SPSO Individual Decisions

C, an MSP, complained on behalf of their constituent (B) about the standard of care B’s late spouse (A) received from their GP practice. A attended an appointment with a GP and received antibiotics and steroids for a possible chest infection. A’s health deteriorated a short time later and they suffered a cardiac arrest at their home. B complained that the practice failed to recognise that A was suffering from a serious cardiac condition. The practice said that a full examination and history had been taken from A. The GP concluded that the symptoms were from the chest wall rather than originating from the heart, with a suggestion of chest infection and narrowing of the airways. A received steroids and an antibiotic in treatment of a chest infection, and given advice on what to do if their condition worsened. On learning of A’s death, a Significant Event Analysis was carried out by the GP, which identified learning points in relation to arranging ECGs (a test that records the electrical activity of the heart, including the rate and rhythm), and strengthening the advice given to a patient about phoning again should their condition worsen. We took independent advice from a GP. We found that it was reasonable for the GP to treat A on suspicion of a respiratory infection having taken a history and clinical examination. While A’s oxygen saturation levels were low, this can also be found in cases of acute or chronic lung disease, such as infection. A also displayed symptoms that were not typical of classic heart attack pain. We found that A’s blood pressure and heart rate were both normal which did not suggest a heart attack. We considered that the GP made a careful assessment and reached a reasonable working diagnosis at the time based on the information available and their clinical judgement. Therefore, we did not uphold C’s complaint. Related reading View Decision Report 202202721 as a PDF (24.8 KB) Updated: January 24, 2024

C complained about the care and treatment they received from the board. C suffered a subarachnoid haemorrhage (a form of stroke caused by bleeding on the surface of the brain). Following a period of admission to different hospitals, C was discharged home. C complained that the board failed to communicate appropriately with them after their admission, that they were not fit for discharge and that inadequate rehabilitation plans were made in the community. C chose to stay at a relative’s property and was eventually admitted to a rehabilitation unit but believed this had affected their prognosis. C also complained that the board failed to respond reasonably to their concerns about the COVID-19 vaccine they had received. We took independent advice from a consultant neurologist (specialist in the diagnosis and treatment of disorders of the nervous system) and an occupational therapist. We found that communication with C was unclear and confusing and did not always address the main points C was raising. Therefore, we upheld this part of C’s complaint. In relation to C’s discharge, we noted that more consideration could have been given to supporting C prior to their discharge, given C’s concerns at the time. However, we found the decision making to be appropriate and did not uphold this part of C’s complaint. In relation to plans for C’s rehabilitation, we found that the board made reasonable plans and attempted to commence the initial assessment that would have established what support C required. However, we found that there was a failure to provide C with written information about the plans for their rehabilitation. C was unable to retain this information when given verbally which meant they were unaware of the plan and could not access the support available to them when they were unable to return to their property as quickly as anticipated. Therefore, we upheld this part of C’s complaint. We also found that the board failed to follow up on a commitment given to C to ex

C complained about the practice on behalf of their spouse (A). A is paraplegic (affected by or relating to paralysis of the legs and lower body) and was receiving district nursing treatment for various wounds, including one on the large toe of their left foot. The condition of A’s left foot deteriorated and they were showing signs of infection. A was seen by a district nurse who took photographs of A's foot and showed them to the duty GP at the practice. The GP made an urgent referral to vascular surgery, which was sent the next day, but did not assess A themselves or communicate the management plan to them. A’s condition worsened and a few days later they required immediate admission to hospital and urgent surgery. A subsequently required amputation of some of their toes. C complained that A’s outcome may have been better had they been assessed by the duty GP and/or admitted to hospital the same day. We took independent GP advice. We were not critical of the fact the duty GP did not carry out a face to face assessment of A. We found that the GP followed the relevant guidelines by making an urgent referral to vascular surgery, which was a reasonable assessment. However, we found that the GP should also have made direct contact with the vascular surgery team for advice as to whether A required to be seen the same day. We found that the GP also should have communicated their management plan to A and to C, as they acknowledged in their complaint response. This would have allowed the opportunity to raise any concerns with the GP directly. On balance, we upheld this complaint.

