SPSO Individual Decisions

C complained about the care and treatment provided to their spouse (A) when they attended A&E. A had fallen from a height and injured their shoulder. A was x-rayed and diagnosed with a soft tissue injury to the shoulder and a minor head injury. A was discharged home and advised to use regular simple pain relief for the shoulder injury. A was later diagnosed with a rotator cuff injury which required an operation. C said that A should have been correctly diagnosed by the doctor in A&E and that the delay left A in significant pain and distress. We took independent advice from a consultant in emergency medicine. We found that A should have been reviewed by a senior doctor before discharge. We also found failings in relation to a lack of follow-up and record keeping. Therefore, we upheld C’s complaint. We also found that C’s complaint was not handled reasonably as there were clear inaccuracies in the board’s complaint response and no reflection on the failings. We made a recommendation to address this.

C complained about the care and treatment provided to their adult child (A). A had addiction issues and was admitted to intensive care with a head injury after a fall. They were later transferred to a different hospital and onto a ward after their condition improved. A received treatment from the addiction team while in hospital and following further scans and reviews, was deemed fit for discharge. A died at home shortly after discharge. C complained that the board failed to provide A with a reasonable standard of medical or nursing care. They also said that the board failed to communicate appropriately with social services or community addiction services prior to A’s discharge. We took independent advice from a consultant neurosurgeon (specialist in surgery of the nervous system, especially the brain and spinal cord) and a nurse. We found that both the medical and nursing care A received was appropriate. Therefore, we did not uphold this aspect of C's complaint. However, we found that A's discharge did not adequately consider their vulnerability and whether A would be safe in the community. We considered that the board did not communicate appropriately with social services and addiction services. Therefore, we upheld this part of C's complaint.

C complained about the care and treatment that their adult child (A) received from the practice following their discharge from hospital. C complained that A had struggled to get an appointment with a GP and that the practice failed to provide a reasonable standard of care in relation to pain management, A’s mental health needs, and follow-up with the health board. The practice said that they were short-staffed and had been working on an emergency-only basis at the time of the complaint. When A had enquired about seeing a GP, there had been no indication that an emergency appointment was required. A was advised to phone again the next day or to attend A&E. In respectof A’s pain, the practice said that the discharge medication had been managed in accordance with their policy and in recognition of the nation-wide shortage of the drugs prescribed. A was given an appointment to discuss pain when they reported that the medication was not working and a prescription for nerve pain was given. In reference to A’s mental health, the practice said that this was discussed during a phone appointment. However, A had breached the practice’s zero tolerance policy during the conversation. A was issued with a warning letter after the incident but was not removed from the practice (as would be policy) in recognition of the mental health difficulties that they were experiencing. This incident was reviewed as a part of a Significant Event Analysis Review (SEAR) and the practice identified learning to manage this type of occurrence in the future. In respect of A’s follow-up with the health board, the practice confirmed no post-discharge requests had been made and that it was the responsibility of the hospital to issue clinic appointments. We took independent advice from a GP. We found that the practice had reasonably managed the discharge prescription for pain medication. While A had been appropriately directed to other services when no appointments were available, we found that the messa

C complained that the board failed to reasonably communicate with their family when their parent (A) was admitted to hospital. A was taken to A&E following a fall at home. A was moved to a ward following an x-ray and medical review showing that A had broken their hip. A underwent an operation later that day and remained in hospital until their discharge nearly seven weeks later. C also complained about the nursing care that A received. We took independent advice from a nurse. We found that there was a failure to communicate with the family about the consequences of delirium. We also found that there was a failure to ensure A had access to bread/toast and milk. There was a lack of acknowledgement and details regarding A’s lost dentures, a failure to inform A or C that A had developed a hospital acquired pressure ulcer, poor record keeping and a lack of evidence of appropriate nutritional care interventions being followed. Therefore, we upheld C’s complaints.

