SPSO Individual Decisions

C complained that the board failed to carry out a reasonable assessment of their late parent (A) when they were admitted to hospital. They were also unhappy with the decision to discharge A and said that the board failed to communicate adequately with them and their family during the time A spent in the hospital. C complained that the board’s complaint response was not consistent with A’s clinical records. We took independent advice from a consultant in geriatric and general medicine. We found that while a reasonable assessment of A’s clinical condition was carried out, the assessment of A’s physical condition and the discussion with their family before discharge fell below a reasonable standard, particularly with respect to A’s mobility. We also found that communication with A’s family fell below a level that they could reasonably expect. Finally, we were critical of the board’s complaint response which appeared to be selective in terms of the information provided rather than being objective. Therefore, we upheld C’s complaints.

C complained about the care and treatment that they received over a series of interactions with the practice. C believed that their symptoms had not been properly investigated. C subsequently suffered a stroke and felt that the outcome for them could have been better if they had been listened to when they contacted the practice. C also felt that the practice’s complaint handling had been unreasonable, failing to provide C with information that they were entitled to and incorrectly directing them to the local NHS Board as part of the complaints process. We took independent advice from a GP adviser. We found that some of the assessments of C did fall below a reasonable standard, although it was not possible to conclude that the stroke could have been predicted or prevented. Therefore, we upheld and did not uphold aspects of these complaints around the assessment of C's symptoms over different periods. We also found that the handling of C’s complaint fell below a reasonable standard. We upheld this aspect of the complaint.

C, an advocate to A, complained on behalf of A that their colonoscopy was performed without sedation or anaesthetic. A was advised at pre-assessment that they could not have pain relief during the procedure, due to having taken methadone prior to the colonoscopy. C also complained about the lack of information on the patient leaflet for methadone users, the attitude of staff, and that the procedure was performed by a trainee endoscopist. The board considered that the care and treatment provided to A was reasonable as A consented to the colonoscopy being carried out without pain relief and understood that a trainee would undertake the procedure. The board apologised for the comments made by staff. We took independent advice from a colorectal surgeon. We found it unnecessary to contain methadone specific information on the patient leaflet as all medication should be considered when administering sedation for all patients. We found that the advice given at pre-assessment was incorrect. There is no contraindication (a specific situation in which a medicine, procedure, or surgery should not be used because it may be harmful to the person) for use of sedation with methadone and being on methadone does not preclude either sedative or opioid pain control. Therefore, we found that A should have been given pain relief during the colonoscopy. We also found that it is the endoscopist's responsibility to understand drug interaction in prescribing medication for pain and sedation and that was not the case in this instance and a second opinion should have been sought. Due to the absence of pain relief, we found that this procedure should have been performed by an experienced endoscopist, to ensure correct technique and minimise the discomfort experienced by A. As such, we upheld C’s complaint.

A was diagnosed with severe heart valve stenosis (when a heart valve narrows and blood cannot flow normally) and was informed that they required heart valve replacement surgery. A referral was made to a specialist unit within another health board. However, A died whilst awaiting surgery, during the early months of the COVID-19 pandemic. C complained that there was a delay in providing A with treatment, and that when A’s condition appeared to deteriorate, they were prescribed only water tablets. C also felt that there was a lack of communication from the Cardiology Department. Additionally, C pointed to a Significant Adverse Event Review (SAER) carried out by the hospital to whom A had been referred, which had concluded that the referral had been, in their view, wrongly categorised as “routine” as opposed to “urgent”. C felt that the care provided to A had been unreasonable. We took independent advice from a consultant cardiologist. We found that it was unreasonable that A was not referred more urgently for surgical consideration, noting that even before the COVID-19 pandemic a routine referral could take up to 18 weeks. We were also critical of the lack of formal arrangements made to keep A under regular review. A was diagnosed with severe chronic obstructive pulmonary disease (COPD) and we found that this was a missed opportunity for A’s management plan to be reviewed. Additionally, we found that we were unable to establish whether the risks of surgery were ever explained to A or whether they were given the choice of treating their symptoms with drug therapy alone. Given the importance of this, we would have expected to see evidence of this in A’s case notes. Therefore, we upheld C’s complaint.