C, an advocate, submitted a complaint on behalf of the family of A. A was a resident of a care home and attended hospital with low potassium levels. A later sustained a leg fracture around the time of the first discharge and was re-admitted to hospital. A later died. C complained that the nursing and medical care provided by the board was unreasonable. We took independent advice from a nurse, consultant orthopaedic surgeon and consultant geriatrician. We found that there were failings in the nursing and medical care provided and that the board failed to carry out a reasonable investigation into the concerns raised. We also found that A did not receive appropriate care and treatment after they sustained a leg fracture. Specifically, there was a lack of recorded consultant input, delays in having a second cast fitted and delays with A being discharged afterward. In addition, the concerns raised regarding how the leg fracture occurred weren’t appropriately investigated across multiple agencies and it took a number of contacts by both C and the SPSO before a full response was provided. Therefore, we upheld this complaint.

C complained to the practice about the care and treatment provided to their relative (A). A began to experience abdominal pain and was reviewed by doctors at the practice a number of times before being admitted to hospital as an emergency. Following discharge, A was seen at the practice again with continuing symptoms and unintended weight loss. They were referred to hospital and again discharged. A colonoscopy performed suggested acute diverticulitis (where small pouches from the wall of the gut become inflamed or infected). A attended the practice again with worsening symptoms and was admitted to the hospital after an urgent request was submitted. A died in hospital a few weeks after. C was concerned about the standard of care provided to A by the practice. The practice met with A's family. The practice carried out a Significant Event Analysis (SEA). The practice responded to C's complaint and noted their frustration that A had been discharged from the hospital without progress in the management of their condition. However, they did not find that they should or could have done anything differently in A's care. C submitted a further complaint to the practice after they received a response from the health board regarding the care provided at the hospital. The practice responded confirming that an SEA had been carried out. The doctor who had seen A had discussed the case with colleagues in the practice and with their Educational Supervisor. These discussions had been informal and had not been documented in A's notes. C was dissatisfied with the complaint responses and brought the complaint to our office. We took independent advice from a GP. We found that most of A's care was of a reasonable standard. However, there was a delay in acting on concerns about A's condition following their second discharge from hospital. Given the significance of the failures identified, we considered that A's care fell below a reasonable standard and upheld this part of C's complaint. C a

C, an advocacy worker, submitted a complaint on behalf of their client (A). A received treatment from the board for muscular dystrophy (a group of inherited genetic conditions that gradually cause muscles to weaken) over a period of four years. While visiting abroad, A received an alternative diagnosis of polymyositis (a group of rare diseases that involve chronic muscle inflammation and weakness, and in some cases, pain). A complained that their condition was not appropriately investigated or diagnosed, leading to a delay in receiving appropriate care. We took independent clinical advice from a consultant neurologist (specialist in diagnosis and treatment of disorders of the nervous system). We found that the investigations carried out by the board were reasonable and on receiving further information from an overseas clinician, the board took reasonable steps to consider this information. We considered that the board reasonably investigated A's symptoms. Therefore, we did not uphold C's complaint. Related reading View Decision Report 202008532 as a PDF (24.29 KB) Updated: August 16, 2023

C complained about how the practice had managed their lithium prescription (a medication used to treat mood disorders). We took independent advice from a GP. We found that the practice acted reasonably in requesting that C arrange blood tests every three months to monitor their medication levels. We were also satisfied that the practice had provided reasonable advice about how to ensure C did not run out of medication. We did not uphold C's complaint. Related reading View Decision Report 202201027 as a PDF (23.99 KB) Updated: May 24, 2023

C complained on behalf of their partner (A). A had a telephone consultation with the practice and reported haemoptysis (coughing up blood) and a fever. A also reported that they had taken a lateral flow test for COVID-19 which was negative. A did not take a PCR test for COVID-19 prior to contacting the practice. The practice considered it was likely that A had COVID-19 and advised that they self-isolate for ten days after symptoms started. A's condition deteriorated and several weeks later they were admitted to hospital and diagnosed with bacterial pneumonia. C complained that the practice did not offer A a face to face appointment and subsequently failed to correctly diagnose their condition of bacterial pneumonia, instead focussing on COVID-19 as being the cause of A's illness. The practice considered that they had been following the guidelines in place at the time and had correctly signposted A to the COVID-19 Hub for further assessment. We took independent advice from a GP. We found that there was no evidence in the clinical record that A had been signposted to the COVID-19 Hub and that haemoptysis was never listed as one of the common symptoms of COVID-19 infection. We found there was a failure to offer A a face to face appointment, particularly given they had reported haemoptysis. We welcomed that during our investigation the practice reflected further and accepted that A's complaint of haemoptysis merited further clinical consideration and assessment. Given that the practice have taken appropriate and sufficient action to learn and improve from this complaint, we did not recommended that they take any further action. However, we recommended that they apologise to C and A for not offering A a face to face appointment.

