SPSO Individual Decisions

C complained about the care and treatment that their late parent (A) received from the board. A was admitted to hospital after a fall at home. A’s condition declined whilst in hospital. C complained that during A’s admission there were clinical errors, inappropriate treatment and insufficient diagnosis work. In C’s view, this contributed to and hastened A’s death. C stated that clinicians had fixated on alcohol as the primary cause of A’s condition. A post-mortem later confirmed this not to be the case and that A had Lewy Body dementia (a brain disorder that can lead to problems with thinking, movement, behaviour, and mood) or similar when they died. C also asserted that A’s two brain bleeds sustained in the fall were not adequately monitored or treated. C highlighted concerns that there was no intervention and no repeat computed tomography (CT) scan carried out to check the condition/size of the two brain bleeds. This was despite a decline in A’s neurological condition. In addition to this, C complained that the board’s communication with A’s family fell below a reasonable standard. C stated that, in their view, A’s two brain bleeds were more significant than clinicians had led the family to believe at the time of admission. They also highlighted an unwitnessed fall on the ward that was not reported to the family. We took independent advice from a neurologist adviser. We found that the treatment provided by the board was reasonable. Given A’s circumstances and presentation, we did not consider the focus on alcohol-related cognitive failure to be unreasonable or that it materially affected the treatment provided. We also found that the decision not to carry out an additional CT scan to be reasonable. However, we highlighted concerns about some of the board’s justification for not carrying out an additional CT scan. We also received a limited amount of advice from an independent nursing adviser about some additional concerns raised by C. We found tha

C complained about the care and treatment that they received from the practice prior to receiving a diagnosis of a cancerous brain tumour, for which C underwent surgery, radiotherapy and chemotherapy. C had eight consultations at the practice over the course of ten months prior to receiving a referral to the neurology department. We took independent advice from a GP. We found that there was a missed opportunity for the practice to review C in person and consider an earlier neurological referral on the basis of C’s worsening symptoms. We upheld the complaint. During the course of the investigation, the practice acknowledged these failings and took action to address them.

C complained that when they developed complications in their pregnancy, the care that they received fell below a reasonable standard. C was six weeks pregnant and considered a high-risk pregnancy due to four previous caesarean section procedures, as well as surgery to reverse a previous sterilisation. C said that they were treated with a lack of empathy and courtesy by staff during scanning. C also complained that they were refused admission despite being known to be a high-risk pregnancy and despite developing vaginal bleeding. When C was admitted they believed that their surgery was unreasonably delayed, resulting in an avoidable rupture to their fallopian tube. We took independent advice from both a registered nurse and a consultant obstetrician (the branch of medicine and surgery concerned with childbirth and midwifery). We found a number of failings on the part of the board. However, the board submitted new information, which included sections of C’s medical records which had not been provided previously. The board acknowledged that this was a failing on their part. We reviewed this information and determined that some of the original questions over the actions of the board were answered by this information. We upheld the complaint that the board failed to provide a reasonable standard of care during C's admission. In relation to C's complaint about being unreasonably refused admission, we found that C was treated reasonably and that the board demonstrated that their procedures were followed by staff. We did not uphold this aspect of the complaint.

C complained on behalf of their spouse (A) about the board not issuing a discharge plan at the point A was discharged from hospital for palliative care before A passed away. As their carer, C wanted to know how to provide care and support for A. C said that this plan was subsequently requested a number of times but not provided. C also complained that following A’s death, their GP provided a copy of the Inpatient Discharge Summary which said ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR). C said that they had not been aware a decision had been made on this and as A’s Power of Attorney, and in order to safeguard A, DNACPR should not have been discussed with A without C being present. We took independent advice from a registered consultant geriatrician (a doctor specialising in medical care for the elderly). We found that the board could not have provided C with a discharge plan as C did not attend hospital that day. We also found that A was not given clear discharge information despite this being complex and their care needs being high. There was also a failure to subsequently provide C with a copy of the discharge plan when requested, and record keeping failures during A’s discharge. We also found that the board failed to communicate with C that a DNACPR decision had been made with A. We upheld the complaint.

