SPSO Individual Decisions

C complained about the level of supervision that their spouse (A) was provided with while they were detained in hospital under the Mental Health (Care and Treatment) (Scotland) Act 2003. A was diagnosed with bipolar affective disorder (a condition that affects a person's mood) and was noted to be disinhibited. A later told C that A had entered a patient’s room and had sexual intercourse with them. C acknowledged that this could not be corroborated by the board, but considered that the board had failed to address their concerns regarding the known issues of A’s disinhibited behaviour and them entering other patient’s rooms. On the basis that there was no available evidence to establish the circumstances surrounding the alleged incident and whether there was any failure by ward staff to monitor A at that time, our consideration of this complaint was limited to reviewing whether the observation arrangements in place were reasonable and appropriate for minimising the risk of such an incident. We took independent advice from a psychiatry adviser. We found that appropriate risk assessments were carried out throughout A’s admission. We were satisfied that A was given a level of supervision that was in-keeping with national guidance and their assessed risks at that time. In the circumstances, we did not uphold this complaint. Related reading View Decision Report 202111275 as a PDF (24.51 KB) Updated: April 19, 2023

C complained about the treatment they received from the board following a knee injury. C’s injury had occurred when level 3 of the Scottish Government’s COVID-19 lockdown measures were in place, which limited travel between local authorities to essential travel only. C’s accident had occurred outwith their own local authority area. C complained that the A&E staff repeatedly asked them about their local accommodation and travel arrangements. C reported that they were only admitted to hospital for one night, and they were obliged to make their own travel arrangements for their discharge the next day despite experiencing severe pain. The board said that C had been timeously assessed and treated at the A&E, with orthopaedics (specialists in the musculoskeletal system) taking over their care due to the diagnosis of a displaced fracture with foot drop. C’s injury had been immobilised with a knee brace and they were assessed using crutches by physiotherapy prior to discharge the next day, with the plan being for C to travel back to their own health board area to arrange further care and treatment of their injury. C was given an immediate discharge letter to pass to the receiving clinical team and a prescription for pain killers. We took independent advice from an orthopaedic consultant. We fond that the board’s treatment of C was reasonable, both in terms of the type of injury they had sustained, and in keeping with the guidance in place at the time for management of orthopaedic injuries during the pandemic. We considered it was appropriate for A&E staff to enquire about C’s travel and accommodation arrangements to help inform their plan of care. They also commented that without lockdown measures in place, C’s injury would have required transfer to a specialist centre for surgical reconstruction. However the guidance at the time had been appropriately followed by the board for non-operative management of the injury with later reconstruction. Therefore, we did not uphold C’

C complained about the care and treatment provided to their sibling (A) by the practice. A had previously been diagnosed with breast cancer a number of years ago. A became ill and attended the practice on several occasions over the year. The GP considered A had gastroenteritis (inflammation of the stomach and intestines). A’s symptoms persisted and A was referred to hospital for a colonoscopy (examination of the bowel with a camera on a flexible tube). The request was rejected. A presented at the practice with the same symptoms on two further occasions and the practice made an urgent ‘suspicion of cancer’ referral to the health board. A scan showed a tumour attached to A’s right kidney. A died some months later. C complained that despite A’s multiple attendances at the practice and concerns that the cancer had returned, the practice failed to reasonably respond to A’s worsening condition and delayed or failed in carrying out appropriate investigations and associated tasks. We took independent advice from a GP adviser. We found that initially there was no unreasonable delay in the practice recognising the seriousness of A’s symptoms and that the appropriate referrals for a colonoscopy and ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) were made. We also noted that it would not have been appropriate for the practice to have undertaken a CEA blood test (carcinoembryonic antigen test, a blood test used to help diagnose and manage certain types of cancers) and that the actions of administrative staff in filing away test results was appropriate and in line with established good practice. However, we found that there was a failure to include clinically important information in referrals and in consultation documentation, and that there was a delay in sending A’s suspicion of cancer letter. We also found that the practice should have considered undertaking some additional blood tests when it was clear A wa