C, an advocacy worker, complained on behalf of their client (A) about the care and treatment provided by the board during a four day admission to hospital. A, a type 1 diabetic (a condition where blood glucose levels are too high because the body cannot make the hormone insulin), was admitted for lower abdominal pain. A received an ultrasound scan on the following day which proved inconclusive. The next day A received a CT scan which showed free fluid, in keeping with a burst ovarian cyst. A was discharged the following day. C complained that A was discharged, having received no treatment, in pain, and without follow-up referrals. C complained that as a type 1 diabetic, A’s diabetes and food intake had not been correctly managed. The board said that treatment, discharge, and diabetes management were appropriate. The board apologised for not offering meals after breakfast on the day of discharge. We took independent advice from a gastrointestinal and general surgeon (specialist in the digestive system). We found that A’s nutritional intake had been appropriately restricted due to investigations which were necessary to rule out surgery. A's diabetes had been appropriately managed via an insulin infusion called a sliding scale. We found that no treatment or follow-up care would be indicated for a burst ovarian cyst as this would usually resolve itself. We found that prior to discharge, A’s pain had reduced such that they were able to manage it with paracetamol alone and that discharge was therefore appropriate. Therefore, we did not uphold this part of C's complaint. C also complained about the quality of complaints handling. We found that although there was a delay in providing a complaint response, this was because a meeting was being organised and that C was appropriately informed of the delays. Post decision correspondence was also delayed. However, this did not breach the Model Complaints Handling Procedure, which does not specify timescales for post decision corr

C complained about the orthodontic care (dentistry dealing with the prevention and correction of irregular teeth) provided to their child (A), particularly that A's treatment had been unreasonably discontinued. The dental practice's decision to discontinue was based on a failure to comply with the requirements of the orthodontic treatment. C complained that the orthodontist had not raised any significant concerns previously, and that there had been a lengthy period without review due to Covid-19 restrictions. We took independent clinical advice from an orthodontic adviser. We found that the records evidenced only intermittent or periodic poor oral hygiene, as opposed to the consistently poor oral hygiene noted by the orthodontist. We also found that there was evidence of valid clinical grounds to support the stoppage of A’s treatment. However, we also found that there were significant failings regarding the way the decision was communicated. At the last appointment A attended, the records give the expectation that treatment was continuing. C tried to contact the orthodontic practice following this appointment to find out when the next review appointment would take place. When they did not receive a reply they submitted a complaint, the response to which communicated the decision to discontinue treatment. This was several months after A had last been seen. The orthodontist failed to clarify in the response why they had not replied to C’s communication after the last appointment, and it was not made clear specifically when it had been decided A’s treatment should be discontinued. We found that the orthodontist’s actions were not compliant with General Dental Council standards for communicating with patients. We found that the orthodontist’s decision to discontinue A’s treatment was unreasonable, particularly in relation to the way it was communicated. As such, we upheld the complaint.

C complained that the medical practice failed to provide reasonable care and treatment to their spouse (A) after they presented with a lump in their right breast. We took independent advice from a GP. We found that the time taken to refer A to hospital when they first consulted the medical practice with the lump in their right breast was unreasonable. It was also unreasonable that the referral was not marked as urgent. The medical practice had carried out a detailed review of A’s care and had accepted that there was a complete systems failure in the care and treatment provided to A. They had made a number of changes which we welcomed and considered were appropriate. Nevertheless, we found that they had not fully acknowledged their specific role and responsibility in relation to the failings which had occurred given their responsibilities for the supervision, training and actions of their employed staff. We also identified additional issues not addressed by the medical practice in their consideration and response to the complaint. In particular, that the medical practice should have a system in place to ensure any outstanding referrals were identified when a colleague is unexpectedly absent due to sickness or ill-health and that it was unreasonable that A was not contacted by the medical practice after the cancer diagnosis given the significance of the diagnosis and their delay in sending the referral and marking it as urgent. We also found that the medical practice did not appear to have considered their duty of candour responsibilities in this case. Therefore, we upheld C’s complaint.

