SPSO Individual Decisions

C complained about the end of life care their late spouse (A) had received from the practice. A had Lewy body dementia (a progressive dementia that results from protein deposits in nerve cells of the brain which affects movement, thinking skills, mood, memory, and behaviour) and was cared for at home by C. When A’s condition deteriorated, C complained that the GP had not visited them at home to assess their decline. C also complained that there had been a delay in initiating their end of life care plan allowing access to appropriate pain relieving medication and to the community palliative care team for support. In response, the practice said that although a GP had not visited A at home in their final weeks, a number of GPs had been in constant liaison with the district nursing team about their care and prescribing appropriate medications. They noted that their duty doctor had not been aware of, or could refer into, the palliative care team but following liaison with the district nursing team, this was progressed and A had received assistance thereafter. We took independent advice from a GP. We found that the practice had not provided a reasonable standard of end of life care to A. We considered they should have carried out an earlier assessment of A’s palliative and end of life needs to inform better care planning, that there was an unreasonable delay in providing A with appropriate pain relieving medication, and noted that staff lacked awareness of the community palliative care team and the referral process. Therefore, we upheld C's complaint.

C complained about treatment provided to their late parent (A) from the board during a hospital admission. C complained that A had been discharged from hospital when it had been unsafe to do so, that staff had failed to insert an intravenous line so that A could receive fluids, that A had developed a pressure sore on their sacrum (a bone in the spine), and that insufficient investigations had been carried out to establish the cause of A’s refusal of treatment. The board stated that A had received fluids intravenously on admission but that their cannula (a tube that can be inserted into the body) had become blocked. Further unsuccessful attempts were made to reinsert the cannula before A declined any more attempts to be made. A also had refused to accept oral treatment and did not wish to undergo investigations to establish cause of their illness, preferring instead to be discharged home. The board also stated that A had been non-compliant and had not wished to change position in bed resulting in the development of a pressure sore, for which arrangements were put in place with district nurses upon A’s discharge. We took independent advice from a consultant geriatrician. We found that the investigations the board had carried out to establish the cause of A’s illness had been reasonable as had the overall treatment provided during A’s admission. We noted that the records showed A had declined several attempts to treat their symptoms and carry out further investigations and that there was no evidence in the available records to indicate that A had lacked capacity to make decisions about the medical treatment that they wished to receive. In relation to A’s discharge, the records also showed that the board had requested an assessment of A to be carried out by their Integrated Assessment Team but that this could not be completed due to A leaving the hospital. We found that management of A’s pressure sore had reasonable. For these reasons, we did not uphold the comp

C complained about the care and treatment provided to their late parent (A) who had a number of medical conditions. During an admission to hospital, A’s condition deteriorated, and they died. C complained that A’s deterioration was not appropriately managed and that they contracted Listeria Meningitis (a serious disease in which there is inflammation of the membranes of the brain and spinal cord, caused by bacterial infection) and Clostridium Difficile (C-Diff; infection of the large intestine triggered by long term use of antibiotics). C also complained that a medication to treat diarrhoea was inappropriately prescribed because A had a diagnosis of ulcerative colitis. C further complained that staff did not communicate with A’s family that they were suspected of having sepsis. C also raised concerns about the board’s handling of their complaint and the standard of record keeping which was referred to in their complaint response. The board acknowledged that the medication to treat diarrhoea should not normally be prescribed in patients with ulcerative colitis and that there was no clear record of the discussions that were held with A’s family. The board confirmed that Public Health investigated the source of listeria meningitis and concluded it was not likely a hospital-based transmission. We took independent medical advice from a consultant gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas). We found that A’s overall care and treatment was reasonable. A was appropriately treated with intravenous steroids and antibiotics and the decision to not provide surgical intervention was reasonable. It was noted that A was at high risk of developing C-Diff given that they had been prescribed a strong immune suppressant. With regards to the listeria meningitis breakout, we found that the board appropriately sought external review and specialist public health and microbiology advice. We also found that

C complained about a delay in diagnosing their late partner's (A) oesophageal cancer. The board had already acknowledged that A’s cancer could have been diagnosed sooner and apologised for failing to fully investigate their symptoms. However, C did not consider that the board had provided a satisfactory explanation as to why A’s cancer was not diagnosed at an earlier stage. We took independent advice from an Ear, Nose and Throat (ENT) consultant. We found that initial examinations had identified a lesion in A’s throat, but that this was not found on a subsequent examination (a microlaryngoscopy - an examination of the throat with magnification). The board, therefore, did not arrange any further ENT follow-up. We noted C’s history and presenting symptoms and considered that there were multiple red flags for cancer. We found that further radiological investigations should have been ordered and that it was unreasonable for investigations to have stopped at that point. We upheld the complaint.