C and their pregnant partner (A) attended a local hospital as A was experiencing abdominal discomfort. A was examined and recommended to attend the main regional hospital, advising C to drive them there. The journey time was approximately 3 hours and on arrival A was examined and advised that labour may be starting. A was later told that labour was unlikely to be starting but remained in hospital overnight and discharged the following day. The following week, A suffered vaginal leakage and attended the local hospital where they were examined by a clinician and advised that they suspected A’s waters had broken. A was advised to go to the main regional hospital and they were told that an ambulance was not needed. C therefore drove A to the main regional hospital. An examination at the main regional hospital revealed that A’s waters had broken and in the early hours of the following day they went into labour. Later that afternoon clinicians gave A and C a number of options: continue with natural labour, attempt a process of augmentation (helping along a labour that's not progressing as it should), or an immediate caesarean delivery (an operation to deliver a baby that involves cutting the front of the abdomen and womb). A and C both agreed to a caesarean. The procedure was carried out and the baby (B) was delivered. However, clinicians had to resuscitate B. A scan of B’s brain three days after birth revealed a likely injury which was later confirmed as periventricular leukomalacia (PVL, a softening of white brain tissue near the ventricles which often causes problems later with muscle control and thinking or learning problems). Following repeated scans over several weeks as the cysts continued to form, this was eventually categorised as grade three level of severity. C raised concerns with the board regarding the care and treatment that A and B had received. C met various clinicians but remained dissatisfied. The board offered to have the events subjected to an externa

C and B complained about the board's handling of reports of alleged elder abuse in relation to a family member (A). They also complained that the board had failed to handle appropriately a referral made to the District Care Panel (DCP) for residential care for A, and had failed to give sufficient consideration to A's circumstances and that they were at risk of harm when rejecting the request. They also complained that following concerns for A's welfare, A had been removed from their place of residence, but the board had failed to properly assess A's care needs or to provide A with a reasonable level of support. In pursuing these matters, C and B said that the board's communication with them had fallen below a reasonable standard. We took independent advice from a social worker. We found that although the Adult Support and Protection (ASP) investigation was procedurally sound, it had been lacking in quality. The board's analysis of A's circumstances and the Personal Outcome Plans were lacking, and were not persuasive in assessing a care need. As such, we found that the board had failed to safeguard A. We upheld this aspect of the complaint. We also found that although the DCP handled A's referral for residential care appropriately, the information provided to the DCP was lacking in terms of the quality of the ASP investigation and the robustness of the case presented regarding A's situation. As such there was a failure by the board to prioritise securing urgent short-term accommodation that took account of A's circumstances. We upheld this aspect of the complaint. We found that following A's removal from their place of residency, the board had followed up with A reasonably. We did not identify any further shortcomings in the board's assessments of A's care or living needs. We did not uphold this aspect of the complaint. Finally, we found that the board had, at times, failed to respond to C and B's questions and requests for information regarding their conc

C complained about the treatment that they and their child (A) received from the board. Over the course of nine months, C and A attended a number of appointments with the board's Child and Adolescent Mental Health Service (CAMHS) in respect of difficulties A was experiencing. C complained about the content and nature of these sessions. In their view, the board failed to progress a neurodevelopmental assessment of A within a reasonable timescale, which C considered was one of the key reasons for the referral. C also felt inappropriate assertions were made about them and their parenting skills. In C's view, they were unreasonably picked on during sessions with CAMHS. As a result of this, C's view is that CAMHS failed A and did not provide them with reasonable care and treatment. C also complained about a child concern referral that was made by the CAMHS service. C considered this to be inappropriate and that it was done in response to them raising concerns about the actions of CAMHS. We took independent advice from two advisers: a mental health nursing specialist and a clinical psychologist, both with a background in CAMHS. We found that the care and treatment provided by CAMHS was reasonable in the circumstances. Given the content of the referrals from A's GP and social worker, CAMHS embarked on an appropriate course of treatment and therapy. While we recognised that this did not result in a positive outcome for C or A, we did not consider the board's actions to be unreasonable. Therefore, we did not uphold C's complaints about the care and treatment provided by CAMHS. Related reading View Decision Report 201902230 as a PDF (24.48 KB) Updated: September 21, 2022