C complained about the care and treatment provided to their late parent (A) by the board. A was under the care of another board and investigations undertaken were suggestive of cancer in the bile drainage system, which was initially thought to be operable. A was referred to the board and admitted to hospital for a percutaneous transhepatic biliary drain (a procedure to drain bile to relieve pressure in the bile ducts caused by a blockage) and biliary biopsies. This was carried out and the three biopsies taken were sent back to the ward with A. The duty consultant and the clinical nurse specialist met with A and relayed the findings of the multi-disciplinary team discussion the previous day. The specialist radiologists felt that there was a thickening of the lining of the abdomen that may suggest the disease had spread and that the nature of the tumour was unresectable. A check tubogram (a dye test to check whether the stent had opened up) indicated that the stent inserted had not fully drained the bile ducts and a second stent was inserted, with the external component of the biliary drain removed. A was discharged shortly afterwards. At a multi-disciplinary team discussion less than two weeks later, it was highlighted that there were no biopsies currently in the pathology laboratory. Further investigation found that A’s biopsies had been disposed of. Four months on, A was made aware by the referring board that the biopsies had not reached the laboratory. A died after a short period. We took independent advice from a general and colorectal surgeon. We found that whilst A had been given sufficient information regarding their care and treatment and the need for a biopsy, the board unreasonably lost biopsy samples and failed to inform A that they had been lost. We also found that the communication between departments, wards and with another board was unreasonable. We upheld the complaint.

C complained on behalf of their parent (A) who was suffering from dementia. A had been found in a neglected state by C’s sibling. A had vomited and it appeared that A had been left unattended overnight with no personal care. A’s incontinence pad had not been changed for what appeared to have been a significant period and was soaked in urine. C believed this failure in care led to A’s resulting aspiration pneumonia (inflammation that's caused by bacteria entering the lungs and causing a severe infection) which was the cause of their death. C also had concerns about other aspects of A’s nursing care including the frequency, quality and recording of care, A's skin care and the monitoring and recording of their vital signs. Lastly, C complained that their complaint had initially been designated a “concern” rather than a formal complaint. We took independent advice from a nurse and a consultant geriatrician (a doctor specialising in medical care for the elderly). We found that there had been a failure to provide reasonable nursing care to A which had been acknowledged by the board. However, we found further issues with respect to ongoing risk assessment, skin care in relation to pressure ulcers, malnutrition screening and the implementation of person centred care planning. It was noted that there were difficulties in definitively assessing the standard of care delivered due to failures to adhere to Nursing and Midwifery Council record keeping standards. Therefore, we upheld this aspect of the complaint. Additionally, we found that unreasonable care had been provided with respect to pain relief. We upheld this aspect of the complaint. We also found that the complaint had not been handled in line with the board’s complaints handling procedure. While there were areas for improvement, on balance, communication with the family had not been unreasonable and we did not uphold this aspect of the complaint. In relation to Cs complaint around the handling of their co

C complained that the board failed to provide them with reasonable care and treatment when they were admitted to an acute medical unit, specifically that they were discharged too soon and that there was a delay in diagnosing that they had suffered a stroke. We took independent advice from an adviser that specialises in acute medicine. We found that the board incorrectly documented that a CT scan had been carried out. Given the seriousness of C’s symptoms and their outcome, it was of concern that this incorrect information was documented in C’s medical records. We found that C should have remained in hospital to be assessed in more detail before they were discharged. We found that more consideration should have been given to C’s symptoms and the possibility that they were related to a stroke. In particular, a CT scan should have been carried out earlier, which could have led to an earlier diagnosis and treatment with medication. On C’s readmission, C’s stroke was visible on a CT scan. It therefore was possible that a CT scan, on their first admission, could have shown C’s stroke. In relation to C’s nursing care, we found that we would have expected to have seen more detailed nursing notes about C before their discharge, for instance, in relation to C’s walking ability. The board apologised for the miscommunication which occurred between nursing staff in relation to C’s fitness for discharge and said that learning had been put in place for effective communication. The board said that this was communicated verbally and therefore there was no paper evidence. We considered this to be unsatisfactory and we upheld the complaint.