C complained to the board on behalf of their partner (A) about the length of time taken to arrange a lumbar puncture test (LP, a procedure used to collect a sample of fluid from the spine) following assessment by a neurologist (specialist of the nerves and the nervous system). C had regularly contacted the board requesting an update on C’s appointment and eventually decided to complain when they were told to ask A’s GP to re-refer them. On complaining, A received their LP appointment. The board advised that the delays had been caused by the Covid-19 pandemic and that A had now been appointed to see a neurology consultant. We found that the board had separate processes in place for arranging LPs depending on whether a patient was seen by a locum consultant or a member of the board’s own staff. As A was seen by a locum consultant, they were required to be added to an anaesthetist’s (administer of drugs) list which ran every three-four months. Had they been seen by the board’s own staff, they would have arranged the LP test directly without the need to refer them to a separate list. In A’s case, the original anaesthetist’s list that they were appointed to was cancelled, as was the second due to the onset of the pandemic, which meant that A was required to wait 10 months for this test. We upheld this complaint. C also complained that the board failed to provide pain relief to A while waiting for the LP test. While we considered C’s expectations to be reasonable in respect of the results of the LP test confirming A’s diagnosis and informing decisions about future care and treatment, including management of their pain, we considered that this aspect of their care to remain the responsibility of A’s GP at this time. As such, we did not uphold this part of C’s complaint. Finally, we found that the board’s complaint handling was unreasonable, particularly in relation to the failure to act on the lack of equivalence in service provision despite this problem being kno

C complained on behalf of their parent (A) for whom they hold power of attorney. C complained that the practice had incorrectly diagnosed and treated A with chronic back pain. C stated that A was later admitted to hospital with a fractured back and pneumonia. The practice advised that there was nothing to clinically suggest a fracture at the time and it would not have altered treatment. They noted that A did not have pneumonia as per hospital discharge. We took independent advice from a GP. We found that a thorough physical examination was undertaken which did not raise concerns of a fracture. We also found that appropriate pain relief is the only immediate treatment for vertebral fractures. There were no symptoms of pneumonia when the patient was seen by the GP and no suggestion of pneumonia in the medical records. We did find one mention of pneumonia in a letter between two third party medical professionals, who were not involved in A’s hospital care. Therefore, we did not accept this as evidence of a pneumonia diagnosis. In light of this, we found that the overall care and treatment provided to C was reasonable and did not uphold C’s complaint. Related reading View Decision Report 202111152 as a PDF (24.31 KB) Updated: November 23, 2022

C’s adult child (A) had spent time in hospital due to abdominal pain, following which complaints had been raised and promises made that action would be taken to prevent any recurrence. A few years later, A spent time in hospital again as a result of abdominal pain and swelling, bruising to the legs and breathing issues. During the admission, A required cardiopulmonary resuscitation (where the heart and/or breathing is re-started if it stops) and died in hospital. A post-mortem examination established that A had rheumatoid arthritis-related constrictive pericarditis (a condition that causes the flexible sac that surrounds the heart to become stiff, preventing the heart from functioning properly). C raised a number of concerns regarding the clinical investigations carried out into A’s symptoms, the time taken to reach a diagnosis and the quality of clinical nursing care provided. C complained about the standard of communication from the board’s staff and expressed their concern that the improvements that had been promised previously had not been implemented by the board. We took advice from an independent nursing adviser. We found that multiple, relevant, investigations were carried out to establish the cause of A’s symptoms, appropriate specialist advice was sought, a reasonable treatment plan was followed and that the true nature of A’s heart condition was not detectable, despite the appropriate investigations having been carried out. Given this, we found that the medical care and treatment provided to A had been of a reasonable standard. We did not uphold this aspect of the complaint. We found that the board’s monitoring and management of A’s fluid balance and wound care was not of a reasonable standard, and that there were apparent issues in terms of the nursing staff’s engagement with A and their family. We found that the board had failed to provide A with a reasonable standard of nursing care. We upheld this aspect of the complaint. While we found the board’s co