C complained about the care and treatment provided to their late spouse (A) for cardiac amyloidosis (the abnormal build-up of a protein (amyloid) in the heart). C complained about delays in referrals, diagnosis and treatment. The Board did not uphold the complaint and considered that there had been no delay in referring A to an appropriate specialist or in their diagnosis and treatment. C was unhappy with this response and brought their complaint to this office. C also complained that the board had failed to adequately investigate and/or respond to their complaint. We took independent advice from a consultant cardiologist (specialist in diseases and abnormalities of the heart) and a consultant haematologist (specialist in blood and bone marrow). We found that A’s cardiology care and treatment was reasonable. However, we also found that there was an unnecessary delay in referring A for specialist haematological treatment and that this treatment was poorly documented. Additionally, we found that the communication with A’s family about A's treatment could have been better. We upheld this part of C’s complaint. As these failures were not identified by the board, we found that the board had failed to adequately investigate and respond to C's complaint. We upheld this part of C's complaint.

C is a kidney transplant patient who was suffering from COVID-19 when they were admitted to hospital. C’s COVID-19 worsened and C developed blood clots in their lungs. C was treated with anti-coagulant medication. However, over time C developed a haematoma (a collection of blood) in their right arm and a large haematoma which caused permanent damage to nerves in C’s left thigh. C complained that staff had not been proactive enough in monitoring the effects of the anti-coagulant medication or in managing the blood clots and haematomas. C also complained that a referral to a neurologist should have taken place at the time and would have improved their long term prognosis. The board explained that the effect of the anti-coagulant was not usually measured, but could be useful in patients with kidney disease. They had therefore monitored as required. Medication was changed due to concerns that the blood clots were getting worse and then stopped in light of the bleed into C’s thigh. A neurology referral was not made, as following discussion with surgical and radiological experts it was determined that supportive therapy was the most suitable management strategy for C’s case. We took advice from a consultant haematologist and consultant neurologist. We found that C had both blood clots and significant bleeding. Both can be life-threatening, and treating one may make the other worse. We found that the monitoring and management of the anti-coagulant medication and the management of the haematomas and blood clots was reasonable and that it was reasonable not to refer to neurology and not to have considered femoral neuropathy. Therefore, we did not uphold the complaint. Related reading View Decision Report 202305722 as a PDF (24.66 KB) Updated: March 19, 2025

C complained about the standard of medical care and treatment provided by the practice. C attended the practice with a lesion on their back which was diagnosed as a seborrhoeic wart (a harmless growth on the skin). C underwent cryotherapy treatment (the use of extreme cold to freeze and remove abnormal tissue) but this was unsuccessful. Therefore, the practice made a a routine referral for an outpatient hospital appointment to have the lesion removed surgically. C opted to be see a private consultant dermatologist (skin specialist) and was diagnosed with cancer. C felt that the practice misdiagnosed their skin cancer which led to a delay in receiving appropriate treatment. We took independent advice from a GP. We found that the care and treatment C received when they first attended the practice was reasonable. However, the practice failed to record a clear description of the lesion in the medical records. This is essential to ensure that subsequent viewers of the lesion can assess whether there has been any significant change. Therefore, we could not say that subsequent care and treatment had been reasonable and upheld C’s complaint.

C complained about the care and treatment received by their young child (A). A had a complex congenital (from birth) heart condition. C complained to the board after A received heart surgery, which had been part of the treatment planned for A. C complained that the board did not reasonably respond to C’s concerns prior to A’s operation. C also complained about the timing of A’s admission to hospital and the timing of the operation. We took independent advice from a consultant paediatric cardiologist (specialist in children’s heart problems). We found that, overall, the board provided excellent care to A and a successful outcome was achieved through A’s surgery. We found that the timing of A’s operation was reasonable considering A’s age. However, we also found that A was not provided with appropriate follow-up plans in relation to care provided before A’s surgery and that A should have been admitted to hospital three days earlier. On balance, we upheld C’s complaint.