C complained about the care and treatment that they received in respect of their cancer. C was diagnosed with colorectal cancer which had spread to their liver and required surgery. The surgery was to be performed in two stages. C complained that the second surgery was not performed within a reasonable timescale and about poor pain relief following the second surgery. The board apologised to C for the poor communication about the arrangements for the second surgery and explained that repeating imaging was required before arranging the surgery and that they did not consider the delay to be significant. The board provided an overview of the pain relief provided and noted that any issues identified were addressed at the time. We took independent advice from a colorectal and surgical consultant. We found that communication with C about when they could reasonably expect to have their second surgery was poor and there was an unexplained delay in their case being reviewed by the multi-disciplinary team. This resulted in a delay of around one month, however we did not consider this would have caused further spread of C’s cancer. We upheld this complaint. We noted that there were some issues with the equipment used to deliver pain relief post surgery, however these were rectified and appropriate additional pain relief was provided promptly. We found the post surgical care and treatment provided to be reasonable and we did not uphold this complaint.

C complained about the care and treatment that they received from the board prior to and during the birth of their child (A). C complained that the midwives were dismissive of their pain levels during labour, failed to properly assess their condition, was wrongly sent home to allow labour to progress, and that staff denied their requests for an epidural. C also complained about the poor communication from the clinical team when they were in theatre for a caesarean section. The board said that they considered the decision to send C home was made in line with current guidelines but apologised if the reasons for the decision were not communicated at the time. The board explained that C’s request for an epidural was not actioned as labour was progressing rapidly and consideration was being given as to whether an emergency caesarean section was required. We took independent advice from a midwifery specialist. We found that the midwifery care provided to C was reasonable. We noted that the board apologised for some shortcomings in the care provided and that this was a reasonable response. Overall, we were satisfied that the decisions taken by the midwives were based on a reasonable assessment of C’s presenting condition. In respect of the medical care provided during the birth, we acknowledged that there may have been a lack of clarity around the consent process, however, overall, we did not find any significant shortcomings in the clinical care and treatment provided to C. We did not uphold C’s complaints. Related reading View Decision Report 202208600 as a PDF (24.52 KB) Updated: December 20, 2023

C complained to the board about the midwifery care and treatment that they received during and following the birth of their baby. In particular, C complained that they had been unsupported during the birth, that their birth plan had not been followed, that the umbilical cord had snapped during delivery and that no meeting had been arranged to discuss the incident despite requesting one. C also complained that there had been a failure to recognise that this had been a traumatic incident for them, and that the board’s response to the complaint had lacked empathy. The board’s response advised that C had been assisted during the birth, however they apologised that C's expectations had not been met at the time. The board also apologised that it had not been understood that C had intended to use the water pool for pain relief only, and that they did not want to give birth in the pool. In relation to the cord snapping, the board explained that this had been recognised as an emergency incident straight away, but on reflection, the emergency buzzer could have been activated sooner. In terms of communication, the board explained that the circumstances of the birth had been discussed with C by the delivery midwife during a post-natal visit to C's home. When a further meeting was requested, the board said a meeting date had initially been offered by text message which C declined. In hindsight, the board recognised it would have been better to arrange this with C by phone. It was further explained that C had been given contact details to arrange discussion with a consultant in keeping with their request, however C had not gone on to take up that offer. We took independent advice from a consultant of obstetrics and gynaecology. We found that a minimum standard of care had not been met on this occasion. We noted that key aspects of the medical notes and birth plan had not been read, as C’s preference not to birth in the pool was clearly documented but had not been known

