, where blood leaks from a large blood vessel) in front of the femoral artery (the main blood vessel supplying oxygen rich blood to the lower body) and had surgery to remove the haematoma. Following the second surgery, A developed an infection in the wound site. The board said that due care was taken to weigh up the risks and benefits of various treatments in A’s case. Whilst there were signs of a haematoma at the puncture site after the procedure, this was not increasing in size when A was discharged, and A’s blood pressure was normal. C complained to SPSO highlighting concerns about the decision to carry out an angiogram, the decision to discharge A, infection control and failures to follow protocol and use an ultrasound to assess the puncture site. We took independent advice from an appropriately qualified consultant cardiologist. We found that carrying out an angiogram was appropriate in the circumstances. We considered the care and treatment following the procedure and on A’s readmission to be reasonable. However, there were a number of factors which should have triggered staff to consider delaying discharge and seeking an ultrasound scan. We found that the need for an ultrasound scan was clinically indicated and that the decision to discharge was unreasonable. As such, on balance, we upheld the complaint.

C complained that the board failed to provide them and their baby (A) with appropriate care and treatment both during and after A’s delivery at the hospital. This included failing to advise C that one of the doctors involved in the delivery of A was a first year speciality trainee doctor and that the use of forceps in A’s delivery resulted in them suffering permanent injuries, erb’s palsy (a condition often caused by birth trauma that can affect the movement and feeling in a baby's arm) and phrenic nerve palsy (respiratory distress which can be caused by nerve damage during birth). C also complained that there was a failure by the board to carry out further investigations of A’s erb’s palsy, a failure to deal with A’s respiratory distress and diagnose that they had phrenic nerve palsy and a failure to adequately monitor A’s weight. We took independent advice from two medical advisers, a consultant obstetrician and gynaecologist and a consultant neonatologist. We found that birth injuries could occur even though there were no obvious difficulties with the birth. Given this and the evidence available, it was not possible to establish the cause of A’s injuries. However, we found there was a lack of communication with C during the consent process, C was not consented for the involvement of junior trainee speciality doctors at the birth of A and it was not explained to C that teaching of staff would take place during the birth. We found that no consideration was given to the use of ultrasound to determine the position of A prior to delivery, in accordance with Royal College of Obstetricians and Gynaecologists guidance, and medical documentation around the events of A’s birth was not of the expected standard in terms of the level of detail recorded. We, therefore, upheld this part of C’s complaint. In terms of the care and treatment of A following delivery, we found that, overall, this was reasonable. We found that there were no concerns about the diagnosis and treatment