C complained about the care provided to their adult sibling (A) when they attended A&E following an accident. C also complained that the board failed to reasonably investigate A’s symptoms when they attended hospital with headaches on two further occasions the following year. A was later diagnosed with a brain tumour and C feels that there were missed opportunities in identifying this earlier. We took independent advice from a consultant emergency physician and a GP. We found that the board undertook appropriate assessments and provided reasonable treatment to A when they attended A&E following their accident. We did not uphold this part of C’s complaint. In relation to A’s first attendance at hospital the following year, we found that the board failed to investigate A’s symptoms. There were clear flags identified in the GP’s referral letter, indicating further investigations should have been carried out, specifically a head CT scan, and this did not occur. Therefore, we upheld this part of C’s complaint. In relation to A’s second attendance, we found that the board reasonably investigated A’s symptoms as they presented at the time, with appropriate investigations undertaken and follow-up advice provided. Therefore, we did not uphold this part of C’s complaint.

C complained about the care and treatment provided to their late parent (A). A was experiencing shooting back pain, tingling sensations, abdominal swelling, weight loss, poor balance and constipation. A contacted the practice on four occasions with deteriorating symptoms. By the last contact, A was incontinent and unable to mobilise. After some delay, the practice organised (seated) ambulance transport to hospital. A was diagnosed with malignant spinal cord compression (MSCC) caused by metastatic renal cancer. A was paralysed and incontinent until they died a few months later. C complained that the practice failed to spot red flag symptoms for MSCC and cancer, missed opportunities to send A to hospital earlier and failed to appropriately manage A’s transfer to hospital. C said that when A was discharged from hospital their pain, nutrition, appetite loss and low oxygen levels were not effectively managed. They also complained that a GP inappropriately discussed A’s terminal prognosis and do not attempt cardiopulmonary resuscitation (DNCPR) decision at a home visit. The practice said that, in previous appointments, they had examined A, conducted blood tests, inquired about symptoms of cord compression, and provided advice on what to do if the condition worsened. They recommended going to the hospital only after symptoms deteriorated. They advised that on discharge, the GP had considered it important to discuss prognosis and DNCPR at the earliest opportunity and had made every effort to do so sensitively. They said that they had adjusted A’s pain medication and referred to palliative care nurses. The practice also said that they had referred to a dietician and it would not be standard practice to check oxygen levels as it would not change the overall palliative care. We found that it had been unreasonable not to arrange a stretcher transfer to hospital at an earlier date. We also considered that it was unreasonable that changes to pain medication had not been timeously

C complained that the board failed to provide their late partner (A) with reasonable treatment for bladder incontinence. A was admitted to hospital following a fall in which they fractured their hip. A was catheterised after undergoing surgery. C complained that when A’s catheter was removed, they developed a bladder problem, and that hospital staff did nothing to rectify A’s inability to control their bladder or investigate what was causing this. C believed if A’s bladder problem had been addressed they may have made a full recovery. A’s condition deteriorated after discharge and they died within a few weeks. When the board originally responded to C’s complaint they said that it was documented in the nursing notes that A was incontinent on three occasions. The board said a urine specimen was taken which returned a positive result for a urinary tract infection and A was treated with oral antibiotic medication. The board said that prior to discharge, A was mobilising to the toilet and there was no mention of incontinence thereafter. C highlighted a number of entries in A’s records which referred to incontinence/use of pads. We asked the board to comment on this, noting this contradicted their position in the complaint response. The board confirmed that if all this information had been considered by the multi-disciplinary team, this may have prompted additional continence support and follow-up being arranged on A’s discharge from hospital. The board confirmed that they were taking forward learning points including an action plan for improvement. We took independent nursing advice. We found that despite a number of references within the multidisciplinary notes to A’s incontinence, there appeared to have been no attempts to explore this further and to provide appropriate support during A’s admission and/or follow-up after discharge from hospital. Although the board missed an opportunity to address these issues, it was not possible to determine the extent of the impact o

C’s parent (A) was admitted to the hospital and diagnosed with a urinary tract infection (UTI) and sepsis. A was transferred to the acute medical unit (AMU) that night and died later the next day. C was concerned about the care and treatment provided to A. C raised a number of complaints with the board regarding the care and treatment that A received, including the provision of oral care. The board accepted that there had been issues with the prescription and administration of anticipatory medication and the care provided to A, and outlined steps that would be taken to prevent any recurrence. C was dissatisfied with the board’s responses and actions and raised their concerns with SPSO. We took independent advice from a nursing adviser. We found that the investigation already carried out by the board, and the steps taken to address the areas for improvement identified were reasonable and did not require further investigation by the SPSO. However, we found that the action taken did not address the issue of the provision of oral care to A and investigated this matter further. In responding to our enquiries, the board accepted and apologised that there had been issues with A’s oral care during their admission. Therefore, we upheld the complaint that the board did not provide A with reasonable oral care.