C complained that the board took too long to offer them steroid/local anaesthetic injections for vulvodynia (chronic pain or discomfort in the vulva). C felt this was dismissive and unsatisfactory. The board said that C did not receive the treatment initially as it was not clinically appropriate at that time. They said in order for the treatment to be effective, there should be a locally tender area to inject which C did not have. The board added that it was important to note that the treatment is unlicensed and so is only to be considered for use when definitely clinically indicated. We sought independent clinical advice from a consultant. We found that it is right for the board to have a cautious approach to the use of unlicensed treatment. We noted that the treatment C received for many years was reasonable. However, it was later indicated that C had developed a localised area of pain and it would have been reasonable to discuss the treatment with C at that point. We considered that whilst the care and treatment provided to C was generally reasonable, the board should have discussed the treatment option of steroid/local anaesthetic injections earlier than they did. For this reason, on balance, we upheld C’s complaint.

C complained about the care and treatment provided to their late parent (A) by Dr Gray's Hospital. C complained that A's colorectal symptoms and weight loss were not properly investigated and that a planned scope investigation wasn't arranged on an urgent basis. C also complained that a head injury A sustained in a fall was not properly investigated and that A was inappropriately discharged when they were unfit to return into C's care. A was re-admitted the following day and died in hospital around two and a half weeks later. C complained about the standard of medical treatment provided during this admission. Furthermore, C complained about the nursing care provided during A's final admission. They complained that visits did not take place in an appropriate location to ensure A's comfort and privacy, and in particular that A was not transferred to a side room in light of their condition. C also considered that A was denied adequate nutrition and hydration. Finally, C complained of difficulties obtaining information from the ward and more generally about communication with the family and the lack of visiting opportunities that they were afforded. We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly). We found that there was no evidence to indicate the need for urgent investigation. We did not uphold this aspect of the complaint. We found that A's care surrounding the head injury was reasonable and that they did not meet the criteria for a head scan. However, we noted that there was a lack of care and attention to A's confusion and falls risk and that they should have been kept in hospital. On balance, we upheld this aspect of the complaint. We noted that A received an appropriate medical review and treatment, apart from a delay in initially being reviewed by a consultant and a lack of attention to A's deterioration prior to their death. We also noted a failure to communicate the DNACPR process t

C complained about the care and treatment provided by the board to their late spouse (A) who was diagnosed with muscle-invasive bladder cancer. C complained about various aspects of the care that A received. These included delay, and ultimate failure, to carry out surgery to remove A's bladder, inappropriately high and missed doses of medication, and initial refusal to offer chemotherapy (a treatment where medicine is used to kill cancerous cells). C also complained about a failure by an out of hours doctor in identifying a deep vein thrombosis (DVT, a blood clot in a vein) that A developed and subsequent provision of insufficient information on medication used to treat the DVT. C further complained about various failures of communication as well as concerns about arrangements for visiting A due to the Covid-19 pandemic and end of life care. We took independent advice from medical advisers with expertise in oncology (cancer specialist), urology (a specialty in medicine that deals with problems of the urinary system), general practice and community nursing. We found that A's pain medication regimen was reasonable and that the timescale for the scheduling of A's bladder removal surgery had been appropriate. We also found that decisions made about the timing of chemotherapy and communication with A had been reasonable. This included communication about A's end of life care and how rules relating to visiting A during the pandemic had been applied. However, a number of failings in the treatment provided to A were also identified. We found that A had not been given appropriate information on the extent of their cancer, the prognosis and the potential treatment options. We also found that there had been an unreasonable delay in the discussing of A's case by the board's multi-disciplinary team, which also understated the extent of A's cancer. Furthermore, we found that A missed doses of regular medication when attending for palliative chemotherapy, that the DVT A