Following the extraction of a wisdom tooth in hospital, C's follow-up care was undertaken by their family health service dentist. C suffered altered sensation following the tooth extraction. Over the course of eight months, C arranged three consultations with their dentist at which the altered sensation was discussed. C was concerned that the dentist's actions had not addressed the altered sensation and raised complaints about this with them and, subsequently, with this office. We took independent advice from a dentist. We found that the dentist provided reasonable care to C and did not uphold the complaint. When this report was first published on 21 September 2022, it was incorrectly categorised as being about a medical practice. This was due to an administrative error which we discovered on 20 October 2022, and for which we apologise. Related reading View Decision Report 201900994 as a PDF (110.88 KB) Updated: October 20, 2022

C complained that the care and treatment that their sibling (A) received from the board was unreasonable. A had previously been diagnosed with breast cancer and had a mastectomy (surgical removal of the breast tissue). When A became ill, the symptoms were considered to be related to irritable bowel syndrome (IBS, a condition of the digestive system that can cause stomach cramps, bloating, diarrhoea and constipation). A's symptoms persisted and A was admitted to hospital on numerous occasions. A scan showed a tumour attached to their kidney and they died some months later. C complained that despite A's multiple hospital admissions and concerns that the cancer had returned, the board failed to reasonably respond to A's worsening condition and delayed or failed in carrying out appropriate investigations. We took independent advice from a consultant colorectal and general surgeon adviser. We found that, overall, there was a failure to adequately investigate symptoms, take into account patient history, and appropriately manage A's care, including acting on findings of sclerotic bone lesions (an unusual hardening or thickening of your bone) and a failure to consider an overarching diagnosis. Whilst the board did carry out a Significant Adverse Event Review (SAER) in relation to A's care and treatment, this failed to identify all of the failings highlighted above. As such, we upheld C's complaint.

C complained that the board failed to fully consider an allergic reaction to a wasp sting as the cause for their blackout which occurred when driving a HGV (heavy goods vehicle). When C was taken to hospital following the incident, a tryptase test was taken (a test to diagnose anaphylaxis, an acute allergic reaction). An ECG (a test to check the heart's rhythm) showed that C had an irregular and fast heartbeat and an EEG (a recording of brain activity) showed abnormal results with potential epileptic activity. Due to these findings, C was instructed not to drive and the DVLA were informed. We reviewed the medical records and took independent advice from an acute medicine adviser. We found that while it was reasonable for the board to arrange for further investigations given that there were a number of potential causes for C's blackout, it would have been reasonable to further investigate an anaphylactic cause for the collapse once the tryptase result was available. Instead, C decided to seek private specialist opinion and the board only referred C to an allergy specialist after a significant amount of time and correspondence from C. We therefore upheld the complaint.

C, an advocate for A, complained about the actions of the board's paediatrics department in relation to child protection concerns raised about A's child (B). C complained that the board did not reasonably communicate with A about the concerns raised and that they took an unreasonable length of time to arrange a child protection conference. C also complained that the board failed to fully involve the family GP in the child protection process and to explain the rationale for proposing to reassess B's autism spectrum disorder (ASD) diagnosis. To investigate C's concerns, we reviewed the relevant clinical records and sought independent advice from a consultant community paediatrician. Our investigation found that the steps taken to invite A to a meeting to discuss the concerns about B and to share a summary of the professionals meeting held were reasonable. We also concluded that from the time the concerns were noted to holding a child protection conference, it was reasonable to consult with other professionals, gather information and attempt to speak with A. As such, we did not consider there was an unreasonable delay in holding the child protection case conference. We also found evidence that the family GP was invited to a professionals meeting by email, however, due to administrative errors outwith the board’s control, the email was not received by the GP. With regards to the reassessment of B's ASD diagnosis, we concluded this was explained both in writing and at a meeting. We therefore did not uphold C's complaints. Related reading View Decision Report 202003203 as a PDF (24.46 KB) Updated: July 20, 2022

C had a wisdom tooth extracted by the board. Subsequently C experienced an altered sensation in their tongue and was advised that this was likely the result of nerve damage, which was a possible side effect of the extraction of a wisdom tooth. C complained that they were not advised of this possible side effect prior to the extraction taking place. A handwritten note on the consent form C signed included mention of altered sensation but C disputed that this had been present when they signed the form. We took independent advice from a dentist. While evidence gathered as part of our investigation could not definitively determine which of these positions was most accurate, we considered that based on the available evidence, the board did not make C reasonably aware of why the extraction was considered necessary, what the risks and benefits of extraction, alternative treatments or no action were, what the percentage likelihood of nerve damage was or what 'altered sensation' meant. Therefore, we found that the board did not reasonably advise C that nerve damage was a possible side effect of the extraction of a wisdom tooth as required and upheld the complaint.