C complained about the delay in the practice diagnosing their parent (A)'s cancer. C said that A was seen by a GP with recurring chest infections but was sent away with antibiotics and their initial requests for a chest x-ray were denied. When the x-ray was arranged and the results received by the practice, the GP did not contact A directly to discuss the results. Instead, A received a copy of the report from the reception staff, which was not easy to understand. C said the communication issues regarding the x-ray also led to a delay in an urgent prescription for antibiotics being passed to a pharmacy. C said that the delays in diagnosis limited the treatment options available to A. C complained that the practice failed to reasonably investigate A’s respiratory symptoms. We took independent advice from a GP. We found that while the majority of the care provided to A was reasonable, there was a missed opportunity to refer A for an x-ray, given their symptoms and the lack of success with previous treatments. Therefore, we upheld this part of C's complaint. C also complained that the practice failed to inform A of the results of the x-ray in a reasonable manner. We found that the x-ray report should not have been provided to A by reception staff and the findings should have been shared in person or over the phone with the GP, including all relevant information. Therefore, we upheld this part of C's complaint.

C complained on behalf of their child (A) about the care and treatment A received prior to their surgery. They complained that some procedures had been carried out during the surgery without parental consent. They also said that A had not been examined prior to the surgery and that they had been left with unnecessary scarring. The board stated that written consent had been provided on the day of the surgery and the clinical notes recorded the procedures to be carried out and the risks of surgery had been explained at that time. The board also stated that A had been examined. However, they apologised if the verbal discussion prior to the operation had not prepared C for the outcome and also apologised if some of the scarring following the surgery was unsightly. We took independent advice from a consultant paediatric urologist (specialist in children's urinary and genital problems). We found that the evidence suggested that the signed consent form had been read by C prior to the surgery and that no unnecessary procedures had been carried out. While there were no records to prove or disprove that A had been examined on the day of the surgery on balance we considered it was likely that A had been examined preoperatively. Although ideally it should have been explained to C during the consent process that there was a possibility that redistribution of the skin could be required during the operation, we found that it was not unreasonable that this was not mentioned. We also found that the care and treatment A had received on the day of the surgery was reasonable and that there was no evidence that the surgery carried out was inappropriate or excessive. Therefore, we did not uphold C’s complaints. Related reading View Decision Report 202209309 as a PDF (24.58 KB) Updated: September 18, 2024

C was diagnosed with a kidney stone by a neighbouring board. Shortly after, they attended Greater Glasgow and Clyde's Urology Department and received an X-ray. C complained that the board failed to identify the kidney stone, resulting in surgery several weeks later and a kidney injury. We took independent advice from a consultant urologist. We found that while it was not possible to determine whether the board failed to identify a kidney stone on the X-ray, the board did have doubt about whether the stone had passed. At this point the board should have checked this by means of a CT scan. We found that it was not possible to determine whether failing to confirm a kidney stone, and delayed treatment, would result in a kidney injury. We upheld this part of the complaint because it was unreasonable for the board to have doubt about whether there was a stone present, but not to confirm this. C complained that the board had failed to arrange a follow-up appointment within an appropriate time period. We found that when passage of the stone was not confirmed, a follow up CT scan should have been arranged within 2 weeks, and that the plan to wait a further 6 weeks in these circumstances was unreasonable. Therefore, we upheld this part of C’s complaint. C also complained that the board did not clearly communicate their diagnosis, and their subsequent request for clarification on how they came to have surgery after being told there was no kidney stone present. We found that there were shortcomings in the board’s communication with C, both in relation to the kidney stone and in providing an explanation as to how they came to have surgery. Both of these might have been relatively easily avoided or resolved. We therefore upheld this part of C’s complaint. We asked the board to reflect on the imprecision of using plain X-rays and consider the possibility of updating practice by using low dose non-contrast CT scans as standard.

