SPSO Individual Decisions

Ms C complained about the care and treatment provided to her by the board in relation to breast cancer screening. Ms C had attended the breast clinic where a mammogram (an x-ray test which can detect breast cancer) noted some microcalcifications (tiny abnormal deposit of calcium salts) in the left breast. These were compared with a previous screening and it was decided that no further investigation was needed. Some months later, Ms C had a further screening and on this occasion it was decided to biopsy the calcifications. The biopsy showed some abnormal features and Ms C was later found to have invasive disease (when germs invade parts of the body that are normally free from them). Ms C complained that pre-cancerous cells were not detected at her screening and there was no follow-up or further investigation at this time. We took independent advice from a consultant in breast radiology (use of medical imaging techniques such as x-rays and other scans to diagnose and treat disease in the body). We found that based on the comparison of the mammogram images from a previous and the most recent scan, there was no indication to carry out a biopsy and it was appropriate not to take further action at this point. Therefore, we did not uphold the complaint. Related reading View Decision Report 201901723 as a PDF (24.34 KB) Updated: July 22, 2020

Ms C was admitted to hospital due to increased suicidal ideation and an overdose. She remained there for a period of around three weeks where she underwent electroconvulsive therapy (ECT, a type of brain stimulation sometimes used to treat depression) as a treatment. In her complaint to the board, Ms C was particularly concerned about whether she had capacity to consent to the ECT treatment given her presentation at her time of admission to hospital and during her stay. Ms C was also unhappy that the hospital did not involve her sister in decision-making. The board explained that whilst Ms C was experiencing moderately severe depressive illness at the time of her admission to hospital, she was assessed as having capacity to consent which was taken by the hospital in an appropriately informed manner. The board agreed that they could be more active in offering patients who are unwell the opportunity to include family members in discussions about significant treatment decisions and took steps to implement this. Ms C was unhappy with this response and brought her complaint to us. We took independent advice from a mental health adviser. We noted that although Ms C experienced undesirable after-affects from the treatment, they were not uncommon or out of the ordinary. There was nothing to indicate a potential loss of capacity to make decisions regarding medical treatment in Ms C's case. We considered that Ms C was properly assessed as having capacity to make treatment decisions and she was provided with appropriate information in relation to the risks and benefits of the ECT treatment to enable her to make an informed decision. The evidence showed consent was re-checked prior to each of the treatments. When Ms C clearly withdrew consent, her treatment was stopped. We concluded that the issue of consent was handled appropriately by the board in Ms C's case. We did not uphold this complaint. Related reading View Decision Report 201900513 as a PDF (24.68 KB) Upda

Miss C complained about the care and treatment the board provided to her late father (Mr A). Her concerns related to the board's out-of-hours service and care provided at Dumfries and Galloway Royal Infirmary. Mr A had been unwell and the board's out-of-hours service was contacted. Mr A was subsequently admitted to hospital with signs of infection but later discharged himself. He was then readmitted after it had been identified that he had staph aureus bacteraemia (SAB, an infection). Subsequently, Mr A suffered a gastrointestinal bleed (bleeding on the digestive tract, and a symptom of a disorder), and developed kidney failure. Mr A then also developed severe heart failure. He was discharged for palliative care and died shortly thereafter. We took independent advice from a GP, a consultant in acute medicine and a nurse. In relation to the treatment provided by the board's out-of-hours service, we found that it was reasonable that a GP did not visit Mr A at home, based on the situation and what was known at the time. We did not uphold this complaint. In relation to Mr A's admissions to Dumfries and Galloway Royal Infirmary, we found that during Mr A's first admission staff had provided reasonable reviews, tests and treatment for Mr A, and the level of clinical care and his treatment was reasonable. However, it had been identified after Mr A left hospital that he had SAB and we found that there was a failure to recognise or act on the seriousness of the SAB result and start proceedings to bring Mr A back to hospital and obtain treatment. In relation to Mr A's second admission, we found that Mr A was given intravenous potassium too quickly and that there was a delay in receiving a transoesophageal echocardiogram (an ultrasound test that uses sound waves to produce moving, real-time pictures of the heart) though it would not have changed his treatment. As such, we found that there were unreasonable failings in the clinical care and treatment provided to Mr A