C complained about the care and treatment provided to their late spouse (A) by the practice. A died due to invasive bladder cancer and urinary sepsis (blood infection). C complained that the practice unreasonably delayed referring A to secondary care for investigation despite presenting with recurrent urinary tract infections (UTIs) that did not respond to antibiotic treatment. C considered that A's bladder cancer may have been identified earlier, and that their death avoided, had the practice referred them for investigation much sooner. The practice's position was that A had a long history of intermittent UTIs, which were usually treated with antibiotics. At one point, all of A's urine samples showed pus cells but a normal range of red cells, which was suggestive of simple UTIs. The early signs of bladder cancer such as blood in the urine were not apparent in A's case until a relatively late stage. The practice considered that abnormalities in A's blood results (increased platelet and white cell count) were caused by A's unrelated medical conditions. We took independent advice from a general practitioner adviser. We noted that patients over a certain age with recurrent or persistent UTIs (i.e. three episodes in 12 months) associated with haematuria (blood in the urine) should be referred for urgent investigation in accordance with national guidelines. In A's case, they had attended the practice three times in four months with recurrent UTIs and haematuria found on dipstick testing. At this point, we found that A should have been referred on an urgent basis in line with the guidance but that the practice did not do so for a further ten months. We found that the practice had failed to identify that A's blood results showed signs of recognised malignancy and that they had repeatedly failed to record A's clinical history and review the results of investigations performed. As such, we upheld this complaint.

C's parent (A) had been treated for kidney cancer and then developed cancer of the bladder. They were receiving dialysis three times a week. The GP practice in this case is managed by the board. A developed back pain and called out a GP, who prescribed dihydrocodeine (an opiate painkiller). They remained in pain the following day and called out another GP, who prescribed diazepam (a medicine used to treat anxiety) and told A to double the dose of dihydrocodeine. After increasing the dosage of dihydrocodeine A became drowsy and unresponsive. They were admitted to hospital and transferred to the Intensive Care Unit for dialysis but did not improve and died of multiple organ failure, and presumed ischaemic bowel disease (lack of blood flow to the intestine). Their death certificate also recorded end stage renal failure and a trial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). C complained that A's GPs should not have prescribed these medications because of A's renal failure. We took independent advice from a GP adviser. We found that each GP had assessed and treated A appropriately, taking into account their presenting symptoms and existing health concerns. We noted that A's treatment options were significantly limited by their renal failure. We found that it was appropriate to prescribe opiates, as pain control was the objective and A was due dialysis which would significantly reduce the risk of toxicity. We found that although the medications had a sedative effect, they did not cause A's subsequent death. We found some shortcomings in documentation but were satisfied that the board had addressed this matter. We found that the GP treatment provided to A was of a reasonable standard and therefore did not uphold this complaint. Related reading View Decision Report 202003195 as a PDF (24.68 KB) Updated: June 22, 2022

C complained about the care and treatment provided to their adult child (A) during two admissions to Aberdeen Royal Infirmary where they had been admitted for investigation and treatment of persistent vomiting and weight loss. We took independent advice from a nurse and asked for their comments on A's care and treatment during both admissions. During the first admission, C complained about A being given incorrect medication, comfort and observation charts being completed inaccurately, and of the poor level of cleanliness in the ward's bathroom. We found that there were failings in these areas, which the board had acknowledged in their own complaint investigation and had identified actions for improvement and learning. Therefore, we upheld this aspect of C's complaint and asked the board to provide evidence of the actions that they had said they planned to take. During the second admission, C complained that A was given the wrong nasogastric feed and failed to take proper action when A self-harmed; was provided with the wrong type of feeding tube; staff failed to communicate properly with C or A during the admission; and A was not given medication on discharge. We found that the care of A's enteral feed (feeding tube leading into the stomach) to be reasonable, however we found that the planning and documentation of A's care after they had self-harmed was unreasonable. We also found that A had been given the wrong length of feeding tube and that the procedure went ahead despite this being known. Therefore, we upheld these aspects of C's complaint. We found that communication with A had been reasonable and we did not uphold this aspect of C's complaint. In relation to communication with C, we found this to be mostly reasonable, however there had been a serious oversight in communicating with C when A had self-harmed. Therefore, on balance, we upheld this aspect of C's complaint. In relation to A's discharge, we found this to be reasonable and we did not uphold t