C complained that the board failed to provide them with reasonable care and treatment. C has a rare demyelination condition (an inflammatory condition that affects the brain and spinal cord) which impacts them both physically and mentally. C is also unable to see clearly and struggles to concentrate. C complained about the care that they received from the board during two hospital admissions. In particular, that staff were unprofessional and unempathetic and became impatient and abrupt when C was unable to do as staff asked. We took independent advice from a senior nurse. We found that there was a lack of communication and understanding of C’s cognitive impairment which resulted in staff not fully understanding the issues C was dealing with on a daily basis and the challenges their diagnosis presents. There was also a lack of appropriate care planning and a failure to complete all documentation and risk assessments. This led to a failure to provide reasonable emotional and psychological care to C whilst an inpatient, a poor patient experience for C and anxiety over future hospital care. Therefore, we upheld C's complaint. In addition, we also found that the board’s response to C’s complaint was poor and did not demonstrate the learning or improvement required.

C complained about the care and treatment that their late parent (A) received whilst in hospital. A was admitted to hospital with light headedness, dizziness, and pain in the hip and leg. C had concerns about the board’s failure to consider A’s previous medical history, decisions made during surgery, communication, care provided, and what was recorded on the death certificate. The board said that investigations into A's blood loss found no issues and that they planned to discharge A. However, due to further bleeding A was not discharged and required emergency surgery. A was made aware of the risks associated with the surgery. This operation was successful, however, a further procedure was required to remove a section of A's bowel. Due to further changes in A’s condition, the board moved A to palliative care. We took independent advice from a consultant in intensive care and acute medicine, a general surgery consultant and a registered nurse. We found that A's care and treatment was reasonable. However, A's medical history was recorded incorrectly by medical staff, affecting the treatment plan, investigations, and diagnosis. We found that A's operations were carried out reasonably. However, the surgical team failed to examine A in person when consulted which was unreasonable. Overall, we considered that the care and treatment provided to A was unreasonable and upheld this part of C's complaint. In relation to nursing care, we found that the care and treatment provided to A was reasonable. We also found that A's death certificate was not completed incorrectly. Therefore, we did not uphold these part's of C's complaint.

C’s spouse (A) was provisionally diagnosed with torticollis (a condition in which the head becomes persistently turned to one side) by their GP resulting in a routine referral to orthopaedics (specialism in the treatment of diseases and injuries of the musculoskeletal system). A’s symptoms continued to worsen and their referral was upgraded to urgent. A had a telephone call with an orthopaedic consultant and an MRI scan was organised. The pain continued to intensify despite strong medication. A presented to the out-of-hours service and also to A&E with worsening pain in their neck. A was referred to the hospital by their GP and advised that they were terminally ill with bladder cancer which had spread to the spine. A later died. C complained to the board with concerns about A’s initial referral to orthopaedics not being treated as urgent, for the delay for an MRI scan, for orthopaedics not being consulted by A&E and further testing not being arranged. C additionally complained about the lack of process for a patient to be moved up the list of clinical priority when presenting to A&E. The board’s response indicated that no red flags were raised in the initial referral, that the orthopaedic consultant organised an MRI scan after speaking with A and that the out-of-hours assessments did not identify immediate orthopaedic review was required. The response also noted that A&E noted a plan was in place for further investigation, that there was no emergency issue which required immediate referral and that the GP was best placed to expedite further care with the orthopaedic team. We took independent advice from a trauma and orthopaedic consultant, a GP and a consultant in emergency medicine. We found that it was reasonable for orthopaedics to treat the original referral as routine, but it was unreasonable that there is no evidence of a clinical summary of the orthopaedic consultation, and thereby no evidence that red flags were explored. We upheld this aspect of

C complained that the practice had prescribed them with Hormone Replacement Therapy (HRT) for a period of approximately four months despite knowing that they were trying to conceive. C said that they had subsequently attended a fertility clinic and were advised by a specialist that HRT would have a negative impact on their fertility. The practice identified learning and improvement from C’s complaint. They apologised to C for the frustration and distress caused to them by their experience. We took independent advice from a GP adviser. We found that it was unclear from the medical records if the prescription of HRT was fully discussed with C to ensure that they understood the implications on their fertility and general health. We found that it was unreasonable for the practice to have prescribed C with HRT in the absence of their clear informed decision. Therefore, we upheld the complaint.