Ms C had a hysterectomy (surgical removal of the uterus) a number of years ago and recently accessed the records held by the hospital that performed it. She noted a report had been prepared post-surgery with advice to be followed in the event Ms C sought Hormone Replacement Therapy in the future. Ms C complained that this report was not sent to her former GP. We found that it was not possible to state the report was not sent to Ms C's former GP. Therefore, we did not uphold this complaint. Ms C also complained about a failure to maintain an adequate record of when the hysterectomy report was sent to Ms C's former GP. We found that the procedure in place for the transfer and recording of information was standard practice at the time in question. We noted that since that time, the board's method of sending and recording this information had changed to an electronic method, and this removed the uncertainty around the transfer of information which had previously existed. Therefore, we did not uphold this complaint. Ms C also complained about a failure to offer a follow-up appointment after her hysterectomy. We found that the decision not to arrange a follow-up appointment following surgery was standard practice at the board and that this was reasonable based on the surgery undertaken. We did not uphold this complaint. Related reading View Decision Report 201810592 as a PDF (24.29 KB) Updated: July 22, 2020

Mrs C complained on behalf of her late mother (Mrs A) whose hip fracture was not diagnosed until approximately nine weeks into her hospital admission, following a fall at home and a further fall during her first night in hospital. We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that Mrs A's hip fracture should have been diagnosed within one week of her admission as there was enough information present to indicate she had a fractured hip and more detailed assessments should have been carried out during this time. Therefore, we upheld this aspect of the complaint. Mrs C also complained that the board did not take reasonable falls prevention measures as Mrs A fell during her first night of hospital, despite having been admitted post-fall, and with a history of falls. We took independent advice from a nursing adviser. We found that there was no evidence that a falls risk assessment was carried out when Mrs A was admitted to the Combined Assessment Unit and there was no evidence of falls prevention measures being put in place at this time, which was unreasonable. Therefore, we also upheld this aspect of the complaint.

Ms C complained to us about the time she waited for a psychology appointment from the board. While she waited, Ms C went back to see her GP because she felt her condition had worsened. Several months after her referral to the board, Ms C had a telephone assessment with a psychologist to assess her needs. Some months after that, Ms C was offered a psychology appointment. The board apologised to Ms C for the delay and explained that they were taking steps to reduce their wait times. We took independent advice from a psychologist. We found that there was an unreasonable delay in carrying out Ms C's telephone assessment. We found that it was unclear why there was such a delay, as it was a relatively routine referral. We found that the delay meant the psychology service was unaware of the worsening in Ms C's condition and they missed the opportunity to offer her an earlier psychology appointment. We found this led to an unreasonable delay in offering Ms C a psychology appointment and we upheld the complaint.

Mr C complained that the care and treatment he received at Dumfries and Galloway Royal Infirmary was unreasonable. Mr C has metastatic (cancer that spreads to other parts of the body) prostate cancer and chronic kidney disease. His complaint primarily concerned his nephrostomies (catheters inserted through the skin and into the kidneys to drain urine). He had experienced problems with catheterisations, and had infections and leaking. He complained that the reasons for his treatment had not been explained to him, especially in relation to his elective transurethral resection of the prostate procedure (a surgical procedure that involves cutting away a section of the prostate) and nephrostomies. We took independent advice from a consultant urological surgeon (a clinician who treats disorders of the urinary tract). We considered that Mr C's initial treatment was reasonable. After catheterisation failed to improve his kidney function, nephrostomies were inserted on both sides. However, we were critical of the follow-up to the nephrostomies, particularly as Mr C was not offered direct access back to the clinical team at the hospital should any problems arise. We considered this especially important in light of subsequent frequent blockages which resulted in an A&E attendance. Taking into account Mr C's particular range of symptoms, we also questioned the decision to operate on Mr C's prostate to relieve obstruction, which carried a low chance of him being able to empty his bladder naturally. Therefore, we upheld this aspect of Mr C's complaint. Mr C also complained that the board's communication was unreasonable. We found that there were shortcomings in record-keeping and could not find evidence that the board had provided Mr C with clear information regarding the prostate surgery and nephrostomies, or the impact that this would have on Mr C long-term. We noted that Mr C did not appear to have been given written information about who to contact in case of diff

