SPSO Individual Decisions

C complained about the standard of care provided by the board to their parent (A). A had a complex medical history including depression for which they were on three types of anti-depressants. This was noted when A was admitted to hospital but staff failed to provide A with their prescribed medication and inform A and their family that the medication had not been given to them. This led to A’s mental health deteriorating. We took independent advice from a registered nurse. We found that the board failed to deliver the required service in relation to medicines, maintain adequate recordkeeping, communicate appropriately, recognise the harm done to A and undertake the appropriate review. Therefore, we upheld this part of C’s complaint. C complained that the board failed to deal with their complaint in a reasonable way. We found that the board’s investigation did not look into an important part of the complaint and that their response did not address the impact on A as a result of the medication being withheld. Therefore, we upheld this part of C’s complaint.

C complained that their late partner (A)’s discharge from hospital was unreasonable. A was admitted to hospital with pneumonia and was discharged after ten days. Less than two weeks after discharge, A collapsed and was readmitted to hospital. A died a few days later. C questioned whether A had been fit for discharge. They also raised concerns about not receiving adequate education on the new medications that A was prescribed on discharge. The board noted that A’s infection had improved with antibiotic therapy and that they had been stable and well enough for discharge home. They explained the rationale for the medications that A had been prescribed and apologised that medical staff did not have a better discussion with them at the time of A’s discharge. We took independent advice from a consultant in acute and general medicine. We found that A's oxygen levels had been stable and their discharge was clinically reasonable. However, we noted that A's sodium level had been low during their admission but had improved on discharge. We found that no follow-up arrangements were made to ensure that A's sodium level was continuing to improve after their discharge. The working diagnosis on A's readmission was that they had had a seizure due to low sodium which led to hypoxia (deficiency in the amount of oxygen reaching the tissues) and cardiac arrest. It is possible that the fall in A's sodium level could have been detected had there been follow-up to re-check this. Therefore, we upheld C's complaint. We also noted a discrepancy between the working diagnosis on A’s re-admission and the recorded cause of death on the death certificate. This was not identified by the board. Therefore, C was not provided with a coherent narrative of events surrounding A’s death and we made a recommendation to address this.

C complained about the care and treatment provided to their spouse (A). A had a history or recurring urinary tract infections (UTI's) and was self-catheterising. The board gave A an indwelling (long-term) catheter to be changed every three months. Over the next several months, A attended A&E five times before being admitted and diagnosed with bladder cancer. C complained about the lack of arrangements to change A’s indwelling catheter, that requests for appointments were ignored and that A was only admitted after multiple visits to A&E. We took independent advice from a consultant urologist (specialist in the male and female urinary tract, and the male reproductive organs), consultant in emergency medicine and a medical director specialising in palliative care. We found that, as the indwelling catheter was a trial, the board should have followed up with A on their progress. There was also unreasonable delays in A being seen by urology and in being advised of their cancer diagnosis. While it was reasonable that A was not admitted by A&E for examination sooner, the board acknowledged that there was a missed opportunity. Therefore, we upheld this part of C's complaint. C also complained that A’s cancer diagnosis, discharge and care arrangements were not clearly explained. We found that the board made reasonable efforts to explain the cancer diagnosis to C and A. However, they did not reasonably communicate how they might manage once A was discharged home, and about the challenges associated with A reaching end of life. Therefore we upheld this part of C's complaint. In relation to complaint handling, we found that the information provided to both C and this office was inaccurate in places and incomplete. Therefore, we made a recommendation to improve the board's complaint handling.