C complained about the ophthalmology treatment (the branch of medicine that deals with the anatomy, physiology and diseases of the eye) that they were provided by the board. They were referred by a consultant (Doctor 1) for a second opinion from a corneal specialist. C complained that they should have been seen by a consultant (Doctor 2) but were instead treated by a junior doctor (Doctor 3). Additionally, C complained about the treatment provided by Doctor 3 and the decision to discharge them from the ophthalmology service. We took independent advice from a consultant in ophthalmology. We found that it was clear that Doctor 1 intended a specialist to examine C and that this did not happen. Although it may have been reasonable for C to have been seen by a junior doctor in clinic, there should have been clinical oversight by Doctor 2, with direct input to C’s management plan. We found that it would have been good practice for the outcome of the consultation to be reported back to Doctor 1, copying the letter to the GP and C. Instead, the outcome was only reported to C’s GP. We upheld this complaint. We also found that Doctor 3 should have tested C’s eye pressure before prescribing fluorometholone (a mild steroid). We upheld this aspect of C’s complaint. Finally, we also found it was unreasonable for the board to discharge C from their ophthalmology service, when Doctor 1 had agreed to follow-up in one year. We upheld this aspect of C’s complaint.

C suffers from chronic pain and had been receiving pain management and musculoskeletal physiotherapy treatment from the board for many years. Changes were made in the board’s approach to pain management which coincided with some experienced consultants retiring. C’s care and treatment was reassessed and a number of treatments previously provided to C were said to no longer be available and an emphasis was placed on self-management. C complained that withdrawing treatments harmed their health and wellbeing, the local pain management service was now limited requiring patients to travel for certain treatments, effective interventions were removed, the board prioritised cost over patient needs, and the transition to self-management relied too heavily on online resources. The board stated that the changes were evidence based and in line with clinical guidelines. We took independent advice from an experienced pain management consultant. We found that the board were correct in stating that the current guidance for the management of chronic pain does not support the long-term use of massage, acupuncture or trigger point injections. We noted that the transition away from this approach towards self-management can be very challenging for patients. We considered that C had been offered a person-centred management plan. We also found that it was reasonable for the board to have explained to C that previous therapies offered in an ongoing sense were likely provided because of discretion and goodwill on the part of a now retired physiotherapist. We noted that this is not uncommon for practitioners, however, approaches to treatment change over time. We did not uphold C’s complaint. However we provided feedback about the need to reflect on cases such as this to inform how best to manage similar situations in the future. Related reading View Decision Report 202110511 as a PDF (24.78 KB) Updated: May 22, 2024

C complained that the board failed to provide hip replacement surgery within a reasonable period of time. C experienced back and buttock pain for several years due to an existing condition. C started to experience new pain in their right leg. Their GP referred them for an x-ray and made an urgent referral to the orthopaedic department (specialists in the treatment of diseases and injuries of the musculoskeletal system) as C had been off work due to debilitating pain in the hip and was concerned about losing their employment as a result. C had a consultation with the orthopaedic surgeon and was told that the hip was badly damaged. C was listed as a priority 4 case (a lower priority) for a total hip replacement. C’s condition continued to deteriorate; they were in severe pain and it was affecting their day to day life. C contacted the board to explain the severity of the problems that they were experiencing and they were reviewed in clinic. Shortly afterwards, C underwent surgery privately. We took independent advice from a trauma and orthopaedic consultant. We found that a number of failings occurred that were not simply as a result of the delays caused by an extensive waiting list. It was unreasonable that C was incorrectly categorised from the outset and that an outdated prioritisation tool was used by the board. It was also unreasonable that the radiological deterioration was not documented and that C’s surgical treatment was not expedited at the further clinic appointment. Therefore, we upheld C’s complaint.