C complained about the care and treatment that their adult child (A) received from the board over a two year period. A had previously suffered an acquired brain injury and since then had developed obsessive compulsive disorder, post-traumatic stress disorder and anxiety, as well as experiencing delusional thinking and periods of psychosis (a mental disorder in which thought and emotions are so impaired that contact is lost with external reality). C raised a number of concerns, including that the board claimed A was reviewed regularly when they were not, that no psychological support was provided for A, that there was a lack of support from the local mental health team, that there was no clear local treatment plan and that in the care programme approach, needs identified were not met, matters were not escalated and no solution was found. We took independent advice from a consultant psychiatrist (a medical practitioner specialising in the diagnosis and treatment of mental illness). We found that A's records showed that they received regular reviews during the period in question and that the letters on these showed a high level of clinical input. However, the evidence showed that there was a delay of over five months from the date of A's discharge from psychiatric hospital and the issuing of the discharge letter, which we found was unreasonable and, for a patient with less clinical/multi-professional input and family interaction, would likely have resulted in significant clinical risk. We found that the overall level of support A received was reasonable. However, we found that there was a lack of focus by the board on the organic elements of A's presentation and how these may have contributed to their psychosis and we were critical of the board's failure to utilise locally available specialist advice which resulted in a lack of psychology and neuropsychiatric input in A's case. We found that these failings were significant and, on balance, we upheld the complaint

C's parent (A) was admitted to Raigmore Hospital following a fall at home. A was diagnosed with delirium. After six weeks on the ward, A was discharged home with a package of care. A required readmission shortly after discharge and their condition deteriorated further. C complained that A's food and fluid intake were inadequately monitored during this period. C complained that the concerns they raised about their parent's physical and mental health were ignored. C also complained about the hospital discharge process. C held Power of Attorney (POA) in respect of A and complained that the board did not have due regard to that. C complained that the board did not appropriately involve them in planning for A's discharge. We took independent nursing advice. Although we were critical of aspects of the board's communication with A's family, we noted that on the whole, A's care and treatment were of a reasonable standard. We therefore, did not uphold the complaint. We were critical of the board for their delay in referring A to a dietitian, but we noted that the board had apologised for this and confirmed learning. We considered that A's family could have been involved at an earlier stage when plans were being made for discharge. Overall, however, we noted that the discharge planning was reasonable, involving appropriate assessments and discussion with C. We did not uphold this complaint. Related reading View Decision Report 202002559 as a PDF (24.42 KB) Updated: March 23, 2022

C's spouse (A) had advanced kidney cancer which had spread to their brain. A was admitted to hospital after they developed breathing problems. They were diagnosed with a pulmonary embolus (blood clot in the lung). A agreed for the pulmonary embolus to be treated in hospital, in the hope that they could be discharged once stable, but their condition deteriorated and they died in hospital. There was a period during A's admission when their medication was stopped while clarification was sought as to their treatment plan. C complained about the clinical decision-making regarding A's care and treatment. C considered that failings in A's care and treatment led to their death in hospital, denying them of the right to be cared for at home. C also complained about the board's communication. We took independent advice from a consultant physician. We noted how difficult this case was, in particular from the perspective of the family. Although we noted certain areas of care that could have been better, we considered that overall the standard of care and treatment was reasonable and that A was nearing the end of their life by the time of their admission. We did not consider that the outcome would have been different had there not been a period of time during which medication was withdrawn pending clarification of A's treatment plan. Therefore, we did not uphold this complaint. We noted that a number of physicians were involved in A's care and treatment and that there had been a degree of uncertainty about A's treatment plan. Although some aspects of communication could have been better, we considered that the clinicians did their best to communicate to A's family how ill A was and to have appropriate discussions with them around resuscitation and escalation. Therefore, we did not uphold the complaint about communication. Related reading View Decision Report 202001414 as a PDF (24.6 KB) Updated: January 19, 2022