Mrs C complained about the care and treatment she received during two admissions to Galloway Community Hospital. Mrs C was admitted with abdominal pain and she was suspected to have sepsis (blood infection). We took independent advice from a consultant in acute medicine. We found that during Mrs C's first admission, there was a delay in administering her antibiotics and that she should have been given intravenous fluids (fluid through a drip). We also found that during both admissions there was an unreasonable delay in investigating and establishing the source of her underlying infection. We upheld this aspect of Mrs C's complaint. Mrs C also complained about the follow-up care she received from the board in response to her ongoing abdominal pain. We took independent advice from a consultant colorectal surgeon (a specialist in conditions of the colon, rectum or anus). We found that reasonable steps were taken to investigate Mrs C's condition and she was given appropriate advice that surgery would not be appropriate treatment for her. We did not uphold this aspect of Mrs C's complaint. However, we gave feedback to the board about the potential benefit of offering out-patient follow-up for patients with complex and unresolved conditions like Mrs C. Finally, Mrs C complained about the board's handling of her complaint. We found that there was a failure to update Mrs C during the board's investigation, which the board had acknowledged and apologised for. We also found that the board failed to investigate and respond to all aspects of Mrs C's complaint. Therefore, we upheld this aspect of Mrs C's complaint and we made further recommendations in relation to this.

Mr C complained to us about the care and treatment provided to his son (Mr A) by the board in the community. Mr A had been diagnosed with paranoid schizophrenia (a serious mental health condition that causes disordered ideas, beliefs and experience), complicated by drug misuse. The conditions of Mr A's treatment were set out in a compulsory treatment order. We took independent advice from a mental health nurse. Mr C complained that Mr A received an inadequate level of support and that restrictive measures should have been put in place when Mr A failed to comply with his treatment plan. We found that Mr A's care plan was reasonable. We found that the board demonstrated good practice by encouraging Mr A to comply with his treatment plan rather than immediately resorting to more restrictive measures. We found that the board did admit Mr A to hospital when it was the only practical way to stabilise his condition. We did not uphold this aspect of the complaint. Mr C complained that there was a failure to take the circumstances of Mr A's family into account and to ease the strain they were experiencing. He also complained there was a failure to communicate effectively with the family. We found that the board acted appropriately by referring Mr C to social work for a carer's assessment. We found there was no obligation for the board to carry out their own assessment of the family's needs as carers. We also found that the board's communication with the family was reasonable. Therefore, we did not uphold these aspects of the complaint. Related reading View Decision Report 201802088 as a PDF (24.05 KB) Updated: July 24, 2019

Mrs C complained about the treatment her mother (Mrs A) received when she attended the emergency department at Dumfries and Galloway Royal Infirmary having experienced a fall, and loss of mobility in her legs. Mrs A was discharged from hospital the same day. The following day, Mrs A was unable to mobilise and was admitted to hospital, where it was later discovered that she had suffered a stroke. Mrs C was unhappy that Mrs A was discharged, and complained that the opportunity for mitigating treatment for Mrs A's stroke and for further observation was lost. Mrs C said Mrs A had been visited at home by her GP the week earlier and that the GP said Mrs A might have had a slight stroke. Mrs C was unhappy that Mrs A's GP had not been consulted. We took independent advice from a medical adviser. We found that the medical treatment Mrs A received was reasonable, and that, on the basis of tests appropriately carried out, stroke was not expected as the cause of Mrs A's mobility problems. We considered that, in the circumstances, stroke mitigating treatment would not have been appropriate and would not have altered the outcome for Mrs A. Therefore, we did not uphold this aspect of Mrs C's complaint. Mrs C also complained about the board's handling of her complaint. We found that Mrs C's complaint was not acknowledged or responded to within the correct timescale. We found that the board had already acknowledged these shortcomings, had apologised, and had explained the action they were taking to address them. Mrs C also raised some issues that were not addressed in the board's response. We found that a clearer explanation could have been given for the reasons for Mrs A's discharge. Therefore, we upheld this aspect of Mrs C's complaint. Related reading View Decision Report 201801523 as a PDF (24.14 KB) Updated: May 22, 2019