C complained about the care and treatment provided to their late partner (A). A had a history of Chronic Obstructive Pulmonary Disease (COPD, a group of lung conditions that cause breathing difficulties). A was suffering from constipation which was treated by the district nursing team at home. When this did not resolve, A was admitted to hospital for review and treatment of their constipation. C said they asked that A be treated and discharged home as quickly as possible. A fell whilst in hospital and fractured their shoulder. A developed a chest infection and subsequently died in hospital. C believed A's condition could have been treated in the community. C felt A's vulnerability had not been recognised by nursing or clinical staff in hospital. C said that A had been designated as an adult with incapacity (AWI) and do not attempt cardiopulmonary resuscitation (DNACPR) without discussion with them as A's power of attorney (POA). C felt A's fall was avoidable had staff listened to the family's requests for 1-to-1 nursing. We took advice from a registered nurse and a consultant respiratory physician. We found that A was not provided with a reasonable standard of nursing care in the community, as more could have been done to treat their constipation at home. Therefore, we upheld this part of C's complaint. In relation to A's care while in hospital, we found both the standard of nursing and medical care to be reasonable. Therefore, we did not uphold these part's of C's complaint. In relation to communication with C as A's next of kin and POA, we found there was a lack of communication regarding A's care and in particular decisions around designating A as AWI and DNACPR. Therefore, we upheld this part of C's complaint. Finally, we found that A's death certificate should have included the fall as a secondary factor in their death. Initially it was believed that C would need to request this amendment, but the responsibility in fact lay with the board, who have been asked t

C complained about their care and treatment following a hysterectomy (a surgical procedure to remove all or a part of the uterus). C complained that they were not provided with adequate pain relief following the surgery, and that they were not fitted with an abdominal drain (a thin plastic tube which is inserted into an abnormal collection of fluid to help remove it from the body). C was discharged a few days later but disputes whether they were fit to be discharged home at this point. C was later readmitted suffering from a blood clot and an infection. C was discharged with oral antibiotics and again disputes whether they were fit to be discharged at this point. A few days later, C began to bleed heavily. An ambulance was called but the wait was likely to be significant and C was taken to hospital by their partner. C was triaged but asked to sit on a chair in a corridor, despite suffering from obvious heavy vaginal bleeding. C was reviewed by a consultant and sent up to the gynaecology ward where they were then taken for emergency surgery. We took independent advice from a consultant obstetrician (specialists in pregnancy and childbirth) and a consultant in emergency medicine. We found that C received a reasonable standard of care following their surgery and was appropriately discharged on both occasions. Therefore, we did not uphold these parts of C's complaint. In relation to C's attendance at A&E, we found that they were not triaged sufficiently quickly and the way C was asked to wait was not appropriate given their condition. C was medically assessed within an appropriate timescale within A&E and appropriately transferred. The board had accepted there were failings in C's care, but they had not set out clearly how they planned to address these issues. Therefore, we upheld this part of C's complaint. C also complained that the board failed to handle their complaint reasonably. We found that the board handled C's complaint appropriately and did not uphold this pa

C complained on behalf of their parent (A) who had been admitted to hospital with pneumonia. C complained that they found medication on the floor and in A's bedside cabinet. C complained that A's personal care needs had not been met, as they had not been washed and they had sore gums and an ulcer in their mouth. C also complained that A had red, sore skin in the groin area. The board apologised for the fallen medication and advised that they were undertaking a project to reduce medication errors. They advised that A had not wanted to shower and that both personal and oral care had been undertaken regularly. They also said that the skin in the groin area had been checked and had only become red on the day that C visited. We took independent advice from a nurse. We found that there appeared to be a design fault with the lockers, such that medication could fall out of the medication pod. We also found that A should have had a personal care plan and had not been offered sufficient personal care or oral care. We found that red skin had been noted 11 days prior to C's visit but had been recorded as healthy in the interim period. This would suggest that the skin was not properly checked. Therefore, we upheld C's complaint.