Following a short psychiatric hospital admission, C presented unwell on several occasions over the course of the next month. C complained that they weren’t sectioned under the Mental Health Act and given appropriate treatment. C’s behaviours at that time had prompted police involvement and the outcome of clinical assessments concluded that these behaviours were not driven by a mental health problem. C disagreed with this and was very distressed to subsequently be subject to a short imprisonment, before a judge ordered that they be admitted to a psychiatric unit. We took independent advice from a consultant psychiatrist. We found that based on the information available at the time, reasonable conclusions were reached by the clinical team regarding the nature of C’s condition and the cause of their behaviours. We found that the action taken was in line with accepted practice in the circumstances. The clinicians all reached a consistent view as to the nature of C’s presenting condition and none were able to identify an underlying psychotic issue. We considered that C’s condition at that time was significantly different to when they were subsequently admitted to hospital, at which time a psychotic cause had become apparent. We did not uphold this complaint. Related reading View Decision Report 202003428 as a PDF (24.35 KB) Updated: October 19, 2022

C complained about the care and treatment provided to their late child (A) by their GP practice. A had attended the practice on several occasions over a five month period with persisting chest symptoms. C complained that the practice failed to recognise the severity of A's symptoms or recognise that symptoms were indicative of a serious cardiac condition until A's health had significantly deteriorated. A subsequently suffered a cardiac arrest resulting in them being transferred to another health board for surgery, where they later died. We took independent advice from a GP adviser. Although we noted that there had been a delay of a few days in responding to A's x-ray report, we found that the practice's care of A was reasonable, with referrals and tests being timeously arranged and in keeping with A's presenting symptoms at the time. Therefore, we did not uphold the complaint. Related reading View Decision Report 202101690 as a PDF (24.18 KB) Updated: August 24, 2022

C complained about the care and treatment provided to their elderly parent (A) during their admission to St Andrew’s Community Hospital for post-surgery rehabilitation. C complained about several aspects of A's care during their admission including in relation to their eating and drinking, management of their medicines, the discharge arrangements, and the general care provided to them as a person living with dementia. We took independent advice from a senior nurse. We found that aspects of A's care in relation to their eating and drinking had been reasonable. However, the board had failed to undertake regular weight checks or re-assess A's risk of developing malnutrition. As such, we upheld this aspect of C's complaint and made recommendations for learning. In relation to the management of A's medicines, their discharge planning, and the care provided to them as a person living with dementia, we found the care provided by the board to A to be reasonable. Therefore, we did not uphold these aspects of C's complaint.

C complained about a delay in diagnosis of cancer due to insufficient investigations undertaken by a number of GP's at the practice. C was later diagnosed with stage 4 lung cancer. C said the signs of cancer were missed, which was likely due to seeing different GP's at each consultation. In addition to this, C had a history of kidney cancer and considered their history was not adequately taken into account. C attended the practice on several occasions, reporting a number of concerns. C said that considering their history of cancer, the early signs of lung cancer were evident. It was only following a CT scan for C's kidney cancer that the oncology team found evidence of stage 4 lung cancer. The practice agreed that some of C's symptoms during this time could explain developing cancer. However, they also considered that the symptoms reported could be caused by a wide range of diagnoses. The practice evidenced that multiple x-rays were taken along with blood tests and vital sign checks, and there was nothing to indicate that cancer was developing. Due to these findings, the practice say that they had no medical reason to request a CT scan or refer C to a specialist team. We took independent advice from a GP adviser and reviewed the relevant medical records. We found that C did not present with any symptoms suggestive of lung cancer but a variety of unrelated problems, some of which were long standing. It was noted there was a lack of red flag symptoms of lung cancer, and as such, there was no requirement for a CT scan or to be referred to a specialist team during this period. In light of this, we found that the overall care and treatment provided to C was reasonable. We therefore did not uphold this complaint. Related reading View Decision Report 202107375 as a PDF (24.6 KB) Updated: July 20, 2022