C complained about the care and treatment provided to their late partner (A) by the board. A had been diagnosed with anorectal cancer which had spread to their liver and was treated over several admissions to hospital. A died while receiving in-patient care. C complained that the board had failed to provide A with reasonable care and treatment while they were an in-patient. C also complained that the board had failed to communicate adequately with them. The board did not identify any failings in A's care and treatment. However, they apologised for an aspect of their communication with C regarding A's diagnosis. C remained unhappy and asked us to investigate. C complained that clinician's had failed to take adequate action in the face of A's condition and that there had been a failure to provide adequate nursing care for A's stoma. C also complained about aspects of the board's communication regarding A's condition and death certificate. We took independent advice from a consultant physician in acute internal medicine and a nurse. We found that the clinical and nursing care provided to A was reasonable. We found that the board's communication with A regarding their condition was also reasonable. Due to conflicting evidence we were unable to make findings about other aspects of the board's communication. Therefore, we did not uphold C's complaints but fed back to the board about keeping clear and accurate records of communication. Related reading View Decision Report 202103732 as a PDF (24.45 KB) Updated: November 22, 2023

C complained about the care and treatment provided to their spouse (A). C said that the board’s actions or inactions caused unnecessary suffering and stress to A and their family through misdiagnosis of A’s condition, poor administration of treatment, and failure to provide care in a proper manner whilst following health and safety guidelines. We took independent advice from a consultant radiologist, consultant in emergency medicine and a consultant oncologist. We found that, overall, the board provided reasonable care and treatment to A, there were no avoidable delays in A’s diagnosis, and the care and treatment prior and after their diagnosis was reasonable, with the exception of a case of poor documentation on a particular admission and poor communication in relation to A’s diagnosis. We did not uphold the complaint. Related reading View Decision Report 202111903 as a PDF (24.19 KB) Updated: September 20, 2023

C asked a doctor at the practice to complete a DVLA medical examination. The doctor advised C that they did not have capacity to assist C and directed them to a private firm who could help. C made a complaint to the practice about the decision and availability of doctors at the practice. In their response, the practice asked C to apologise for insulting staff or they would be removed from the practice. C was subsequently removed from the practice list. C made a further complaint to the practice regarding the decision to remove them from the practice list. The practice responded to the complaint, explaining the rationale for removing C. C was dissatisfied with the responses provided by the practice to their complaints. We found that, whilst C's complaint was likely to have been difficult for staff to learn about, the practice's response was poor. Demanding C apologise was not an appropriate manner in which to try and establish an understanding or re-build trust between a complainant and members of staff. Therefore, we upheld this part of C's complaint. We also found that it was not reasonable for the practice to have treated C's complaint as having caused an irretrievable breakdown of the relationship between C and the practice. The practice did not follow the appropriate process should they have wished to warn C about the appropriateness of the complaint. Therefore, we found it was unreasonable for the practice to remove C from the practice list and upheld this part of C's complaint. The practice apologised to C.  While we acknowledge that an apology was given, that apology did not, in our view, meet the SPSO guidelines on apology, as was required by our recommendation.  In this respect it only partially met the recommendation. Our office tried to engage constructively with the practice over a considerable period of time about giving a further apology, recognising that the original circumstances giving rise to the complaint, were rooted in an already difficult relat

C made a complaint to the practice regarding the care and treatment provided to their late spouse (A). A attended the practice with pain and a family history of cancer. C said that the practice caused unnecessary suffering and stress to A and their family through misdiagnosis of A's condition. They also said that there was an unreasonable delay in progressing the ultrasound and that this led to poor management of A's pain. A was later diagnosed with lung cancer. We took independent advice from a general practitioner adviser. We found that overall the practice did provide reasonable care to A. We found that the practice took reasonable steps to investigate A's symptoms and their actions were reasonable based on the information known at the time. As such we did not uphold the complaint. Related reading View Decision Report 202111931 as a PDF (24.17 KB) Updated: June 21, 2023

C complained that the board failed to provide their adult child (A) with adequate care and treatment by discharging them from hospital when they were not medically fit to be discharged, highlighting A’s ongoing incapacity at that time. A was admitted to hospital following an insulin overdose. Following treatment in an intensive care unit, they were transferred to a general ward. A was discharged after an in-patient stay of several days. A was readmitted to hospital by ambulance transfer the day after their discharge. We took independent advice from an emergency medicine consultant adviser. We found that it was unreasonable for the board to have discharged A. We found that there were failings in the discharge process which had led to A being discharged with an unaddressed medical condition. Therefore, we upheld the complaint. We also found that there had been delay in undertaking a psychiatric review. We provided feedback to the board about this.