C complained about the care and treatment provided to their late spouse (A). A was diagnosed with pancreatic cancer. C was unhappy with the delays with A's treatment and said that these prevented A from receiving any treatment before their death. The board said that their intention was to treat the cancer and that A was required to meet with a consultant to assess their fitness for surgery. The board said that the delay in meeting with a consultant was to allow the health board to carry out two multidisciplinary meetings, for some of A's symptoms (such as jaundice) to improve, and for other investigations and procedures to be carried out (such as, imaging scans and the fitting of stents). The board acknowledged that there was a delay in a PET-CT scan (where a drug is injected before the scan to help clinicians identify how certain body functions are working) being carried out due to failures in the drug production. The board said that when this fails, there is no back-up facility in Scotland to provide a replacement batch. We took independent clinical advice from a consultant colorectal and general surgeon. We found that the timeframe for A's treatment could have been improved even with the allowable delays from the PET-CT scan. We considered that the investigations carried out were reasonable and the early scan and procedure to fit a stent were good points in the treatment pathway. However, the length of the pathway could have been improved and A's lengthy pathway to the offer of chemotherapy was unreasonable. The timing of the clinic appointment and PET-CT could also have been improved. Whilst we recognise some of the delays experienced could not be predicted or avoided, on balance, the timescale for A's pathway was unreasonable. Therefore, we upheld C's complaint.

C complained about the care and treatment they received from the board in relation to knee replacement surgery. C said that a surgeon failed to adequately advise them of the potential risks of a total knee replacement and therefore failed to obtain their informed consent for the operation. C also complained that the surgeon failed to adequately examine their leg either pre or post operatively. C said that they had experienced a mal-alignment of their leg as a result of the operation leading to significant pain and loss of mobility. The board was unable to identify the cause of the mal-alignment of C's leg, but did not identify any failings in their care and treatment. 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, despite some failings, the consent process in C's case was reasonable. We also found no evidence that the board's surgeon failed to adequately examine C's leg either pre or post operatively. Therefore, we did not uphold these parts of C's complaint. C also complained that the board failed to adequately investigate or respond to their complaint. We found that the board's complaint response was unreasonable and upheld this part of C's complaint.

C complained about the care and treatment their spouse (A) received from the practice. A had contacted the practice on several occasions with worsening symptoms including headaches, and problems with vision and mobility. C complained that the practice unreasonably failed to undertake tests or act on results, such as when a discrepancy was found in the power of A's legs. C considered the practice unreasonably treated A for anxiety and failed to recognise there was a serious underlying reason for A's symptoms. A was ultimately found to have a brain tumour and died within a few days of receiving this diagnosis. In responding to C's complaint, the practice provided a letter each from two of the GPs involved in A's care which explained their decision making in respect of the presenting symptoms at the time. The practice also explained they had undertaken a Significant Adverse Event Review (SAER) of A's case for learning and improvement. We took independent advice on the complaint from a GP. We found that A had initially been treated for labyrinthitis (an inner ear infection) and urinary tract infection which was reasonable and in keeping with the symptoms reported by A at the time. We also found that after A was given a new prescription for glasses, it was appropriate to trial the glasses for improvement of the symptoms of headache and light headedness on standing. In relation to A's upper leg weakness, we found that this can occur for many reasons and, in isolation, would not suggest a more serious underlying cause. Referring to the working diagnosis of anxiety, we considered that this was not unreasonable in the circumstances. However, the complaint presents a significant learning opportunity, highlighting the need for recognition that symptoms can deteriorate within a short time, and consideration that confused or difficult reporting of symptoms by the patient could in itself be an indicator of an underlying cause. We considered that the practice had provided a reason