C complained on behalf of their parent (A) who had stage one oesophageal cancer at the time of the complaint. A was admitted to hospital via the A&E and later diagnosed with pulmonary embolism (PE, a blockage of an artery in the lungs). C complained that the board delayed in diagnosing the PE and that the care and treatment they provided to A was subject to delays and unreasonable. C was concerned that A had been incorrectly treated as a palliative patient when their cancer was not advanced and that should not have impacted the care A received. The board apologised for the delay in diagnosing PE and for the delays to A's care that happened whilst they were an in-patient e.g. delay to x-ray being carried out. The board considered various aspects of A's care, such as, when they decided to use a nasogastric (reaching or supplying the stomach via the nose) feeding tube and the action they took to manage A's sepsis, to be appropriate at the time. We took independent clinical advice from advisers with relevant experience. We concluded that the board failed to diagnose the PE when they should have, that they failed to carry out the x-ray when it should have been done, and that they delayed starting antibiotics to treat suspected pneumonia. We considered that if these delays did not happen, it is likely that A would not have needed to be admitted to a high dependency unit for care. We noted that the decision to use a nasogastric feeding tube was taken reasonably and in line with relevant guidelines. In light of this, we found that there was an unreasonable delay in diagnosing PE and that there was a delay in starting antibiotics for suspected pneumonia. These delays likely led to A's condition worsening and contributed towards the requirement for A to be admitted to a high dependency unit. There were also communication failings that led to a delay in an x-ray being carried out. We identified failings in the way in which the board handled the complaint. We found th

C complained that the board failed to provide their child (A) with orthognathic treatment (orthognathics is a specialist subset of dentistry which involves surgical correction of growth issues with the jaw and lower face) within a reasonable timescale. A's teeth were overcrowded to the extent that they caused pain in their head and jaw and difficulties with eating and speech. Following referral to an orthodontist, A was placed on the waiting list for orthognathic treatment. However, despite it being identified that A would require surgery, their treatment was not progressed. The board explained to C that this was due to a shortage of orthognathic specialists in their area and that an agreement with neighbouring health boards for them to provide treatment had come to an end. C complained that the board had failed A by not providing the required treatment within their area, or making arrangements for the treatment to be provided in another area, or privately. The board were open and honest about the fact that they struggled to provide specialist orthodontic and orthognathic appointments over a number of years due to staff recruitment issues and the loss of arrangements with neighbouring health boards. They acknowledged and apologised for the fact that this led to substantial delays for A. We commended the board for their transparency in this respect and acknowledged that there were a number of factors beyond their control that limited the provision of these services and contributed to a long waiting list for all patients in the area. We took independent advice from an orthodontic specialist. We found that, whilst it was recognised at an early stage that A would benefit from orthognathic surgery, this treatment would not have been available to A for a number of years. Surgery was first discussed when they were 11 years of age. We noted that, prior to surgery, there would be 12 to 36 months of preparatory orthodontic treatment and this would not normally start

C underwent surgery for removal of a complex cyst on their right ovary. C complained that during the surgical procedure the board unreasonably removed their left ovary despite their express wishes it should be retained. They said that in the absence of a fully informed pre-surgical consultation, the board had not understood their surgical choices and had unreasonably prepared them for surgery. They said that following surgery, the board had failed to provide them with adequate pain relief and had withheld their medication. C also complained that the board's handling of their complaint was inadequate and that there were delays and inaccuracies in their response. We took independent advice from an appropriately qualified adviser with experience in obstetrics and gynaecology (pregnancy, childbirth and the female reproductive system). We found that the surgical procedure performed was in line with the recommendations of a multidisciplinary team (MDT) and that the board had acted on what they believed were C's express instructions and for which written consent had been obtained. As such, we did not uphold this part of the complaint. We found that despite reasonable attempts to include C in the pre-surgical decision-making and consent process, the board had failed to clarify with C their understanding of the proposed surgical plan and the circumstances in which C's left ovary was to be removed. We also found that the board had not telephoned C following the MDT team meeting as had been agreed, and some of the pre-surgical discussions that had taken place between the parties were brief or had not been documented in the clinical records. Therefore, on balance, we upheld this part of the complaint. Following C's surgical procedure we found that there were two occasions where analgesia (pain medication) had been delayed after being requested, and on one of those occasions where it appeared to have been an inadequate dose. However, we found that C's usual pain regime