C’s elderly spouse (A) spent approximately ten weeks in hospital. While in hospital, A fell on two occasions. C complained about the medical, nursing and physiotherapy care and treatment provided by the board. We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). We found that the medical care after A’s falls was reasonable. We found that the board had taken reasonable and proportionate actions to acknowledge, apologise for and support learning and improvement regarding the provision of pain relief and a delay in reviewing an x-ray after A’s first fall. We found that the board did not reasonably handle A’s prescriptions for haloperidol (a sedating medication) or codeine (a type of painkiller). On balance, we upheld this part of C’s complaint. We took independent advice from a registered nurse. We found that the care and treatment regarding A’s falls was unreasonable, as a mechanical aid should have been used to assist A from the floor, and risk assessments and care plans should have been updated. We found that A should have been more closely supervised prior to their second fall. We also found that the board’s post-fall protocol was not reasonable in its current form. Finally, we found that A’s hygiene needs were not reasonably met in hospital. The board had taken some action to support learning and improvement regarding the management of falls. On balance, we upheld this part of C’s complaint. We took independent advice from a physiotherapist. We found that the care and treatment provided to A was reasonable, and physiotherapy sessions were appropriate, timely and sufficient, considering A’s clinical presentation. We did not uphold this part of C’s complaint. Additionally, we found that some points of the board’s complaint response were incomplete and made a recommendation to address this.

C’s parent (A) was admitted to the hospital's A&E three days after a fall. A had a complex medical history including chronic pain. On admission, A reported lower right-sided chest pain, associated with gradually increasing shortness of breath. A chest X-ray showed no evidence of r ib fractures but a subsequent CT scan showed multiple right-sided rib fractures (from ribs 3-10), a flail segment (when three or more consecutive ribs are fractured in two or more places, causing a segment of the rib cage to become detached from the rest of the chest wall), an intercostal haematoma (solid pooling of blood between the ribs) and a right sided pleural effusion/haemothorax (build-up of fluid/blood between the ribs). A was treated in the Intensive Care Unit (ICU) for one week before being stepped down to the Medical High Dependency Unit (MHDU). A was reviewed by the ICU team as and when required and after becoming acutely unwell they were transferred to ICU again, where they died a few days later. In relation to A’s admissions to MHDU, C complained about problems with A’s medication, concerns around pain management and the nursing care A received, in particular issues around fluid and nutrition, and not responding to alarms or adhering to observational guidelines. C also complained that staff in the MHDU failed to provide appropriate care and treatment in response to A's deterioration. We took independent advice from a consultant in critical care and a senior critical care nurse. We noted that management of A’s condition was complex given their history of chronic pain together with a severe acute injury. We found a number of failings in A’s pain management, including doses of sustained release oxycodone being administered outwith the appropriate dose interval, an increase in dose of oxycodone which was not clearly justified, and lack of involvement of the acute pain service for ongoing support after A returned to the MDHU from ICU. Taking all of this into account, we found tha

C’s elderly parent (A) spent two months in hospital due to extensive bruising on their arms and legs with no obvious cause. A suffered acute hip pain while in hospital and became dependent on oxygen. C complained about concerns that they had regarding many aspects of A’s experiences, including A’s discharge after a few weeks and readmission just over a week later. On the day of readmission, A had been visited by district nurses who had administered morphine to A. A died on readmission. We took independent advice from an adviser specialising in medicine for the elderly. C complained that A was unreasonably discharged. We found that steps had not been taken to ensure that A and C had been provided with reasonable information about the medication that A had been prescribed. Therefore we upheld this aspect of the complaint. Additionally, C complained that district nurses unreasonably failed to administer an appropriate amount of morphine to A. We found that the district nurses’ should have administered an additional dose after the initial dose of morphine did not take effect. Therefore, we upheld this aspect of the complaint.

The complainant (C) had a right top hip replacement. Some years later, C began to experience back pain and left ankle pain for which they attended physiotherapists and podiatrists. C told us that two years after their hip replacement, a podiatrist identified that C had a leg length discrepancy. C complained that they now have a leg length discrepancy of approximately 17 mm which they considered to be unacceptable. The board said that leg length discrepancy is a recognised risk following hip replacement surgery. This was confirmed on a form signed by C prior to the procedure. We took independent advice from a consultant orthopaedic surgeon. We found that the risk of leg length discrepancy was reasonably discussed before the procedure and that the true discrepancy was 5mm which was reasonable. We noted that the operation was carried out to a reasonable standard. As such, we found that the care and treatment provided by the board was reasonable and we did not uphold the complaint. Related reading View Decision Report 202300379 as a PDF (24.27 KB) Updated: October 23, 2024

C complained about the care and treatment provided to their late parent (A) by the board. A was living independently but fell and injured their knee. A was admitted to hospital and underwent surgery. C believed that A did not receive adequate food or drink and that A was not provided with antibiotics timeously. A died in hospital and C complained about the way that A’s end of life care was managed, as well as a delay in providing C with a death certificate. We took independent advice from a consultant physician and a registered senior nurse. We found that A’s medical and nursing care fell below a reasonable standard. During the end-of-life period, we also found that A’s nursing care fell below a reasonable standard, although their medical care was reasonable. We also found that there was an unreasonable delay in providing C with A’s death certificate. We upheld the complaint.