C complained about the attitude of a doctor during an inpatient admission. C stated that the doctor had treated them in a dismissive, derogatory and unprofessional manner. C further complained that the doctor removed their diagnosis, stopped their medication and made no arrangements for them to receive support following their discharge. C told us that the actions of the doctor had resulted in them not receiving a reasonable standard of care. We found that the inpatient doctor's communication and documentation did not meet the required professional standards and impacted on the board's overall communication of C's care and treatment needs. The clinical records evidenced a dismissive and disrespectful attitude towards C. The doctor's documentation lacked a clear clinical rationale for the decisions that they made about C's diagnosis and medication. Therefore, we upheld this part of C's complaint. In relation to the standard of care C received, we found that board staff had ensured that C's care and treatment needs were met. The decision to discharge C from inpatient care was reasonable and the community-based care that was provided was appropriate to C's identified needs at the time. When it was clinically indicated, the board arranged a further inpatient admission and reviewed C's diagnosis and treatment plan. There was evidence that the doctor did not stop C's medication. Therefore, we did not uphold this part of C's complaint.

C complained about the care and treatment provided by the practice. C was diagnosed with polycystic ovary syndrome (PCOS, a condition that affects the function of the ovaries) a number of years ago and had previously had an ovarian cyst removed. Over the following years, C experienced a number of symptoms, including abdominal pain which the practice attributed to irritable bowel syndrome (IBS, a common condition that affects the digestive system). C complained that the practice did not explore a potential link to their PCOS. C attended A&E with severe pain. It was identified that C had a large ovarian cyst which required surgery. C complained that the practice's failure to diagnose the cyst exacerbated their symptoms and led to prolonged pain and discomfort. C also complained about poor postoperative care by the practice. The practice confirmed they were satisfied that their treatment of C's symptoms was appropriate in the circumstances and explained that the NHS does not offer routine surveillance scans for patients with PCOS or to patients who have a history of cysts. We took independent advice from a GP. We found that prior to C's attendance at A&E, there was no significant evidence of a cyst and in the absence of any other clinical indication it was reasonable to attribute C's symptoms to IBS. With regard to C's concern about the postoperative care provided, we noted that the practice diagnosed an incisional hernia and referred C to the Surgical Admissions Unit where an ultrasound was carried out but failed to show anything. A subsequent CT scan identified three hernias. We concluded that the GP's presumed diagnosis of a hernia was reasonable and therefore C was appropriately referred to the Surgical Admissions Unit. Overall, we were satisfied that the care and treatment provided to C was reasonable and we did not uphold C's complaints. Related reading View Decision Report 202206401 as a PDF (24.71 KB) Updated: October 18, 2023

C complained about the care and treatment their grandparent (A) received when they were admitted to hospital. A was acutely unwell with a poor prognosis and was treated in the COVID-19 ward for a number of days. A's condition improved and they were discharged home. C complained that A did not have capacity to consent to treatment and that treatment to address A's confusion made their symptoms worse. C believed that clinicians failed to clearly communicate the treatment plan for A, that it was unreasonable for clinicians to focus on end of life treatment and that staff failed to meet A's basic needs. In response to the complaint, the board explained that A was admitted with possible aspiration pneumonia and COVID-19. They said A was treated for COVID-19 and with antibiotics and that the care and treatment in this regard together with the assessment of A's capacity, was appropriate. Nursing staff gave A regular oral hygiene, but due to high flow oxygen therapy this was difficult. Appropriate assessment and treatment was undertaken with respect to A's skin. We took independent advice from a consultant geriatrician (specialist in care and treatment of the elderly) and a nurse. We found that whilst many aspects of A's care were reasonable and of a standard expected, there was a significant failure with respect to the assessment of A's delirium. We also found that there were significant failures with respect to the level of personal care provided to A. Therefore, we upheld C's complaints relating to medical and nursing care and treatment. In relation to communication with C and their family, we found that the records documented an appropriate level of communication with respect to decisions made about A's care. Therefore, we did not uphold this part of C's complaint. C complained that the board failed to handle their complaint reasonably. We found that there was discrepancies and apparent inaccurate information contained in the board's response. Therefore it was reasonabl