C complained about the care and treatment provided to their late parent (A) by the practice in the months prior to A’s death in hospital. C complained that the practice failed to look at A’s leg and foot pain and that A was only prescribed water tablets. C also said that no home visits were arranged for A, that they were informed that A had a hiatus hernia (when part of the stomach moves up into your chest), and that A’s family did not receive a telephone call back when promised. We took independent advice from a GP. We found that there was no failure on the part of the practice to look at A’s leg and foot pain or that A was prescribed water tablets. We also considered that there was no need for home visits in the time specified and that A had been diagnosed with a hiatus hernia in hospital. Finally, we considered that the practice had provided a reasonable explanation in relation to not phoning the family back given that A’s family had called an ambulance for A by the time in question, so a telephone consultation was no longer required. Therefore, we did not uphold C's complaint. We did provide feedback to the practice that they may wish to remind staff of the importance of keeping clear documentation for every home visit. Related reading View Decision Report 202107115 as a PDF (24.4 KB) Updated: March 22, 2023

C complained about the care and treatment that their parent (A) received from the board. A and their partner (B) both contracted Coronavirus (COVID-19). A had a history of diabetes and had previously had a stroke. After contracting COVID-19, A began to display signs of delirium. Concerned for A’s welfare, B contacted the GP who in turn arranged for the COVID-19 team to visit at home. The COVID-19 team attended and recommended that A be admitted to hospital for review that day. A was discharged the same day. A’s condition worsened at home and the COVID-19 team was called back to visit. A was readmitted to hospital, where their condition continued to deteriorate. A was transferred to the Intensive Care Unit (ICU) where they later died. C considered whether it was appropriate for A to have been discharged home after the first hospital visit given the extent and nature of A's condition. In response to the complaint, the board believed that the plan of care for A was appropriate, but recognised that communication with A’s family could be improved with respect to arrangements for A’s discharge. Following the complaints response, C and family members met with representatives of the board to discuss concerns. The note of the meeting records shows that the board acknowledged and apologised that no phone call was made to obtain information about A’s circumstances at home. The board also recognised that the decision to discharge may have been queried had a consultant understood B was unwell at home. C disputes the account of the meeting and believed all present agreed with the position that A should not have been discharged. We took independent advice from a geriatrician (doctor who specialises in treating older patients). We found that it was reasonable to determine that A was clinically fit for discharge. We noted that this was a complex situation and A had not stated concerns about the decision to discharge. We also noted that there was no indication in the re

C complained that there was an avoidable delay by staff at a community hospital in referring them to the specialist clinic at the local general hospital when they suffered a detached retina. C attended four consultations at the community hospital before they were referred to the specialist clinic and they felt that the delay had had an adverse effect on their sight. The board maintained that appropriate treatment was provided. We took independent advice from an ophthalmology (the branch of medicine that deals with the anatomy, physiology and diseases of the eye) adviser. We found that the clinicians at the community hospital had taken advice from specialists at the general hospital and had monitored C’s condition by regular ultrasound scans. When C’s condition deteriorated and evidence of retinal detachment was found on a scan, C was referred to the specialist for continuing treatment. We therefore did not uphold the complaint. Related reading View Decision Report 202100803 as a PDF (24.22 KB) Updated: December 21, 2022

C complained about the care and treatment they received from the board having required hip surgery following a fall. Specifically, C was concerned about the type of hip surgery they received, their post-operative care, the arrangements made for their discharge home, and the way in which the board had responded to their complaint. In responding to C, the board did not uphold the failings they had identified, and they provided a rationale for the type of surgery C received, and for the care and treatment given. We took independent advice from an orthopaedic surgeon (specialist in the treatment of diseases and injuries of the musculoskeletal system). We considered the procedure chosen for C to be evidence based and appropriate to their particular circumstances. We also found the post-operative care and discharge planning for C to be reasonable. Finally, we considered the board’s complaint response to have appropriately responded to the matters they had complained about. Therefore, we did not uphold C’s complaints. Related reading View Decision Report 202007052 as a PDF (24.18 KB) Updated: November 23, 2022

C's baby (A) was born with a rare genetic disorder and died four days after their birth. C complained about the board’'s failure to identify A's condition during prenatal scans. C complained that despite A's face not being visualised in two abnormality scans, a further scan was not arranged. We took independent advice from a consultant obstetrician and gynaecologist (a specialist in pregnancy, childbirth and the female reproductive system). We found that the board had appropriately followed national and departmental guidance in relation to the scans. We found it reasonable that A's condition was not detected during C's pregnancy. Although imaging of A's face was not possible during the second scan, we found there was no requirement to carry out a further anomaly scan or take any further action in relation to this. We therefore did not uphold this complaint. Related reading View Decision Report 202101818 as a PDF (24.17 KB) Updated: July 20, 2022