C complained on behalf of their parent (A) that the board unreasonably failed to proceed with hip replacement surgery within a reasonable timeframe. C said that A was referred for physiotherapy before being added to the waiting list for surgery. They complained that this was unreasonable as it was known that it would not help given the extent of deterioration in A’s hip joint. C also complained that several of A’s appointments had been cancelled or postponed, and that the board had failed to act on an urgent referral sent by A’s GP. As it was unclear when A would receive their surgery, they opted to have this carried out privately. In responding to C’s complaint, the board confirmed that they must take all reasonably practicable steps to ensure that they comply with treatment time guarantees. This includes considering whether to send patients to another care provider if they cannot provide treatment by the patient’s treatment time guarantee. In A’s case, the board noted that A had elected to make their own arrangement for private surgery and, therefore, the NHS offer of treatment was no longer relevant to them. We took independent medical advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). At the point of referral to orthopaedics, we found that A was reasonably referred for physiotherapy and added to the waiting list as a routine category patient. At the pre-operative assessment clinic, we found that an x-ray was taken but it had not been reported or reviewed. At this point, A should have been re-prioritised to urgent in keeping with the physical changes that they had reported and the radiological deterioration evident on the x-ray. It was unreasonable not to re-prioritise A at this time. In reference to the urgent referral sent by A’s GP, A continued to be considered as a routine category patient. However, it was clear A’s case had been expedited as they were offered a place on a priva

C complained about the care and treatment that their late parent (A) received from the board following A’s admission to hospital having suffered a stroke. A developed COVID-19 symptoms and this was confirmed by a positive swab. A’s condition deteriorated with them developing COVID-19 pneumonia and they sadly died. C complained to the board about their parent contracting COVID-19, which they felt must have been hospital acquired as A was shielding prior to admission. C complained that A was unnecessarily transferred between wards which increased the risk of exposure to the virus. C reported concerns that there were known COVID-19 cases in a neighbouring ward and possibly within A’s ward. C was concerned that A wasn’t offered the opportunity of home rehabilitation. The board’s response stated that national infection prevention and control guidance for COVID-19 was followed at all times. They advised that it wasn’t always possible to accommodate all shielding patients in a single room. They advised that A was transferred between wards according to their care needs. They said that they could not meet A’s rehabilitation needs at home due to capacity issues with their community stroke team. We took independent clinical advice from a nursing adviser specialising in infection control. We found that A required inpatient care to ensure that they received appropriate investigations and treatment for their suspected stroke. We found that the care provided to A in treatment for their stroke was reasonable and in keeping with their diagnosis. We found that the board did not comply with relevant guidance on COVID-19 by failing to document the assessment of A’s COVID-19 risk pathway during their admission. We found that there was an unreasonable delay in isolating A from the other patients once A’s diagnosis of COVID-19 was suspected. Given these failings, we upheld the complaint.

C complained about the care and treatment that they received from the board. In particular, C complained that the board failed to adequately investigate their presenting symptoms of pain and nausea, or keep adequate medical records during an attendance at the Surgical Immediate Assessment Unit (SIAU). Following their attendance, C wrote an account of their experience on Care Opinion (an independently operated platform for individuals to post comments about their care experiences). The board contacted C in response to their post asking that they write to them about their concerns. Despite doing so, C said that they did not receive a response from the board, and that they subsequently submitted a formal complaint through the board’s complaints handling procedure. The board’s response to the complaint said that C had been assessed properly and that the clinical findings did not indicate that further investigation was required. The board acknowledged that C had not been seen by a senior clinician as planned, however, they noted that they had left the SIAU against advice before they were able to see C. We took independent advice from a consultant general and colorectal surgeon. We found that C did not receive an adequate clinical examination. We found that the documentation of this encounter was unreasonable, noting that there was little information relating to the discussion which took place with a senior clinician, and no documentation of the worsening advice given to C. As C had already followed a 4-week plan by their GP to ‘watch and wait’ without any improvement in their symptoms, it was unreasonable to discharge C without undertaking or planning further investigation at this time. It was also noted that the emergency and final discharge letters from this attendance were not sent until several months after this attendance. We upheld this aspect of the complaint. In relation to the board’s handling of C’s complaint, we noted that C had first posted a comment