C and their spouse (B) complained about events during two periods of hospital treatment for their child (A). A has complex medical needs. They are cared for by C and B at home, however they have required multiple and prolonged spells in hospital. C and B complained about the care and treatment A received, communication by the board, communication within the board and how their complaint was handled. In response to C and B’s complaints, the board acknowledged a number of failings in A’s care and treatment and the way in which they had communicated with C and B. They also said that consideration should have been given to earlier involvement of social work and the community children’s nurse. We took independent advice from a consultant paediatrician and a social work adviser. We found that the care and treatment A received on their first admission were unreasonable. We considered that there was inadequate dietetic support, an unreasonable reliance on C and B's assessment as to whether intake was sufficient, and a lack of information and help for the family when A required emergency care after a gastro-jejunal tube (G-J tube, a tube used to vent the stomach and small intestine) procedure. We upheld this aspect of the complaint. In relation to A's second hospital treatment, we considered the care and treatment to be reasonable. We did not uphold this aspect of the complaint. We also found a lack of reasonable communication with C and B about A's care and treatment and a lack of reasonable communication between the board’s staff during A's second admission. We upheld these aspects of the complaint. Finally, we found that the board failed to handle C and B's complaint reasonably. We upheld this aspect of the complaint.

C complained about the care and treatment provided to their late parent (A). A attended Raigmore Hospital with symptoms including lethargy, bruising and weight loss. A was found to be severely anaemic (a low level of red blood cells) and had a very low platelet count (small cells that help the blood to clot). A was asked to attend Caithness General Hospital for regular platelet treatment and further investigations into their condition. Around a month later, A became unwell and they attended A&E at Caithness General Hospital. A was discharged home the same morning. Two days later, C became concerned about A as they looked 'black and blue'. C phoned the consultant haematologist (a specialist in diseases of the blood and bone marrow) for advice. They told C to contact A's GP if they were concerned about A's condition. By the next morning, A had become very unwell and they were taken to Caithness General Hospital by ambulance. A was found to have intracranial bleeding (bleeding within the skull). A was airlifted to Aberdeen Royal Infirmary that evening for platelet treatment. A's condition continued to worsen and they died the next day. We took independent advice from a consultant haematologist. We found that there was no evidence A was told about the possible complications they could develop from their low platelet count, such as the risk of internal bleeding. We found A was unreasonably discharged home from Caithness General Hospital, as they should have been referred for emergency platelet treatment. In relation to C's phone call to the consultant haematologist, we acknowledged a GP should normally be the first point of contact. However, we considered appropriate action was not taken in response to the phone call, given C had described signs of A having internal bleeding. For these reasons, we upheld the complaint.

C complained on behalf of their child (A) who has a background of low mood and anxiety. C complained about the assessments of A by two paediatric consultants. C also complained that the Child Adolescent Mental Health Service (CAMHS) unreasonably rejected referrals from A’s GP due to social work’s involvement with the family. We reviewed the relevant medical records and took independent advice from a consultant paediatrician and registered mental health nurse. We concluded that the assessments by both paediatricians were reasonable and appropriate tests and follow-up were arranged. We did not uphold this aspect of C's complaint. However, we considered that it was unreasonable for CAMHS to reject the referrals on the basis that they failed to risk assess A in accordance with the board’s guidance. On that basis, we upheld this aspect of C's complaint.

C was referred to Raigmore Hospital by their midwife with high blood pressure. C was pregnant and there were concerns they had pre-eclampsia (a condition that causes high blood pressure during pregnancy and after labour). C said that on attending the hospital they did not receive reasonable treatment over a four-day period. C also considered the care provided to their newborn child (A) was unreasonable. We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system) and a consultant neonatologist (a doctor who specialises in the medical care of newborn infants, especially ill or premature newborns). We found that the tests carried out when C attended the ward were reasonable and in line with relevant guidelines. We considered it was reasonable that C was initially discharged prior to their later admission and when C’s condition worsened, appropriate action was taken. As such, we did not uphold this complaint. In relation to C's concerns about A's health, we considered that the actions taken after concerns were raised about A’s condition were reasonable. While we considered that the communication and documentation was below a reasonable standard, the clinical care provided to A was reasonable. As such, we did not uphold this complaint. However, feedback was provided to the board. C complained that the board failed to reasonably respond to their complaint. We found that while the response to the complaint was accurate in relation to the medical records, it would have been good practice to provide more detail as to the board's position on certain points. A consultant spoke with C after events and arranged for further details to be provided regarding A’s care, which was good practice, particularly considering the board had identified communication issues. While further detail could have been given, and we provided feedback to the board on this point, on balance, we found t