C complained about the board regarding the care and treatment provided to their late parent (A). Following a diagnosis of bladder cancer, the board identified that A would require heart surgery before they would be fit enough for bladder surgery. They referred A to another health board to provide that surgery, but this took a number of months to arrange and carry out. C told us that, by the time the heart surgery was completed, A's cancer had progressed to a point where treatment was no longer possible. We took independent advice from an oncology consultant (a doctor who specialises in the diagnosis and treatment of cancer). We found that the board failed to identify radiotherapy as a possible alternative treatment, despite this advice being given by their oncology team. In addition, we found that the board had mishandled the referral to the other health board for heart surgery, failing to ensure that the other board were made aware of the urgency required. Then, when there were inevitable delays in surgery as a result, the board failed to identify that the window for treatment was closing. For these reasons, we upheld C's complaints.

C complained about the care and treatment that their child (A) received from a dentist at the dental surgery. C raised a number of concerns, including that the dentist failed to detect decay in A's tooth and provide appropriate treatment for this, and failed to carry out a radiograph (a type of dental x-ray) on A's tooth sooner. We took independent advice from a dentist. We found that the dentist failed to record the presence of a mark on A's tooth during their third appointment, assess if there had been any deterioration of that mark, carry out further investigations and carry out radiographs at an earlier stage. We also found that the dentist's notes had extremely limited detail added and were below the expected standard. Given the failings in the detection and treatment of the decay in A's tooth and in carrying out a radiograph sooner, we upheld C's complaint.

C complained about the care and treatment provided to their parent (A). A had Alzheimer's disease (the most common cause of dementia) and C had a full power of attorney (POA) in place that was active at the time. This enabled C to make decisions about A's welfare. A was admitted to Forth Valley Royal Hospital via the acute assessment unit, and was later transferred to a ward. C said that when admitted to hospital A was continent, could walk with a stick, slept through the night, and was eating and drinking. C said that the board made inappropriate changes to A's medication during their admission, and that, when later discharged, A had lost weight, was not eating and drinking, was very frail and could not stand up, and was doubly incontinent. C also had concerns about the way A was treated and spoken to by nursing staff, and that they were discharged with a very large pressure ulcer. The board apologised for the way in which A was spoken to and treated by nursing staff and that the staff involved have received training and would be monitored going forward. The board also said communication with family members was not documented as it should have been. The board said it would be expected for A's weight to reduce as they lost excess fluid. They explained that there was a change in A's appetite during their admission, however acknowledged that a referral to a dietician should have been made in light of this change in A's appetite. The board said that A's mobility was at one point assessed as unsafe, but later it was recorded that A could mobilise with a walking frame. A's continence was recorded as variable during their stay and that A would often get up and mobilise to the bathroom. In relation to A's pressure ulcer, the board said that A had pressure damage to their sacrum (lower back) on admission to the ward and that it was documented regularly over A's admission. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine

C complained about the care and treatment that they received from the board during an in-patient stay at Forth Valley Royal Hospital. C was admitted to the hospital while in the early stages of labour. C gave birth a few days later and was discharged to their home the following day. After discharge, C's health began to deteriorate and were later admitted to a different hospital, where they received a blood transfusion and treatment for an infection. C complained that the board had failed to inform them that they had a yeast infection and failed to provide them with any treatment for this. C also complained that a clinician knowingly recorded an inaccurate pulse rate on their records and that the board failed to appropriately treat their post-natal high blood pressure and/or blood loss. We took independent advice from an obstetrician (a doctor who specialises in pregnancy and childbirth). We found that the board had failed to inform C that they had a yeast infection. Therefore, we upheld this aspect of their complaint. We found insufficient evidence to establish that an inaccurate pulse rate had been recorded on C's records. We also found that C's blood pressure and/or blood loss were within normal limits when they were discharged from hospital. Therefore, we did not uphold these aspects of C's complaints. However, we did find that clinicians failed to reasonably respond to C's high pulse rates at one point during their admission. While this issue was not raised by C in their complaint, we considered that it was reasonable to make recommendations to the board in relation to this matter.