C complained on behalf of a relative (B), about the care and treatment provided by the board to B's late spouse (A). When A first felt unwell, they visited their GP on three occasions where they were prescribed antibiotics and told they had a chest infection. Following an x-ray, A was prescribed medication to increase the amount of urine produced, with a plan to carry out a follow up x-ray. A visited the GP again with breathlessness and was referred to the hospital where they were admitted and diagnosed with COVID-19. Blood tests showed that A had an infection and a chest x-ray reported fluid on the right side of A’s chest. A was initially treated for infection with COVID-19 and a suspected bacterial infection. A was discharged from hospital with a plan to repeat the x-ray as an outpatient. A few days later, A was readmitted and diagnosed with lung cancer and was showing signs of spinal cancer. A was further told that there was a cancerous tumour pressing on their lungs. A’s breathing worsened, they had severe weight loss and they were not eating. Only one family member at a time was permitted to visit A. Staff said that more of A's family would be able to visit if their condition deteriorated. A remained in hospital until their death a week later. In considering C’s complaint, we took independent advice from a consultant in general and respiratory medicine and a senior nurse. We found that the decision to discharge A from hospital was reasonable and did not uphold this aspect of C's complaint. However, we found that it was unreasonable that A's pleural effusion (fluid build up) was not treated on or shortly after admission. Therefore we upheld the complaint that the board unreasonably failed to carry out further investigations whilst A was on the ward. We also found that A was unreasonably left sitting and sleeping in a chair during their admission, that A’s family were not given any additional time to visit when A was at end of life and that there was a failure by

C complained about the care and treatment provided to their late partner (A) who was admitted to hospital due to abdominal pain, severe lower back pain, weight loss and reduced appetite. A CT scan identified a left hepatic vein thrombosis (a blood clot in the vein draining the liver). A was commenced on anticoagulant (blood thinning) medication. A further CT scan showed that A had new thrombus in the portal vein (the main vein draining into the liver). Following discussion with haematology (specialists in conditions of the blood), A’s anticoagulation medication was changed. Several days later A complained of a headache and vomiting and was given pain medication. The following morning A was found to be unresponsive by nursing staff. Levetiracetam (an anticonvulsant medication) was administered and A was taken for a CT scan which showed extensive intracerebral haemorrhage (bleeding into the brain tissue). Protamine (medication that partially reverses the effects of the anticoagulation medication) was administered and advice sought from neurology (specialists in conditions of the nervous system) who said that on review of the scans, the extent of the bleeding was not survivable. A died shortly after. C complained that the board unreasonably failed to warn A of the risks of anticoagulation medication and unreasonably administered protamine and levetiracetam shortly before A's death. C complained that the board unreasonably failed to include anticoagulation medication on the death certificate and failed to communicate to A’s family that it was a cause of death. We took independent advice from a consultant in acute medicine. We found that the use and timing of both levetiracetam and protamine was reasonable. We did not uphold this part of C's complaint. However, we found that the board failed to warn A of the risks of the anticoagulation medication before commencing the treatment. We also found that the board unreasonably failed to include the anticoagulation medication o

C, a support and advocacy worker, complained that the board failed to provide reasonable nursing care and treatment to their client (A).Specifically, they had concerns that while A was a patient in hospital, there was an unreasonable lack of attention, poor attitude from nursing staff and unreasonable nursing care. C was also unhappy about the board’s complaint handling. We took independent advice on this complaint from a nursing adviser. We found that the board’s nursing documentation was a poor standard, not in line with guidance and was in breach of the Nursing and Midwifery Council: The Code requirements. We also found that board’s lack of documentation had led to the board being unable to evidence that care was carried out to a reasonable standard. Lastly, we found that the board unreasonably failed to respond accurately to the complaint. We therefore upheld these complaints.