C underwent re-root canal treatment from the dentist in an attempt to treat an abscess (a painful swelling caused by a build-up of pus) which had formed under one of their teeth. After attempts to resolve the issue were unsuccessful, C was referred to a specialist. C complained that the re-root canal treatment was not carried out by the dentist in a reasonable manner and limited further treatment options for C. We took independent advice from a specialist in dentistry. We found that the treatment provided was reasonable. While the treatment did not resolve the presence of C’s abscess, it was not unreasonable. As such, we did not uphold this complaint. Related reading View Decision Report 201904615 as a PDF (24.02 KB) Updated: September 22, 2021

C, a support and advocacy worker, complained on behalf of their client (B) about the care and treatment provided to B's spouse (A). A received a diagnosis of lung cancer that had spread to their brain and neck. A was discharged home with anticoagulant injections (medicine to prevent blood clots) that B agreed to administer whilst further treatment and care was awaited. A subsequently underwent a course of radiotherapy and physiotherapy before being admitted to hospital where they died the following day. C complained about the treatment A received. We took independent advice from a consultant physician and a nurse. We found that it was reasonable for A to have had a consultation that B thought was unnecessary and that, while a definitive decision could not be reached on whether relevant staff had failed to recognise deterioration in A, no opportunities had been missed in A's treatment. We did not uphold this aspect of the complaint. C complained about the care A received. We found that reasonable follow-up support was either provided or offered to A and B. We did not uphold this aspect of the complaint. C complained about specific communication between the board and B and A. We found no evidence indicating unreasonable communication on the board's part. We did not uphold this aspect of the complaint. Finally, C complained about the board's response to the complaint submitted on B's behalf. We found that the response had been reasonable and, therefore, did not uphold this aspect of the complaint. Related reading View Decision Report 201902674 as a PDF (24.41 KB) Updated: August 18, 2021

C complained about the care and treatment provided by the board to their parent in law (A) at Raigmore Hospital. C complained that the board missed a diagnosis of urosepsis (a condition where sepsis impacts structures of the urinary tract) and to put in place appropriate falls prevention measures. The board said that A was at the end stage of their conditions and that A was treated in accordance with national and international guidance. The board recognised that A suffered several falls and said that they have since made improvements to their falls prevention practices. In investigating C's concerns, we took independent advice from a consultant geriatrician (a specialist in medicine of the elderly) and a registered nurse. We found that while there was an unreasonable delay in performing a urine test, any treatment would have been unlikely to improve A's health or alter the outcome and that overall, the medical care and treatment was reasonable. We also found that appropriate falls assessments were carried out and A was appropriately recognised as a high falls risk. We did not uphold the complaints, however we have asked that the board reflect on the timing of the urine test. Related reading View Decision Report 201907331 as a PDF (24.3 KB) Updated: August 18, 2021

C complained on behalf of their parent (A) about the care and treatment A received from their GP practice; in particular, that there was a delay in referring A for further investigations which led to a delay in A being diagnosed with colon cancer. We took independent advice from a GP. We found that all appropriate investigative tests were carried out at A's first attendance at the practice. On their second attendance, we found that the care and treatment A received was reasonable and that tests were undertaken with appropriate follow-up to a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines) who A chose to see at a private hospital. Following receipt of the consultant gastroenterologist's report, we considered that there was no unreasonable delay by the practice in making an urgent referral to the gastroenterology out-patient clinic at an NHS hospital. We considered that a rectal examination should have been performed when A attended the practice, however, this was a minor criticism and had not impacted on A's future treatment. We noted that this had been addressed in the Significant Event Analysis (SEA) carried out by the practice. On balance, we considered that the practice provided A with reasonable care and treatment. Therefore, we did not uphold the complaint. Related reading View Decision Report 201910988 as a PDF (24.4 KB) Updated: August 18, 2021