Mrs C complained about the nursing care and treatment given to her late husband (Mr A) at Dumfries and Galloway Royal Infirmary. She also complained that communication by the board was poor. Mr A had a complicated medical history. As he began to experience an increase in symptoms, he was admitted to hospital. Mrs C said that when she visited she found him in an undignified state. Later, she found that he had six stitches to a head wound, about which she had not been informed. We took independent advice from a registered nurse. We found that the assessment taken on Mr A's admission noted that he could not properly answer questions to elicit information about his mental state, and that despite this, no further enquiries were made into whether or not he could be experiencing delirium, as was required. Similarly, despite his low score about his mental state, which should also have triggered a falls prevention plan and care plan, this did not happen. Mr A went on to fall twice, the second fall required him to have stitches. Furthermore although Mr A also appeared to be suffering delirium, the prescribed care for this was not evidenced in the nursing records and there were gaps in his care. We also found little record of conversations with Mrs C and she had not been told about his head wound until she visited him. Given these failures, we upheld both aspects of Mrs C's complaint.

Mr C complained about the lack of pain relief provided to his late mother (Mrs A) and that she did not have a regular doctor who saw her during her admission to Castle Douglas Hospital. Mr C also complained about the board's communication with him about the decline in his mother's condition. We took independent advice from a nursing adviser. We found that Mrs A's pain was assessed appropriately during her admission and the pain relief provided to her was reasonable. Mrs A was reviewed by doctors during her admission and the input from medical staff was reasonable. We also found that the board's communication with Mr C was reasonable. Therefore, we did not uphold the complaints. Related reading View Decision Report 201805122 as a PDF (23.62 KB) Updated: May 22, 2019

Mrs C complained about the care and treatment given to her late husband (Mr A) by the practice before his death. In particular, she said that he was given a specific medication in tablet form althought it was known that he had swallowing problems, that communication from the practice had been poor and that Mr A had had sepsis (a blood infection) which had gone undiagnosed. We took independent advice from a GP. We found that Mr A was taking many different medications all in tablet form and there was no information in his medical records to indicate that he had a problem swallowing medication. We also found that the records showed appropriate communication and no evidence that Mr A had sepsis. We did not uphold the complaint. Related reading View Decision Report 201803700 as a PDF (23.7 KB) Updated: May 22, 2019

Mrs C complained about the care provided to her late husband (Mr A) by the practice. Mr A who suffered from chronic obstructive pulmonary disease (COPD, a disease of the lungs in which the airways become narrowed) attended the practice on a number of occasions reporting breathing problems but felt that the doctors did not listen to him. Mr A was later admitted to hospital with pneumonia (an infection of the lungs) where he suffered a heart attack and died. Mrs C complained that the practice failed to provide Mr A with appropriate treatment in view of his symptoms. We took independent medical advice from a GP. We found that the practice had carried out thorough investigations into the symptoms reported by Mr A and that his COPD did result in him having breathing issues. We also found that the practice prescribed appropriate antibiotics but that Mr A's condition and symptoms were drastically different between his final two consultations and it was only at that time that a hospital admission was required. Therefore, we did not uphold the complaint. Related reading View Decision Report 201804677 as a PDF (23.89 KB) Updated: April 17, 2019