C complained that the practice unreasonably refused to offer a face-to-face appointment to their child (A) who is immunosuppressed with asthma and had a cough for over three weeks. The practice advised that if A had shown symptoms of shortness of breath or wheezing, a face-to-face appointment would have been arranged. C did not identify these symptoms and so C was advised to double the dose of A’s inhaler and get in contact if A worsened. It was also noted that A had an appointment with paediatrics later that day. We took independent advice from a GP. We found that it was not reasonable to rely on a parent / carer to determine whether a child is wheezing or short of breath. A was immunosuppressed and at higher risk of infection. While it is acknowledged that A had a paediatrics appointment later that day, there is no record that this rationale for declining to see A was a factor in their decision making at the time. As such, we upheld C’s complaint.

C complained about the care and treatment provided to their late spouse (A) by the practice. A was provisionally diagnosed with torticollis (where the head becomes persistently turned to one side associated with painful muscle spasms) by the practice. Six months later A was admitted to hospital and diagnosed with transitional cell carcinoma (a type of bladder cancer) and a secondary tumour was growing on the spine. A died a few month's later. C complained that the practice failed to provide a reasonable standard of care and treatment in the months before A’s diagnosis and once A was discharged from hospital. We took independent advice from a GP. We found that the practice unreasonably failed to arrange face-to-face appointments, or carry out more detailed clinical examinations, history taking and assessment of red flag symptoms. There was a lack of continuity in the care A experienced and it was unreasonable that there was a delay in actioning a referral upgrade to urgent. While we accepted that there was a poor prognosis, earlier intervention might have improved the management of A’s pain. Therefore, we upheld this part of C's complaint. In relation to A's care after their hospital admission, we found that it was unreasonable that A was not reviewed by a GP until seven days after discharge and not directly examined by a clinician when they reported a new symptom. We also noted that no detailed assessment was carried out of A’s analgesic (painkiller) requirements. We found that the practice did not provide reasonable care in accordance with the relevant standards on discharge. Therefore, we upheld this part of C's complaint. We also found that while the practice completed a Significant Event Analysis, this learning could have been carried out in a more timely way. We noted that the practice's own complaint investigation did not identify the full extent of the failings in this case. While areas for learning and improvement have been recognised and acknowledged by the

C complained on behalf of their parent (A) who suffered from dementia and was admitted to hospital with multiple medical issues including a chest infection, delirium, kidney failure and poor mobility including recent falls. C raised a number of complaints, including that there were failures in the medical care provided to A with respect to falls and post falls care and seizures. C also complained of failings in nursing care relating to diet and nutrition, hygiene and cleanliness, and the general monitoring and awareness of A’s condition. Lastly, C complained regarding restrictions on visitation and poor communication. We took independent advice from a consultant specialising in the care of the elderly and a second experienced nursing adviser. We found that the medical care provided appeared to have been reasonable. We therefore did not uphold this complaint, however, we were critical of the standard of medical record keeping and we provided feedback to the board about this. We found that there were failures to complete the necessary risk assessments and care documentation including the risk assessment tool for malnutrition, monitoring fluid balance and applying appropriate wound care and a failure to identify and respond to a deterioration in A’s condition. We therefore upheld this complaint. We found that general communication with the family appeared reasonable, and that pandemic restrictions were an unfortunate reality for many patients and families. However, it appeared that there had been a failure to notify the family that A had significantly deteriorated. This resulted in the family not being present when A passed away and on this basis we upheld the complaint regarding communication.