C complained about the treatment which their partner (A) received when they attended their GP practice with confusion and could not walk unaided. A could not provide a urine sample and was given a prescription for antibiotics. A collapsed in the car park following the consultation and was taken to hospital. C believed that the GP should have arranged a hospital admission for A. The practice felt that appropriate clinical treatment had been offered. We took independent clinical advice from a professional adviser. We found that the GP had carried out an appropriate assessment of A and had diagnosed A as having an infection and therefore prescribed alternative antibiotics with advice to seek further medical advice should their condition deteriorate. It could not have reasonably been foreseen that A would collapse shortly after leaving the GP practice. We did not uphold the complaint. Related reading View Decision Report 202102039 as a PDF (24.17 KB) Updated: January 19, 2022

C complained about the care of their late parent (A) at Falkirk Community Hospital (FCH). A had a cognitive impairment and gained access to washing-up detergent that had been mistakenly left out in the staff kitchen area. A subsequently became unwell and advice was sought from the out-of-hours (OOH) GP service prior to eventual transfer to Forth Valley Royal Hospital (FVRH), where their condition deteriorated and they died the following week. C raised a complaint with the board, seeking answers as to what happened, and the board commissioned a Significant Adverse Event Review (SAER). The board were unable to conclude with any certainty whether detergent was ingested and contributed to A’s death. C complained to us about inaccuracies and inconsistencies in the SAER and clinical records, and also about timescales surrounding the SAER and complaint processes. We took independent clinical advice from a nursing adviser and a GP adviser. It was not possible from the evidence available and advice obtained for us to confirm whether A ingested detergent. We found that the SAER was open, transparent and evidence-based. The report acknowledged that there were inconsistencies and inadequacies in the records. However, we considered that the SAER did not adequately probe into the contact with, and actions of, the OOH GP. The initial advice given by the GP was to monitor A, when the observations should have prompted medical review. The GP assumed these observations were incorrect. When the GP later advised transfer to hospital, this was left to nursing staff to arrange and clear advice was not provided surrounding the urgency of the ambulance request. We found that the GP deviated from standard practice and failed to provide appropriate care to A. While the SAER acknowledged that record-keeping standards were not adhered to, we highlighted a further shortcoming in that the transfer from FCH to FVRH was not formally documented. We found that there was delay in staff completing an i

C complained about the treatment their spouse (A) received for their pressure sores from district nurses. When A died, one of the main causes of death was noted to be multiple pressure sores. C said that there was no examination by a GP at any point. They believed the pressure sores had become infected, causing sepsis and leading to A’s death. The board outlined the steps district nurses had taken when they identified that A’s sacral and heel pressure areas were starting to break down. They told us that over a four-month period, district nursing staff carried out more than 80 visits as well as providing support over the phone. They said the district nursing team involved A’s GP and the tissue viability service, who agreed with the care and advice that was being provided. We took independent advice from a nursing adviser. We found that A’s clinical records showed risk factors which increased their risk of developing skin damage: weight loss, poor mobility and double incontinence. We noted that the advice to patients with pressure sores is to move and regularly change position and to use a pressure relieving mattress, cushions and boots. District nurses ordered appropriate equipment for A and monitored A’s pressure areas closely. We found that there was evidence in the notes of appropriate advice being given to A and C regarding sitting in a chair for a long period of time and the detrimental effect this could have on the skin, especially the heels and sacrum. The boots provided to A were returned to the equipment store despite documented advice that these should be worn. We considered that there was clear evidence of partnership working between the carers, district nurses, and the wider multi-disciplinary team. Noting the complications associated with A’s incontinence, we found that the documented evidence demonstrated the appropriate treatment being delivered. Therefore, we did not uphold this complaint. Related reading View Decision Report 201910693 as a PDF (24.74

C complained about an admission to Forth Valley Royal Hospital two weeks after undergoing emergency bowel surgery there. C was admitted with a fever and vomiting and spent many hours on a trolley in A&E in severe pain. They were diagnosed with an abdominal abscess (a painful swelling caused by a build-up of pus). C complained that the abscess was drained by a surgeon while they were still on the trolley in unsterile conditions and with no anaesthetic. C complained that they were left with the wound open and that they did not receive antibiotics until later that evening, after they were transferred to the Surgical Assessment Unit. C complained that they were left with a soaked dressing and a foul-smelling wound until the following morning. They complained that failings in their care and treatment led to development of an MRSA infection (a bacterial infection that is resistant to a number of widely used antibiotics) and a hernia at the wound site. We took independent advice from a consultant in emergency medicine. While acknowledging the length of time C had to wait for a bed, we found that generally C’s care and treatment were reasonable. We found that C was assessed appropriately and received reasonable treatment for their condition within an acceptable timescale. However, we noted that there had been a delay in C receiving antibiotics which was unreasonable. Whilst recognising how difficult C’s experience had been, on balance, we did not uphold the complaint about the standard of care and treatment in A&E. We also took independent advice from a general surgeon. We found that C had generally been treated appropriately and that the development of MRSA and a hernia had not occurred as a result of any failings in care and treatment. Despite there being no significant clinical failings, we acknowledged C’s extremely poor patient experience including the board’s apparent failure to ensure that C was kept clean with their wound dressing changed in a timely manner. On bala