Mr C complained about the care and treatment provided to him in relation to surgery he underwent at Dumfries and Galloway Royal Infirmary. Mr C felt that the board had failed to provide reasonable care and treatment to him leading up to the surgery and action was not taken to prevent the deterioration which led to surgery. Mr C also felt that when he was in hospital he was not provided with reasonable nursing care and treatment, and that the care and treatment provided to him after surgery in relation to occupational therapy (a method of helping people who have been ill or injured to develop skills or get skills back by giving them certain activities to do) was unreasonable. We took independent advice from a diabetologist (a doctor who specialises in the treatment of diabetes), a nurse, and an occupational therapist. We found that the care and treatment leading up to Mr C's surgery was reasonable as all appropriate investigations were undertaken and he was provided with treatment in line with the relevant national guidance. We did not uphold this aspect of Mr  C's complaint. In relation to the nursing care provided to Mr C, we found that Mr C had been provided with the wrong dose of medication for four days during an admission, which we considered unreasonable. We also found that the communication from nursing staff to Mr C was unreasonable as they did not appear to have taken into account his mood or mental wellbeing. We upheld this aspect of Mr C's complaint. Finally, in relation to the occupational therapy input for Mr C after his surgery, we found that there was no evidence that Mr C's ability to use his wheelchair in restricted spaces was explored, there was little evidence that Mr C was given sufficient opportunity to practice functional tasks prior to discharge and there was no evidence that Mr C's mental health and wellbeing was considered by the occupational therapy team. Therefore, we upheld this aspect of Mr C's complaint.

Ms C underwent abdominal surgery at Dumfries and Galloway Royal Infirmary and complained about the way in which it was carried out. Ms C also complained that the follow-up care and treatment was unreasonable. We took independent advice from a consultant surgeon. We found that the board failed to explain all the recognised risks and complications of the surgery to Ms  C prior to the surgery. We considered that this was not in line with the General Medical Council guidance on consent. We also found that the board were unable to confirm the operating consultant surgeon's experience in this type of surgery. We concluded that there was a lack of evidence to demonstrate that the operating consultant surgeon was appropriately trained, experienced and had conducted a sufficient number of cases to perform the surgery without the direct involvement of a plastic surgeon. Therefore, we upheld this aspect of Ms C's complaint. In relation to follow-up care and treatment, the board acknowledged and apologised for failings highlighted in their own complaint investigation. They found that Ms C's symptoms and pain were not fully considered in order to identify and prompt the removal of stitches sooner and that communication around this had been unreasonable. Following our investigation, we also found that an urgent GP referral and ultrasound scan should have prompted urgent surgical review. We also noted that there was no planned review following earlier treatment and that there were no post-operative instructions on operation records. Therefore, we upheld this aspect of Ms C's complaint.

Mrs C complained about the standard of medical care and treatment provided to her late husband (Mr A) at Dumfries and Galloway Royal Infirmary. Mr A had a complex medical history and his condition deteriorated soon after admission. He was first transferred to the high dependency unit and then the intensive care unit. Mr A died a few weeks after he was admitted. Mrs C was concerned that medical staff failed to recognise the significance of his deterioration, diagnose him and refer him to the intensive care unit within a reasonable time. Mrs C was also concerned about treatment decisions and management, and lack of communication from medical staff. We took independent advice from an adviser who specialises in general medicine. We were satisfied that the overall standard of medical care and treatment provided was reasonable and we did not uphold Mrs C's complaint. However, we found failures in communication and that Mr A and Mrs C were not kept updated about his condition as they should have been. We made recommendations to the board in light of these findings.

Mrs C complained that the board failed to carry out her total knee replacement appropriately in Dumfries and Galloway Royal Infirmary. Mrs C suffered pain and stiffness after the operation and eventually had to have a revised total knee replacement at another hospital. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). Although there was evidence of malalignment (incorrect or imperfect alignment) of the knee on the x-rays and CT scan carried out some time after the operation, a few degrees of variation would not be unusual. This was unlikely to have contributed to the stiffness Mrs C experienced. We found that that without the benefit of hindsight, there was no evidence that the operation had not been reasonably carried out. Therefore, we did not uphold this aspect of Mrs C's complaint. Mrs C also complained that the care and treatment provided to her after the operation was unreasonable. We found that, in general, the care and treatment provided to Mrs C after the operation was reasonable. However, we found that a letter the board issued to the hospital where she had the revised total knee replacement contained a number of inaccuracies. For this reason, we upheld this aspect of Mrs C's complaint. Finally Mrs C complained that the board refused to lend her a continuous passive motion (CPM) machine. We found that it would not be routine for a patient to be given a CPM machine. We found that the board's actions in relation to this matter were reasonable. We did not uphold this aspect of the complaint.