C complained about the care and treatment provided to their parent (A). A was admitted to hospital (Hospital 1) following a period of delirium which was a result of a urinary tract infection (UTI). They were treated with antibiotics but their delirium continued. A was transferred to another hospital for a period of rehabilitation (Hospital 2). C said that a nurse refused to take a urine test when A was showing symptoms of a further UTI, on the basis that A had no temperature. C also complained about a delay in prescribing antibiotics. A’s condition deteriorated again during their admission. C asked for a doctor to be called but they were told that no doctors were available. A deteriorated further that night and required admission to Hospital 1, where they died the following day. C complained that A was denied access to a doctor. They also complained about communication and a lack of compassion from staff. A’s admission was during a time when visiting was restricted because of COVID-19 guidelines. C complained that staff should have allowed more frequent access to A when A was confused and distressed. We took independent clinical advice from a consultant geriatrician (specialist in medicine of the elderly). We found that A’s symptoms were not sufficiently clear to have merited a prescription of antibiotics sooner than they were prescribed. We noted that deterioration in older frail adults is often unpredictable and rapid, and found no failings in care and treatment provided to A. Based on the information available, we found no failings in communication, although we noted that the board had apologised to C already for certain communication failings. We found that staff were following the appropriate policies for visiting. Therefore, we did not uphold C's complaint. Related reading View Decision Report 202208175 as a PDF (24.69 KB) Updated: July 24, 2024

C’s spouse (A) presented to A&E with neck pain. A was discharged home as it was noted that they were on a waiting list for an MRI scan, following an urgent referral by their GP to orthopaedics (area involving the musculoskeletal system). A was admitted to hospital four days later and advised that they were terminally ill with bladder cancer which had spread to the spine. A later died. C complained to the board that A&E did not consult orthopaedics or arrange further testing when A presented with continuing pain despite prescribed medication. The board’s response indicated that A was appropriately assessed by the A&E doctors and as A was waiting on an MRI, the discharge letter to the GP advised to follow up with the hospital where the MRI was being organised. The board said that the GP was best placed to expedite further care with the relevant team. We took independent advice from a consultant in emergency medicine. We found that A&E carried out an appropriate assessment, including consideration of any red flags which warranted further investigation or onward referral. We found that as A had already been referred to the spinal team and had an MRI ordered it was reasonable not to investigate A further. We found that the board acted in accordance with NICE guidance in how they managed A’s care and treatment, which was reasonable. Therefore, we did not uphold the complaint. Related reading View Decision Report 202207983 as a PDF (24.49 KB) Updated: June 19, 2024

C complained about the care and treatment that their late parent (A) received whilst in hospital following a stroke. C said that the board failed to provide appropriate nutrition for A when they lost the ability to swallow. A required a percutaneous endoscopic gastrostomy (PEG) feeding tube to be fitted (a tube passed into the stomach through the abdomen to provide a means of feeding). However, there were delays with this and A died shortly after the procedure was carried out. C was concerned that other types of feeding were not considered by the board and that staff were not appropriately qualified to deliver alternative feeding. The board said as soon as it became apparent that a PEG feeding tube would be appropriate, a referral was made to have this done. A dietician identified another method of feeding called TPN (a type of nutritional fluid administered to a patient intravenously) however, ward staff were concerned that they were not trained on how to deliver this method of feeding. As such, a decision was taken to expedite the referral to have the PEG tube fitted instead. Before surgery could take place, A had to be tested for COVID-19. The results of the test were not back in time for surgery to be carried out on the day it was initially scheduled. The board apologised for the delay that this caused. We took independent clinical advice from a consultant geriatrician (specialist in medicine of the elderly). We found that the clinical decisions made in the management of A’s nutrition were reasonable. TPN feeding is not typically used in cases like this one. The standard of care was in keeping with guidance and was of reasonable quality. However, the delay in receiving the results of the COVID-19 test, and the failure to expedite this, was unreasonable. This led to the delay in treatment. On balance, we upheld C’s complaint.