C complained about the care provided to a family member (A) at Woodend Hospital and Aberdeen Royal Infirmary. Immediately prior to the episode of care we considered, medical investigations had been performed which indicated that A had metastatic cancer (cancer which has spread from one part of the body to another). A was then referred to the urology department (specialists in the male and female urinary tract, and the male reproductive organs). We took independent advice from a urology adviser. In response to C's complaint, the board acknowledged that there had been a failure to request a CT scan as planned and apologised for this. We found that there was a failure to expedite a flexible cystoscopy (bladder examination using a narrow tube-like telescopic camera) and keep A informed about their care. In addition, we found that A should have been referred to oncology (specialists in the diagnosis and treatment of cancer). In view of these findings, we concluded that the care and treatment was unreasonable and we upheld C's complaint. C also complained about the board's actions leading up to the decision whether or not to carry out a full post-mortem examination following A's death. C considered that the board had failed to follow the procedure that applied in the circumstances that the nearest family members did not agree about a post-mortem. C was also unhappy with the lack of communication about this matter. We considered a number of pieces of relevant legislation and guidance and took into account comments from the adviser. The circumstances leading to the decision about post-mortem were complex. On balance, we found that the board acted reasonably in this instance and we did not uphold the complaint. We provided feedback about good practice for the board to consider. Finally, we found that the board's response to C's complaints could have been clearer in one respect. We also found that the board did not respond to a related complaint (about A's treatm

C complained on behalf of their child (A) about the service received from the practice and the way in which their complaint was handled. A commenced a course of treatment with the practice because due to a dental overjet (when the upper teeth protrude outward and sit over the bottom teeth), they qualified for NHS funding. A and C agreed to proceed with a functional appliance to correct the overjet. A wore the appliance some of the time, but they did not comply with the treatment in full. A was warned of the necessity to comply and given several reminders. A also missed an appointment. C was sent a 'wish to continue' letter in which they were advised that they should get in touch within four weeks or A would be discharged back to the dentist. C contacted the practice within this period of time to discuss other options for A. As C did not receive a response, they raised a complaint. During this period A was discharged back to the dentist. We took independent advice from an orthodontist. We found that, although it is accepted that the clinical decision may not have been different, we considered there should have been a further clinical discussion before A was discharged. We upheld this aspect of C's complaint. In relation to the complaint handling, we upheld this complaint on the basis that there was a delay in responding to C's concerns in full and C was not signposted to this office.

C brought a complaint about the care and treatment that their late spouse (A) received during three admissions to Aberdeen Royal Infirmary. C was concerned that A did not receive appropriate treatment and was discharged on each occasion. A was initially admitted following a heart attack, and died a few months later due to heart failure. We took independent advice from a consultant cardiologist (medical specialist dealing with disorders of the heart). We found that the care and treatment A received during two of these admissions was reasonable, including the decision to discharge A. However, during one admission the board acknowledged that there was a missed opportunity to provide cardiology input and seek an in-patient echocardiogram (a heart scan that uses sound waves to create images). We found that it was unreasonable that no input was sought from the cardiology department during this particular admission and that an opportunity was lost to make the correct diagnosis and to optimise possible treatment options. We upheld the complaint but also noted that it was not possible to say definitively whether this would have changed A's survival prospects.

C attended Aberdeen Royal Infirmary after being referred by their GP for left leg pain and swelling behind the knee. Investigations revealed the presence of a Baker’s cyst (fluid-filled swelling at back of knee) and C was discharged home with no further treatment planned. The pain continued to bother C over the weekend and they sought further medical opinion and returned to the hospital six days later. This time a deep vein thrombosis (DVT, blood clot in a vein) was diagnosed and C was discharged home on blood thinning medication. C believed that the DVT must have been present at their initial presentation to hospital and that action should have been taken at that time to address their symptoms and therefore there was a missed diagnosis. We took independent advice from two clinical advisers: a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant physician. We found that although there was no evidence of a DVT on the original ultrasound scan, staff failed to act in accordance with guidance and arrange a D-dimer test (a blood test that can be used to help rule out the presence of a serious blood clot) and a further ultrasound scan within seven days. Staff gave C advice to seek further medical opinion should their clinical condition deteriorate which C did. There was no delay to the actual diagnosis of DVT and C’s treatment regime would not have altered in the period until the second scan was performed. However, we upheld the complaint on the basis that there was a failure to act in accordance with the guidance.