Mr C complained about the treatment he received for an injury to his achilles tendon (a band of connective tissue joining the heel bone to the calf muscle) at Dumfries & Galloway Royal Infirmary. In particular, Mr C considered that there was a delay in referring him for surgery to repair his achilles tendon. Mr C also complained that, after his surgery, he was not given appropriate treatment for the problems he experienced with the surgical wound. We took independent advice from a consultant orthopaedic and trauma surgeon (a doctor who diagnoses and treats a wide range of conditions of the musculoskeletal system). We found that it was reasonable that Mr C was initially given conservative (non-surgical) treatment for his injury, by way of a cast. We did not consider there was an unreasonable delay in referring Mr C for surgery on his achilles tendon. The adviser explained that Mr C was at particular risk of the surgical wound being slow to heal. We considered that the treatment Mr C received for his difficulties with the wound was reasonable. We did not uphold Mr C's complaints. Related reading View Decision Report 201705814 as a PDF (23.84 KB) Updated: February 20, 2019

Mrs C complained about the clinical treatment which she received at Dumfries and Galloway Royal Infirmary. She had undergone surgery for a leg fracture and she said she was informed by a consultant that the wrong size of screws had been used to fix the fracture. Mrs C felt that her recovery period following the surgery was too long and this was due to the error with the screws used to hold the fracture. We took independent advice from an orthopaedic consultant (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the screws which had been used sat slightly differently than would be expected but they were not excessively long. Mrs C had suffered a very significant injury and that would have accounted for her ongoing pain and mobility issues. The screws would have been contributing to the discomfort, however, to a lesser extent than the injury itself. We did not identify any failings in the treatment. Therefore, we did not uphold Mrs C's complaint. Related reading View Decision Report 201804347 as a PDF (23.83 KB) Updated: February 20, 2019

Mr C complained about the care and treatment he received at Dumfries and Galloway Royal Infirmary. Mr C received an injection into his hip for pain relief but the needle was placed in the wrong place causing Mr A pain. Another consultant had to remove the needle and gave a further injection in another place. Mr C said that he continues to suffer pain from the procedure and that he had been unable to return to work. We took independent advice from an orthopaedic consultant (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that adequate consent had been obtained from Mr C and that he was advised of the potential risks and the possibility that the procedure may not be successful. We noted that Mr C had suffered a rare but recognised complication of the procedure. The supervising consultant had to take over when difficulties were encountered and this is normal practice. Therefore, we did not uphold Mr C's complaint. Related reading View Decision Report 201803425 as a PDF (23.8 KB) Updated: January 23, 2019

Mrs C complained about the care and treatment that her mother (Mrs A) received at Dumfries and Galloway Royal Infirmary. She was admitted to hospital with a large haematoma (a localised collection of blood outside the blood vessels) on her right leg. Mrs A received treatment and was later discharged. After a visit from the district nurse, Mrs A was readmitted to hospital and her leg was operated on the following day. Mrs A was eventually discharged to a hospital outwith the board. Mrs C complained that the board failed to provide appropriate treatment for Mrs A's haematoma following her admission to hospital. She also complained that the board unreasonably discharged Mrs A from hospital. We took independent advice from a registered general nurse and a consultant in general medicine. We found that there was a lack of wound assessment, inappropriate wound assessment and a failure to debride the wound (to remove the damaged tissue from the wound) before discharge. We were also concerned about the use of dressings which stuck to Mrs A's leg and considered Mrs A should have been referred to a wound care specialist. We considered that these failings would have contributed to the time taken for Mrs A's wound to heal and her pain during that period. Initially Mrs A received appropriate medical care, with appropriate investigations carried out on admission and clear attention to detail. However, we found that Mrs A should have received a greater level of medical review prior to discharge, and her care therefore fell below a reasonable standard. We upheld this part of Mrs C's complaint. In relation to Mrs A's discharge, we found that Mrs A should have received a debridement before discharge. We were also concerned about the level of medical review Mrs A received in the days before her discharge. Given the severity of Mrs A's wound a few days later, and the lack of detail in the records at the time of discharge, we were not confident that Mrs A's wound had improv