C complained about the board regarding treatment provided to their late spouse (A) at the end of their life. C was concerned that the board had failed to provide A with reasonable care and treatment, and failed to manage their diet appropriately. C was also concerned about the board's recording of an incident where A fell and broke their hip, as well as that the board refused to allow A to attend a relative's funeral. We took independent advice from an appropriately qualified clinician. We found that the board had provided reasonable care and treatment throughout, including managing A's diet appropriately and keeping a reasonable record. There was no record in the clinical notes that the board had refused to allow A to attend a relative's funeral. Given these points, we did not uphold C's complaints. Related reading View Decision Report 201903992 as a PDF (24.04 KB) Updated: May 18, 2022

C complained about the care and treatment that they received from the board after they were diagnosed as having a tumour in their bowel. C underwent surgery to remove their tumour. Following the procedure, they experienced a number of complications that led to extended hospital treatment and the need to be fitted with a stoma (a surgically made pouch on the outside of the body). It was ultimately established that their surgery failed to heal properly, possibly due to a fault with an item of equipment used to staple their bowel. C complained that the issues resulting from their surgery had life-changing consequences. C raised a number of concerns regarding the care and treatment that they received from the board at the time of their surgery and once they had been discharged. They also did not consider that the board adequately took responsibility for the issues that affected them. We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). It was evident from C's complaint that they went into surgery expecting a straightforward procedure. The procedure was complicated by C's high body mass index (BMI, a measure for estimating human body fat) and took several hours longer than they had anticipated. Whilst we were critical of the board for not explaining to C that their BMI was a potentially complicating factor, overall we were satisfied that the surgery was carried out reasonably. During the procedure, the surgeon made reasonable adaptations when issues arose and there was no indication at the time of the issues that would later affect C. We were also satisfied that there was no indication at that time that there was a fault with the equipment being used during the procedure. Therefore, we did not uphold this aspect of C's complaint. Following their surgery, C experienced a significant amount of pain. We were largely satisfied that the board's staff took this seriously and took app

C complained about the care and treatment their parent (A) received from district nurses in relation to the management of sores/ulcers on their legs while resident at a care home. In particular, C complained that district nursing staff had failed to adequately monitor and treat A's sores/ulcers to such an extent that dressings would become saturated in exudate (fluid), requiring care home staff to apply further dressings. C stated that this had led to A developing significant infection requiring admission to hospital, where they died a short time later. C further complained that district nursing staff had failed to identify the deterioration in A's legs and had not alerted A's GP nor made a referral to a specialist tissue viability practitioner (a specialist in aspects of skin and soft tissue wounds including acute surgical wounds, pressure ulcers and all forms of leg ulceration). In response to C's complaint, the board stated that A had been reviewed frequently by district nursing staff, who had not identified any signs suggesting that A's legs had become infected. The board concluded that district nursing staff had delivered consistent and appropriate care and that referral to a tissue viability specialist had not been indicated. We took independent advice from a district nursing adviser. We found that there were a number of failings in relation to how A's sores/ulcers had been managed, specifically that wound assessments carried out were incomplete and not carried out at the required frequency and that the wound dressings used were inappropriate, often contradicting the findings of examinations, and contrary to current guidelines. We noted that district nursing staff had failed to carry out baseline observations and tests to check for the presence of infection or sepsis (blood infection) despite noting that A was as “flat” and “lethargic”. We also found that the district nursing staff's record-keeping was poor and not in accordance with relevant profession

C complained that the board failed to provide them with reasonable treatment. C was hospitalised with a right sided homonymous hemianopia (a visual field defect involving the two right, or the two left, halves of the visual fields of both eyes). C believed that a previously diagnosed arachnoid cyst (a non-cancerous fluid-filled sac that grows on the brain or spinal cord) could be the underlying cause of their clinical symptoms. C underwent CT and MRI scanning. The board concluded that C's arachnoid cyst was stable and unchanged from a previous MRI, and was unlikely to be the cause of their vision loss. Following a deterioration in their symptoms, C sought private neurosurgical opinion (specialist in surgery on the nervous system, especially the brain and spinal cord) and underwent a craniotomy (procedure to open skull to gain access to the brain) to drain the cyst resulting in partial and ongoing recovery of their vision. C complained to the board that they should have been referred for neurosurgical review and received treatment through the NHS pathway sooner. They said that clinicians leading their care had repeatedly dismissed their concerns that the cyst could be the underlying cause of their symptoms and had excluded several sources of significant information from the clinical decision-making process, including a discrepancy in the scan measurements which had in fact shown the cyst had increased in size. We took independent advice from a neurosurgical adviser. We found that, despite a marginal increase in the cyst identified through retrospective radiology analysis, C's progressively worsening symptoms could not have been explained purely on the basis of imaging, and there was no evidence to support an argument that an earlier opinion from a neurosurgeon should have been requested. Our investigations found that although multi-disciplinary opinion may have been helpful in this particular case given C's continuing and unexplained neurological symptoms, the

