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 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 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 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 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’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 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 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’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 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 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 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 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

C complained about arterial surgery. The board accepted that there were issues related to the systems in place at the time for the sharing of information between board sites and communication, and apologised for this. We took independent advice from a cardiology adviser. We found that there was nothing to suggest that there was poor clinical practice or decision making and found that, the issues related to the sharing of information between board sites and communication meant that aspects of the care and treatment C received fell below the standard C could reasonably expect. We upheld C’s complaint.

C complained on behalf of a family member (A) who was diagnosed with breast cancer and died less than two years later. C complained that during a consultation the consultant oncologist (specialist in the treatment of cancer) treating A had given the impression that despite having a condition that was treatable but not curable, A was likely to live for many more years. C noted that they had been present when this had been explained, and that it was evident that A had made important life decisions based on what C considered, in light of subsequent events, to be have been highly misleading communication. C also noted a lack of documentation relating to the initial consultation. In response, the board stated that the oncologist treating A was clear that it had been explained that they had metastatic, stage four cancer. The consultant was also certain that they had not stated that the treatment would definitely work in an on-going sense and life-expectancy would be unchanged. The board apologised if this has been the impression formed by A. We took independent advice from an oncologist. We found that the board’s position that it was not the oncologist’s custom to discuss life expectancy at the first meeting in order not to overwhelm a patient, and that such predictions can be very difficult to make was reasonable. Additionally, we noted that a letter had been sent to A’s GP following the initial consultation. We found it was not unreasonable for a letter to be in lieu of additional notes in a paperless system, and that it is not a requirement for a copy to also be sent to the patient. We also noted that this was one of a number of records and communications with A’s GP that were somewhat generic in nature, noting that while a further letter referenced discussions of palliative options, which implied a discussion about the seriousness of A’s condition, this letter could have been more specific in relation to what exactly was discussed. Overall, we found that while communi

C complained about the care and treatment that their late parent (A) received from the board. C complained that the board failed to reasonably treat an ulcer on A’s toe or manage their related pain. C also complained that A was unreasonably transferred to a nursing home from the ward when they were too frail and unwell to leave the care of the hospital. C advised that the communication with them in relation to A’s transfer was unreasonable, both in the way the matter was discussed with them by the social worker and as the ward failed to explain that their parent was nearing the end of his life. C said that they were only made aware of this by a GP at the nursing home who explained A was receiving end of life care. The board's response to C’s complaint confirmed that A had received treatment for their toe ulcer during their inpatient admission, with follow-up treatment planned following their discharge to the nursing home. On the matter of A’s referral to nursing home care, the board advised that this had been discussed with C by phone. The board said that the documentation of the phone call reflected that C was in agreement with the plan, with the purpose of the referral being to arrange long term care for A. Prior to discharge, A was reviewed by a ward doctor and it was determined that they were fit for discharge based on their improving blood results following a recent chest infection and as their observations were stable. The board expressed regret that A returned to hospital 10 days later having deteriorated since leaving hospital. We took independent advice from a consultant physician and geriatrician. We found that a plan to manage A’s toe ulcer had been put in place and that they advised that A had received pain relief as required. We considered that the plan of care made by the board was reasonable. In reference to A’s discharge to the nursing home, we found that this had been arranged in discussion with C, noting that A was not suitable for further

C complained about the care and treatment that they received from the board following a stillbirth. C complained that the board had failed to provide them with adequate support following the birth of their child. C also complained that a consultant had acted unreasonably by discussing their child’s post mortem results with them, without prior warning and without the presence of their partner, during a consultation several months later to discuss the progress of a new pregnancy. The board did not identify any failings with the support provided to C. However, they apologised for the distress caused to C during the meeting with the consultant. They said that the consultant was required to make a plan of care for the new pregnancy and that this inadvertently led to the discussion and counselling of C’s previous pregnancy. The Board said that C’s partner was unable to attend the meeting due to restrictions on hospital visiting in force at the time due to the pandemic. C remained unhappy and asked us to investigate. C complained that the support provided to them was inadequate. C also complained that the consultant had acted unreasonably. We took independent advice from a consultant obstetrician. We found that inpatient care discharge arrangements, including handover of C’s care to community midwives was as expected. We did not uphold this complaint. However, we found that there had been a failure to adequately prepare for C’s consultation. In the circumstances, we found that it was unreasonable to have progressed with C’s consultation without offering them the choice of re-scheduling so that consideration could have been made to their partner attending, or offering a remote appointment. We upheld this complaint.