C attended the Grampian Medical Emergency Department (GMED) out-of-hours service with severe pain in their arms and shoulders. They were referred to the Acute Medical Initial Assessment Unit (AMIA) and then transferred to the Stroke Unit, a unit that has capacity to receive patients with non-stroke problems when the hospital is busy. C received multiple tests, including multiple electrocardiograms (ECG, test to check a patient’s heart rhythm and electrical activity) in order to diagnose the cause of their symptoms. It was determined to be a trapped nerve in C’s neck and C was discharged from hospital with a prescription for medication for nerve pain and sensitivity. C complained that there were failings in communication and record-keeping during their admission and that this lead to the unnecessary repetition of ECG tests and a delay in administering pain medication. They also raised concerns that they had been told they had a liver infection requiring antibiotics but this was not recorded, meaning that antibiotics were not prescribed. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the treatment C received during their stay in hospital was reasonable and consistent with the symptoms they experienced and that the communications recorded were reasonable. Therefore, we did not uphold these complaints. Related reading View Decision Report 201904735 as a PDF (24.46 KB) Updated: September 22, 2021

C, an advice worker, complained on behalf of their client (B) about the treatment which B’s late adult child (A) received from their GP practice. The practice is being managed by the board. A had contacted the practice on a number of occasions over a six-month period reporting problems with their mental health. A was a student studying away from home. A subsequently completed suicide. B felt that the staff from the practice had failed to take fully into account A’s personal circumstances which all pointed to the fact that A was at increased risk of attempting suicide and that they failed to provide them with appropriate treatment. We took independent clinical advice from a GP. We found that the GPs involved had formed a good relationship with A. They had recorded A’s mental health symptoms and provided a reasonable level of care and treatment by prescribing appropriate medication and monitoring A’s behaviour. There was also the involvement of a counsellor but there was nothing to indicate that A was going to take their own life. We did not uphold the complaint. Related reading View Decision Report 202007689 as a PDF (24.27 KB) Updated: September 22, 2021

C complained about the treatment that their parent (A) received at the ophthalmology department (the branch of medicine concerned with the study and treatment of disorders and diseases of the eye) at Aberdeen Royal Infirmary. A had been referred to the hospital by two opticians who believed that A's eyes required a review from hospital specialists. Following the consultation, A was told to use a magnifying glass but that further medical intervention was not required. However, A continued to have problems with their sight within the next year and while abroad had to seek emergency medical review. A had to have surgery for the removal of both cataracts (when the lens, a small transparent disc inside the eye, develops cloudy patches). C believed that A did not receive appropriate treatment at the consultation and that consideration should have been given to the removal of their cataracts. We took independent clinical advice from an ophthalmologist (a doctor who examines, diagnoses and treatsdiseases and injuries in and around the eye). We found that A was appropriately assessed and treated and at that time there was not a clinical need or indication for eye surgery. It appeared that A's sight deteriorated following the consultation and that could not have been predicted. We did not uphold the complaint. Related reading View Decision Report 202006727 as a PDF (24.39 KB) Updated: August 18, 2021

C, a support and advocacy worker, complained on behalf of their client (A) and their partner. A and their partner's child (B) was born at 30 weeks gestation. B was severely disabled and died when they were two years old. B's parents had been told that B had suffered hypoxic ischaemic encephalopathy (HIE, a form of brain injury that occurs when the brain does not receive sufficient oxygen) due to a lack of oxygen in the period prior to their birth. Despite HIE being detailed in B's records as a diagnosis, the board contended that B did not have this condition when responding to B's parents' formal complaint. B's parents considered there to have been an unreasonable delay to A receiving an emergency section following their urgent referral from Peterhead Hospital to Aberdeen Maternity Hospital. C asked us to investigate whether the level of care that A received from the board fell below a reasonable standard and whether any deficiencies in the standard of care may have contributed to B's health problems. We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system) and a senior midwife. We found that A was appropriately given a cardiotacograph (CTG, a way of recording the fetal heartbeat and the uterine contractions during pregnancy) at Peterhead Hospital on the first date complained of, and was appropriately transferred to Aberdeen Maternity Hospital. In relation to the second date complained of, we found that A was again appropriately transferred to Aberdeen Maternity Hospital, although we noted that a CTG was inappropriately stopped at one time, once A had been transferred. However, we also found that transfer to the labour ward took place at an appropriate time and that the decision to move A to theatre and carry out an emergency caesarean section was taken at an appropriate time. The advice we were given did not indicate a connection between the results of