C complained about the board, regarding their treatment of a benign cyst. C complained that since being seen by the board they failed to take a proactive approach despite the pain and discomfort they were experiencing. C also complained that the board unreasonably prescribed antibiotics for an infection of the cyst which later transpired to not have been present. On investigation, we took independent advice from a GP clinical adviser. We found that the board's treatment of C had been overall reasonable. On this basis, we did not uphold C's complaint. Related reading View Decision Report 202007201 as a PDF (23.95 KB) Updated: March 23, 2022

C complained about the care and treatment of their late parent (A) in the weeks prior to their death in Queen Margaret Hospital. C raised concerns that staff failed to notice and act upon A's deteriorating condition, and particularly a dramatic deterioration on the day that A died. C noted that the post mortem identified evidence of a chest infection, and they complained that A died of an easily treatable condition. C raised concerns about the stoppage of A's diuretic medication (drugs that enable the body to get rid of excess fluids), which they considered contributed to a fluid build-up in A's lungs. We obtained independent medical advice from a consultant geriatrician (a doctor specialising in medical care for the elderly), who noted from the records that the expected level of observations took place. We found that sufficient attention was paid to A's fluid build-up, and that the decision to stop their diuretic medication was reasonable in the circumstances. However, we noted that A's vomiting and unstable observations in the days prior to their death were not acted upon. We noted that this should have prompted further clinical review. While we could not be certain that this would have identified a chest infection or how unwell A was, we considered that this should have received more attention from medical staff. We found no evidence to support that any dramatic deterioration in A's condition was overlooked on the day A died. On balance, we upheld this complaint.

C complained that the board failed to investigate, diagnose and treat gastrointestinal (relating to the stomach and intestines) problems and swallowing difficulties that they had experienced over a number of years. As a result of previous abuse, C required invasive procedures to be carried out under general anaesthetic. C complained that the board placed unreasonable emphasis on their trauma when making decisions about their treatment. We took independent clinical advice from a consultant in gastroenterology (medicine of the digestive system and its disorders) and hepatology (liver disease). We considered C's initial treatment plan to be reasonable: a CT scan of C's colon followed by an upper GI endoscopy (a medical procedure where a tube-like instrumentis put into the body to look inside) as recommended by the private clinic that they attended, and a colonoscopy (examination of the bowel with a camera on aflexible tube) if indicated by the results of the CT scan. We found that the decision not to carry out a colonoscopy at this stage was reasonable, given the risks of performing this under general anaesthetic and the previous normal investigations. We were critical of the board's failure to offer C a flexible sigmoidoscopy (an imaging test done to monitor the colon and rectum for the presence of ulcers, polyps or other abnormalities) after they developed rectal bleeding, but noted that this did not impact on C's overall treatment plan. C had gone on to have a colonoscopy under a different NHS board, which did not identify any significant pathology. We did not consider the emphasis placed on C's childhood trauma to be excessive and we noted that reasonable investigations were carried out into C's swallowing difficulties. Therefore, we did not uphold this complaint. With regard to C's complaint that the board's complaint response contained inaccurate information, we found that generally their response was thorough and detailed. With the exception of an incorrec