Ms C complained about the nursing care provided to her father (Mr A) at Dumfries and Galloway Royal Infirmary. Ms C raised a number of concerns including: • Mr A having suffered a fall that resulted in a wound to his arm; • the suitability of his diet; • his developing of a pressure ulcer; • him not seeing a dietician and; • poor record-keeping, specifically the failure to record her father's fall. We took independent advice from a nurse. We found that risk assessments about the risk of developing a pressure ulcer and being nutritionally compromised had not been completed correctly. This resulted in Mr A not receiving adequate pressure ulcer prevention interventions and being assessed at a lower risk of being nutritionally compromised than he should have been. We also found that important records relating to fluid intake and weight were not kept up to date and that the board failed to follow their policy when they became aware of Mr A's fall. We considered the care and treatment Mr A received was unreasonable and upheld this complaint. Ms C also complained about the board's responses to her complaints. Ms C was concerned about the tone of the board's response, whether the response reasonably addressed the complaints she raised, the time taken to respond and the efforts to communicate the response when it was clear Mr A was in the final days of his life. We found that the tone of the response had been reasonable but not all of the issues raised had been responded to and that some of those that were, were unreasonable. We found that the response had been provided within a reasonable timescale but the board had not acknowledged Ms C's complaints as they should have. We found that it was unreasonable for the board to have refused to read their decision letter, which was awaiting a final signature, to Ms  C over the telephone so she could communicate it to Mr A before he died. Therefore, we upheld this complaint.

Mr C complained on behalf of his wife (Mrs A) about a delay in carrying out a CT scan (a scan that creates detailed images of the inside of the body). Mrs A was taken to A&E at Dumfries and Galloway Royal Infirmary and following a CT scan, was diagnosed with having suffered a stroke. Mr C felt that the scan should have been carried out sooner. We took independent advice from a medical adviser. We found that records of Mrs A's history and examination were inadequate. This meant that we were unable to conclude what Mrs A's condition was at the time of her assessment in A&E and, therefore, if the CT scan was completed within a reasonable time frame. We upheld Mr C's complaint.

Mr C complained about the care and treatment provided to him during two admissions at Dumfries and Galloway Royal Infirmary. Mr C had Hodgkin's Lymphoma (a cancer of the lymphatic system, which is part of the immune system). Mr C complained that he should not have been discharged after he felt unwell during an admission for a blood transfusion. We took independent advice from a consultant haematologist (a doctor who specialises in blood). We found that the follow-up arrangements made prior to discharge were unreasonable. We, therefore, upheld this part of Mr C's complaint. During a subsequent admission, Mr C experienced a build-up of fluid in the lining of his lungs. He complained that there was a delay in carrying out a procedure to drain the fluid. We found that medical staff appropriately monitored whether a drain was needed to improve Mr C's symptoms and we did not consider that there was an unreasonable delay. We did not uphold this aspect of the complaint. Mr C also experienced a build-up of fluid around his heart which required a procedure (pericardiocentesis) to drain the fluid. Mr C complained that the two attempts to carry out this procedure were not of a reasonable standard. We found that the first attempt was halted after Mr C became uncomfortable. The second attempt was stopped after concern was raised that Mr C's heart was damaged. Mr C was then transferred for emergency assessment, where the procedure was carried out successfully and no significant damage to Mr C's heart was identified. We took independent advice on this from a consultant cardiologist (a doctor who specialises in the heart and blood vessels). We found that the first attempt at pericardiocentesis was not performed to a reasonable standard and was not documented adequately. However, we found that the board had carried out an internal investigation and that the operator involved had since reflected on what had happened and identified learning points. Despite the complicatio