C complained that surgery performed to remove material from their leg was not carried out to a reasonable standard. C broke their leg and underwent an operation to insert pins, plates, and a device known as a ‘TightRope’ (a device where string is passed through a channel in the bone and secured with ‘buttons’ at each side) to stabilise their leg. C developed an infection in their leg and subsequently underwent a further procedure to remove the ‘TightRope’. The procedure was not successful, some material was retained in C’s leg and the infection persisted. C then underwent further procedures to have the material removed completely, however, the infection proved to be too advanced and C had a below knee amputation. C complained that the board did not appropriately remove the ‘TightRope’ material during the initial procedure when they should have done. The board said that although there was an intention to remove all of the ‘TightRope’, the material is not always visible. Cutting through the ‘TightRope’ in order to pull it through, staff expected all of the material to come out. Staff assumed that they had removed all of the suture, however, some of the material had stayed behind. The only way to have fully confirmed this would have been to make a larger hole through the bone, which could have allowed further spread of the infection. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the surgeon who carried out the initial procedure to remove the ‘TightRope’ should have been familiar with the device, including the volume of material, and should therefore have been able to assess whether removal was complete. The surgeon should have curetted (cleaned/scraped) the channel in the bone to ensure that all material was removed. We noted that an experienced surgeon would likely have undertaken a more complete removal of the material and suggested that the board

C, an advocate, complained on behalf of A about treatment that they received after sustaining a knee injury. A ruptured the anterior cruciate ligament (ligament connecting the thigh bone to the shin bone) and underwent an arthroscopy of the knee (a type of keyhole surgery). This was followed up with a second surgery at a later date to complete the reconstruction of the ligament. During the surgery, the surgeon’s scalpel snapped and to remove the tip of the blade, the surgeon had to create a larger incision. C raised concerns about the actions taken following the incident. The board acknowledged the incident and explained that damage to instruments is a rare but known complication of surgery. We took independent advice from a consultant orthopaedic surgeon. We found that when the blade snapped, appropriate care was provided to A. It was appropriate to create a larger incision and the incident was appropriately communicated to A. However, we found that whilst a datix incident report was completed, a more in-depth investigation could have been carried out. There was no evidence that the board considered either the possibility of improper use of the instrument or that there was a defect in the instrument. We also considered that the board should have discussed the incident at a departmental level. In conclusion, we upheld C’s complaint about care and treatment in relation to the initial surgery. We did not uphold the complaint about the post operative care provided to A as we were satisfied it was reasonable.

C complained on behalf of their partner (A) about the care and treatment they received from the practice. A was prescribed an anti-inflammatory drug by a rheumatology consultant (specialists in diagnosing and managing chronic inflammatory conditions). The medication was issued on repeat prescription by the practice. C told us that the medication had risks and the practice failed to carry out appropriate medication reviews or update A about the risks. C said A was not aware of the risks of the medication and trusted that it was safe to use long-term. They felt it was unreasonable for the practice to assume A would have read the leaflet with the medication to identify any changes or to know to ask for a medication review. The practice said that the medication was prescribed by the rheumatology service and would have been monitored by them. The practice highlighted that at the time the medication was prescribed, it was not considered high risk, and that the risks only became known after A had been prescribed the medication for a number of years. The practice noted that A did not proactively contact the practice to review their medication periodically but acknowledged that they did not contact A either. We took independent advice from a GP. We found that national guidance states that patients should have annual checks when taking medication of this sort. The responsibility for carrying out these checks lies with whoever is issuing the prescription. When discharged from the rheumatology service, the practice should have invited A for a review and arranged appropriate follow-up. The practice should have carried out medication reviews and informed A about the change of risks associated with the medication. We found that it was unreasonable for the practice not to have carried out medication reviews or informed A about the change in risks. Therefore, we upheld C's complaint.

C complained that their late sibling (A) should have been given a telephone or face-to-face consultation with a GP following increasing contact with the practice and an escalation of symptoms relating to chest pain that resulted in A's death from acute myocardial infarction (heart attack). C also complained that the practice's handling of the resulting Significant Adverse Event Review (SAER) was unreasonable. The practice considered the care and treatment of A to be reasonable. The GP was shielding at home during the COVID-19 pandemic and could not see patients face-to-face. The practice stated it was subject to restrictions imposed by the Scottish Government at the time. The practice also said that A was appropriately triaged and their care managed by a range of healthcare professionals. We took independent clinical advice from a GP. We found that A should have been offered a telephone consultation with the GP and a face-to-face appointment with the locum GP. We found that A's care was delegated to nursing staff when GP input was required and there was a lack of review between the GP and nursing team when A's symptoms failed to resolve. We also found that the SAER failed to identify learning points, failings and reflection and did not include the health care professionals involved in A's care. Therefore, we upheld C's complaints.