C was referred to the Ear, Nose and Throat (ENT) department of board by their GP after suffering extreme sore throats and infections. A diagnosis of recurrent tonsillitis (swelling of tonsils located at the back of the throat due to infection) and possible reflux (the flow of a fluid through a vessel or valve in the body in a direction opposite to normal) or allergy was offered. C was prescribed Gaviscon and recommended allergy tests, which later showed allergies to dust mites. C was seen again in clinic later where their symptoms were reported to have resolved and C was discharged. Some years later a pre-cancerous lump was found on C's breast. The results of a biopsy confirmed oesophageal (organ which connects the throat to the stomach) cancer, for which C received chemotherapy and an operation. C believed that they should have been referred to a specialist following their referral to ENT previously and that the prescription of Gaviscon had been unreasonable. C complained to the board. The board responded with the conclusion of their investigation that, in the circumstances, the prescription of Gaviscon was reasonable and no further referral from ENT was indicated. C was dissatisfied and raised their complaint with us. We took independent advice from a consultant. We found that the board's actions were reasonable in the circumstances, that there was no indication at that time that further investigation or referral was required and that the board did not unreasonably fail to diagnose or treat any condition. We did not uphold the complaint. Related reading View Decision Report 202002770 as a PDF (24.5 KB) Updated: January 19, 2022

C complained on behalf of their late child (A) who died of cancer. A received treatment from the dermatology department for a mole on their back. The mole was removed and, following testing, it was found to be cancerous. A had further treatment from the plastic surgery department to excise (remove by cutting) more tissue from the area, which was tested and confirmed no cancer cells were present. After, A presented with abnormal lymph nodes, tests confirmed that they were cancerous. A underwent a procedure to remove the lymph nodes and some painful lumps on their body. After this procedure, A refused any further treatment. C complained that the board did not do enough in the early stages to treat A's cancer. C felt that the procedure to remove the initial mole should have been more thorough, that A should have been monitored more closely for any spread of cancer, and that other treatments should have been considered at an earlier date. C said that they were unhappy with the board's communication with A and their family and that they were unhappy with the way in which the board handled their complaint, as they felt it was not consistent with their recollection of events. We sought independent advice from clinical advisers with relevant experience. Both advisers reached the view that the care and treatment provided to A by the dermatology and plastic surgery departments were reasonable both in the early stages, and when the cancer later returned. It was also their view that the board's communication with A and their family members was reasonable. In light of the evidence and the advice received, we found that the care and treatment provided to A and the communication from the board to A and their family was reasonable. We also found that the board's response to C's complaint was in line with what was recorded in the medical records. Our investigation did not identify any evidence that would cause us to doubt the board's position as detailed in their response

C complained about the care and treatment their late parent (A) received from board. A was admitted to A&E at Victoria Hospital following a fall at home. A was found to have fractured their femur and was subsequently transferred to a ward. A died shortly after transferring to the ward. No post-mortem was required by the Procurator Fiscal and a heart attack was recorded as the likely cause of death. C said that they were told by the board's staff that tests carried out in the A&E did not indicate any problems with A's heart. As such, no additional monitoring was required when A transferred to the ward. C complained that the board's staff failed to note and act upon a number of “red flag” symptoms that should have highlighted that A was at increased risk of a heart attack. C noted that A had been given a high dose of morphine by the ambulance crew. C complained that the board's staff failed to adequately monitor A's general condition or their reaction to the morphine. We found that A's general condition was reasonably assessed in the A&E. An echocardiogram (a heart scan that uses sound waves to create images) was carried out and did not raise any concerns about A's heart. Whilst A displayed a number of symptoms that could have been linked to a heart problem, the tests carried out by hospital staff were thorough and gave no indication that there was a need for any specific additional heart monitoring when A transferred to the ward. A was given a high dosage of morphine by the ambulance crew. We accepted medical advice that the hospital staff should have been aware of this and that they should have monitored A's response to this medication. We found no record of the morphine dosage having been recorded upon A's admission to hospital, or of specific monitoring taking place to check for any adverse reactions to the medication. A displayed symptoms that could have been caused by morphine. It was not possible to determine whether A's death was caused by a probl