C complained about the nursing care that they received whilst an in-patient at Forth Valley Royal Hospital. C complained that during their stay in the hospital there were errors in the administration of their medication and that they were manhandled by a member of staff when trying to get out of bed. They also said that there was a delay in providing pain relief after this incident. We took independent advice from a nursing adviser. We found that, overall, the care given to C with regards to moving and the handling of pain control was reasonable. However, while we found no evidence that their medication dosages were incorrect and we were satisfied that C's medication was given as appropriate, there was an occasion when a prescribed dose of morphine was not recorded as being given. While we had no reason to doubt C's recollection of events which had led to them complaining they had been manhandled, there was no record of the incident in the clinical records and the staff member's recollection was different to C's account of what happened. However, C's pain score had not been checked at this time and had it been checked, this may have shed a light on the matter. We found that the failure to record C's pain score was unreasonable. On balance, because of the failure to administer all C's morphine doses as prescribed and because of the failure to record C's pain score, we upheld the complaint.

C complained about the care and treatment that they received after they underwent a minor surgical procedure as a day patient at Forth Valley Royal Hospital. C said that after the procedure they did not recover well from the anaesthetic (drugs administered to cause numbness of pain) and experienced severe chest pain. Despite this, they said that staff had tried to discharge them before they had properly recovered from the anaesthetic and that staff had ignored the symptoms they were experiencing. C said that they had experienced a heart attack and were later admitted to the Intensive Care Unit (ICU). They complained about the conduct of staff while they were there and that they acted inappropriately. We took independent advice from a consultant anaesthetist (a medical specialist who administers anaesthetics) and a nursing adviser. We found that, while there was a lack of detail in the clinical records, the evidence available demonstrated that the anaesthetic for the procedure had been given in accordance with good practice and guidelines and doses of drugs were appropriate. In particular, there was no evidence of over dosage of general anaesthetic drugs. We noted that there may have been some delay in recognising that the chest pain C was experiencing was not resolving, however, this had no effect on the outcome and when investigations showed that some heart muscle damage had occurred, appropriate treatment was started. We also found that the nursing care given to C had been reasonable and that the nursing notes were completed to a good standard. We noted that the board had apologised that C felt that a member of staff's attitude had been dismissive and also for the behaviour of staff in ICU. We considered that the care and treatment given to C was reasonable and did not uphold the complaint. However, having reviewed the handling of the complaint, we concluded that the board failed to appropriately investigate and respond to C's complaint. In particular,

C complained about the treatment provided to their parent (A) by the board. A had prostate cancer for a number of years. A's symptoms worsened in the period complained about and it transpired that the cancer had spread to A's liver. C considered that the care and treatment provided by the board in the period prior to A's death was unreasonable, with the board failing to reasonably respond to A's worsening condition. We took independent advice from a consultant in palliative medicine (caregiving approach aimed at optimising quality of life and reducing suffering among people with serious, complex illness), a registered general nurse and community health specialist nurse practitioner. C's first complaint was that the board failed to reasonably respond to A's reduced haemoglobin levels. We found that A's haemoglobin levels were appropriately managed with regular review and assessment of symptoms, and the prescribing and monitoring of 'safer' medication before planning a transfusion. We noted that there was appropriate escalation of the transfusion date once doctors became aware that the haemoglobin had fallen further. Based on A's condition at the time, the initial planned date of admission for transfusion was reasonable. As such, we did not uphold this aspect of C's complaint. C complained that the board failed to reasonably manage A's pain. We found that the levels of pain medication prescribed were reasonable. We noted that pain was not identified as a problem or symptom during A's hospital stay, therefore, discharge without regular morphine medication was reasonable. On discharge, the board appropriately handed over care to the GP, the local hospice and community palliative care. We found that when A exhibited pain, they were reviewed in line with guidance and appropriate medication was prescribed. District nurses administered pain medication through the 'just in case' medications prescribed while A was at home. As such, we did not uphold this aspect o