C complained about the care and treatment provided to their spouse (A) by the out-of-hours (OOH) service. A had a headache, temperature and dizziness and collapsed twice. The OOH GP spoke with A and A's family and prescribed painkillers for their headache. A later started hallucinating and the OOH service sent an advanced nurse practitioner who diagnosed A with a urine infection. A was later taken to hospital where they died from organ failure a few weeks later. We took independent advice from a GP. We found that it was reasonable for the GP have carried out a telephone consultation instead of a home visit and that the telephone assessment conducted appears to have been reasonable. We also considered that it was reasonable for the OOH GP to have obtained a medical history from A and A's family and that given the symptoms described and the results of the urine test, the diagnosis of a urine infection was reasonable, as was treatment with antibiotics rather than admission to hospital. We also found it reasonable that a Significant Adverse Event Review was not considered given that there were no direct issues raised with the OOH service at the time of events. We did not uphold C's complaint but provided feedback to the board that the notes of the telephone consultation were inadequate given that reasonable record keeping is an integral part of patient care. Related reading View Decision Report 202110695 as a PDF (24.48 KB) Updated: October 18, 2023

C complained about the care and treatment provided to their late partner (A) who was admitted to hospital with hallucinations and delirium. C complained that hospital staff labelled A an alcoholic and that this negatively impacted the treatment that they received. A was treated for a suspected urinary tract infection (UTI) but died in hospital. C was critical of several aspects of the treatment A received, including concerns about their nutritional intake, the medication they were given and the staff's response to the rapid deterioration of A's condition. In their response, the board apologised that C had been given the impression that staff felt the only cause of A's delirium was alcohol excess. The board explained A's clinical presentation and the reasoning for treating them for suspected UTI and alcohol withdrawal. The board explained A's condition rapidly deteriorated in hospital and resulted in a cardiac arrest. The board's position was that the care provided was reasonable. We took independent advice from a consultant in respiratory and general medicine. We found that a reasonable working diagnosis of a possible infection was determined and the treatment plan was appropriate. We considered that the care and treatment provided was reasonable. Therefore, we did not uphold C's complaint. Related reading View Decision Report 202200345 as a PDF (24.4 KB) Updated: August 16, 2023

C complained that the board failed to provide reasonable care and treatment to their late parent (A), who died following an admission to hospital. This included issues relating to A contracting COVID-19, that the board unreasonably failed to carry out an SAER/independent review, and that the board failed to reasonably respond to the complaint. We took independent advice from a specialist in geriatrics (medical care for the elderly). We found that the board had carried out a review of A’s care and had accepted some failings, including that there had been an unnecessary transfer and a delay in cleaning. They apologised for this and had taken improvement action and organised training, which we welcomed and considered were appropriate. Whilst there were a number of aspects of care provided to A which were appropriate and reasonable, given the unnecessary transfer, the apparent delay in cleaning, and failings with regard to communication, on balance, we upheld this aspect of the complaint. We also identified complaint handling failings. Whist the complaint response was detailed and lengthy, and attempted to address all of C’s concerns, we upheld this aspect of the complaint, given the lack of detail in the complaint response regarding learning and improvement actions.

C complained on behalf of their late parent (A) who passed away from cancer. C complained that the practice had unreasonably failed to diagnose A’s cancer. A was suspected of having a chest infection and was given multiple courses of antibiotics. A also had a number of blood tests which C said that A was not always sure what the blood tests were for, nor were they told the results. We took independent advice from a GP adviser. We found that the blood tests which were carried out were done so for clinical reasons and that there was no error in the taking or analysing of the blood test results. Some of the blood tests were requested by hospital departments. The practice explained that they would not normally contact a patient if the test results were normal. A CT scan carried out by the hospital did not show any malignancy and this would have been reassuring for the GP’s treating A. We did not uphold this complaint. Related reading View Decision Report 202108773 as a PDF (24.25 KB) Updated: July 19, 2023