C developed an infection following a wisdom tooth extraction, which was not diagnosed and subsequently spread to their brain. C was reviewed in hospital on several occasions, including out-patient reviews by oral and maxillofacial (OMF) surgeons (specialists in treating diseases and injuries of the mouth and face) and an in-patient admission to Victoria Hospital. C questioned how the infection was missed on so many different occasions by so many different people. The board indicated in their response that there were no clinical signs which led them to suspect bacterial infection, and jaw joint problems were being considered as the cause of C's symptoms. C was then suspected, during their in-patient admission, to have viral encephalitis (inflammation of the brain). A plan to carry out an MRI wasn't pursued due to noted improvement in C's condition. The responsible consultant reflected that an MRI should have been performed during the admission, and that not doing so may have delayed the identification and treatment of the infection in C's brain. We took independent medical advice from a consultant OMF surgeon and a consultant physician. While it was noted that C's infection presented atypically and was difficult to diagnose, their C-reactive protein (CRP, inflammation marker) was raised when they initially presented and this wasn't acted upon. A CT scan also showed subtle signs of infection but this wasn't picked up at the time. An urgent out-patient MRI was requested to look for joint problems and not to exclude infection, otherwise it may have been carried out sooner. We also found that the subsequent in-patient assessment didn't give due care and attention to C's recent wisdom tooth extraction and hospital attendances. It was agreed that the failure to pursue an in-patient MRI contributed to the failure to correctly diagnose and appropriately treat C's infection. We considered that the decision to discharge C with a persistent headache was unreasonable.

C complained to the practice about the lack of care provided to their late parent (A). C said that A had reported breathing and sleeping problems in a telephone consultation to the GP but the GP had only provided medication and A died from a suspected heart attack a week later. The practice believed that appropriate treatment had been provided. We took independent advice from a GP. We found that there was no evidence that A had reported breathing problems to the GP and that there were no recorded symptoms which would have indicated that A required a face-to-face GP consultation, a hospital admission, or that A would suffer a sudden event a week after the telephone consultation. Therefore, we did not uphold the complaint. Related reading View Decision Report 202103401 as a PDF (24.06 KB) Updated: December 22, 2021

C complained to us about the care and treatment their adult child (A) received from the board regarding their mental health over a one-year period. A was an in-patient for part of this time and C complained that it was inappropriate to allow A to make decisions about their care, including time out of the ward. C raised concerns about A’s diagnosis and the medication they were prescribed, as well as the level of support in place for A. We took independent advice from a psychiatrist. We found that the care and treatment provided to A in relation to their mental health was reasonable and in line with relevant guidance. We also found that the symptoms exhibited by A were consistent with their diagnosis and that the medication put in place for A was reasonable. We did not uphold this complaint. C also complained that the care and treatment A received regarding their physical health whilst an in-patient had been unreasonable. We found that the approach taken during A’s admission to hospital was reasonable and in line with the expected approach. The focus of clinicians was on A’s psychiatric symptoms and their physical health was treated in line with the arrangements already in place for them in the community. It was reasonable for the referral to rheumatology (specialists in rheumatism, arthritis, and other disorders of the joints, muscles, and ligaments) to be passed to A’s GP on discharge. We did not uphold this complaint. In addition, C complained that the communication and engagement with them with regards to input into A’s care and treatment had been unreasonable. We found that the communications recorded in A’s medical notes were of an appropriate standard and well recorded. We did not uphold this complaint. Related reading View Decision Report 201901140 as a PDF (24.49 KB) Updated: October 20, 2021

C complained that the practice refused to provide their late parent (A) with an in-person GP appointment. A had a history of lung cancer which had been treated with radiotherapy (a treatment of disease, especially cancer, using high-energy radiation) previously. A contacted the practice by phone to report pain in their right leg and buttock. A was not seen in-person due to COVID-19 guidance, however a telephone consultation was arranged. The consulting GP considered that A’s symptoms likely resulted from sciatica (back and leg pain caused by irritation or compression of the sciatic nerve) and prescribed treatment for this. Further phone consultations followed with the GP and others at the practice on four other occasions. The consultations consisted of a mixture of planned contacts by the GP and unplanned contacts by A. C later contacted the practice and expressed concern that A’s condition had not improved. C asked for A to be seen in person. A was seen by a GP that day. A’s case was discussed with an oncology (cancer) nurse specialist. It was agreed that A’s condition required further investigation. A was subsequently referred to an oncology clinic and was diagnosed with metastatic lung cancer. A died the following year. We took independent advice from a GP. We found insufficient evidence to suggest that the practice had refused any request from A for an in-person appointment. However, we did find that there had been a unreasonable delay in providing A with an in-person appointment. On consideration of relevant guidance, the clinical record and specialist advice we found that A should have been seen in-person on the third contact they had with the practice. We considered that the delay in providing A with an in-person appointment was brief and were unable to conclude that the delay had a material impact on A’s prognosis. In the circumstances, we upheld the complaint.