C, an advocacy worker, complained on behalf of A about the care and treatment they received from the board. A had been referred to the Ear, Nose and Throat (ENT) department when they noticed a growth on their neck. A was diagnosed with a positive squamous cell cancer (type of cancer that starts as a growth of cells on the skin) in their left tonsil which had spread to their neck lymph nodes. C complained about the standard of communication from the ENT department and a failure to provide appropriate treatment which they considered led to A's terminal diagnosis. The board provided an overview of the care and treatment provided and were satisfied that appropriate care was provided. Due to the metastatic nature (spread) of A's cancer, the only treatment available was palliative. The board also noted there was regular communication with A and they were copied into letters that were sent to A's GP. We took independent advice from a consultant ENT surgeon. We found that the clinical decision making with regards to treatment for A's cancer was appropriate and clearly set out in the records. While we recognised that A may have been under the impression that their cancer had been successfully treated, we were satisfied that the records documented detailed discussions which took place between clinical staff and A on multiple occasions regarding their diagnosis and treatment plan. We acknowledged it was possible that A may not have understood the complex and technical terminology used, however overall, we did not find that the clinical team failed to communicate with A. As such, we did not uphold C's complaints. Related reading View Decision Report 202300410 as a PDF (24.65 KB) Updated: November 22, 2023

C complained about the care and treatment provided to their infant (A). C's concerns related to A's urinary function. C had concerns about the monitoring they had received whilst pregnant with A, the care provided to them and A immediately post- birth as well as during A's early years. C raised issues about the assessment of A's bladder function, A's renal health and the pain and discomfort A was suffering. C also felt that the family had not been listened to and their concerns dismissed or minimised. C had sought a second opinion at a hospital in England and believed board medical staff criticised the family for taking this step. They also said that the board failed to liaise with the hospital in England, resulting in A not receiving treatment or care for an extended period. The board had accepted that communication with the family could have been better but considered the standard of care and treatment provided to A was reasonable. We took independent advice from a consultant paediatrician. We found that A's symptoms were reasonably investigated initially and that they were referred to urology timeously. We also found no clear evidence that A's bladder had been damaged by failings on the part of the board. Therefore, we did not uphold these parts of C's complaint. We found that the impact on A and their family of their condition was not adequately acknowledged and that the board had failed to communicate appropriately with C and their family. We also found that the board did not act when it became apparent that A was no longer being cared for by a hospital in England, resulting in avoidable delays in their care. Finally, we considered that the board failed to handle C's complaint reasonably. We upheld these parts of C's complaint.

C complained about the care and treatment that they received during their labour and delivery of their baby (A). In particular, C complained that the standard of care and treatment they received had been unsafe, that there had been a lack of communication in relation to their requested position during labour, the use of forceps and the provision of pain relief. C also complained that they had been unable to give their informed consent for the use of forceps. The board, when responding to C’s complaint, accepted that some aspects of C’s care did not meet the standard that they would expect in terms of communication and C’s requested positioning throughout the labour and delivery of A. As a result of C’s complaint, the board had shared the complaint with the midwifery staff responsible for C’s care. The board asked them to reflect on C’s experience and consider ways of improving care for the purpose of providing person centred care. The board also accepted that they had failed to arrange C's postnatal review clinical appointment. The board said they had taken action to review and amend the process for appointing consultant led postnatal follow-up. The board indicated that, while the event had not been recorded as an adverse incident and a Datix (an incident/risk management reporting system to collect and manage data on adverse events) had not been submitted, a review had been carried out and action had been taken as a result of that review. We took independent advice from a consultant obstetrician (a doctor who specialises in care during pregnancy, labour and after birth). We found that during C’s labour there were significant periods of loss of contact (LOC) during the recording of the foetal heart rate. However, we also found that, while labour would have been complicated by the LOC there was no evidence that C or A were put at risk. We also found that the actions of staff during this period were reasonable and proportionate to the needs of C and the clini

C complained about the care and treatment of their late partner (A) during multiple admissions to hospital. C raised concerns that a coronary angiogram (a scan to check for blockages in the blood vessels) was unreasonably delayed, which in turn meant necessary vascular surgery could not take place. C complained about a lack of cohesion between vascular, cardiology and renal teams, and a lack of communication with the family. We took independent clinical advice from a cardiology adviser and a vascular adviser. We found that there was a lack of cohesion and coordination in the management of A’s treatment plan. We considered that multidisciplinary meetings should have taken place to agree a treatment plan, and provide the cohesion that was lacking in the approach to A’s treatment. Overall, however, we found that the clinical decisions made by each team were reasonable and reflected A’s clinical condition at the time. We found nothing to suggest that the lack of cohesion impacted directly on the treatment A received or the eventual outcome for A. In particular, we found that there were good reasons not to proceed with the coronary angiogram, and that it was unlikely any vascular intervention could have been provided due to A’s competing illnesses. On balance, therefore, we did not uphold the complaint that A’s clinical care and treatment was unreasonable. However, we upheld the complaint about the communication with A and their family. The board had already apologised for the poor communication and acknowledged that the multidisciplinary team did not keep the family as informed as they could have. Notwithstanding this, the board considered that A had capacity to make decisions regarding their own care and treatment. However, this assertion did not appear to have been based on any formal assessment. We found that there was evidence only once in the records of a capacity assessment having been undertaken. We found this concerning, particularly as C had raised