C complained on behalf of their sibling (A) about the care and treatment that they received during a hospital admission. A had a cannula (a thin tube inserted into a vein or body cavity to administer medication, drain off fluid, or insert a surgical instrument) fitted which then became infected and caused them to develop sepsis (an infection of the blood stream). C complained that A had requested the cannula be removed sooner and that this was declined. C also complained that A had advised staff that they felt unwell and that this was not taken seriously, and also that their medication had not been properly managed. We took independent advice from a consultant in acute internal medicine. We found evidence in the medical records that A declined to have the cannula removed. There is no other documentary evidence from the time about A either refusing, or requesting, to have the cannula removed. We found that the care and treatment provided was reasonable. We also found that A's medication had been properly managed and that they did not note any failings in the communication with A and their family. We did not uphold this complaint. Related reading View Decision Report 202106489 as a PDF (24.35 KB) Updated: June 21, 2023

C complained about the care and treatment provided to their partner (A). A had been suffering from an extended period of constipation which the District Nursing Team had attempted to treat at home. A's GP referred them to hospital for further treatment. A died following a fall in hospital. C raised a number of concerns about the GP's assessment of A's condition and the decision to refer them to hospital. C said that the GP should have visited A at home, should have considered alternative treatments at home, and that the GP made assumptions about A's wishes and condition. C believed that there were no grounds for admitting A to hospital and that the GP's actions led directly to A's death. We took independent advice from a general practitioner adviser. We found that the care and treatment provided to A was of a reasonable standard. It was not a requirement for the GP to visit A at home prior to referring them for admission. The admission had been discussed with C, and the decision to refer A for hospital admission was a reasonable clinical judgement for the GP to make in the circumstances. The GP's referral had acknowledged C and A's wishes for resuscitation to be attempted and the advice did not consider that there was an unreasonable focus on this in the admission. We found that the care and treatment provided to A was reasonable and that the practice had acted appropriately when considering and responding to C's concerns. We did not uphold C's complaints. Related reading View Decision Report 202104070 as a PDF (24.5 KB) Updated: June 21, 2023

C complained about the care and treatment that their child (A) received from the board. A had an autistic spectrum disorder (ASD) diagnosis and a history of treatment through the board's Child and Adolescent Mental Health Service (CAMHS). A was placed on an urgent waiting list for further assessment and treatment. A was assessed and was assigned medication and individual therapeutic work. Following a number of appointments, A was discharged from the individual appointments, was seeking support in the community and was supported with accommodation. C reported concerns about A's behaviour, including an incident where they set a mattress on fire. A subsequently attended another appointment thereafter. C complained that professionals failed to respond adequately to an escalation in A's behaviour which should have prompted an urgent appointment. C also complained that a later appointment did not result in a reassessment of A and the support that they required. In response to the complaint, the board said that there was no evidence of any new psychiatric symptoms that required urgent assessment, and that the later appointment was appropriate with a plan for A agreed at the time. We took independent advice from a mental health services specialist. We found that appropriate assessments were completed following C's reports of concerns about A's behaviour. We found that the decision not to carry out an urgent psychological review was reasonable and that the records showed a thorough and detailed assessment was carried out at the later appointment. We found that the conclusions reached were reasonable. As such, we did not uphold the complaints. Related reading View Decision Report 202104211 as a PDF (24.65 KB) Updated: June 21, 2023

C raised complaints about the nursing and medical care their parent (A) received whilst in hospital. English was not A's first language and C also raised complaints about the board's communication with A and their family and whether appropriate follow-up care was provided by the board following C's discharge. The board had accepted that A's nursing care fell below a reasonable standard in several areas, including the standard of record-keeping, the failure to discuss A's personal care with their family, and the assumptions that were subsequently made about A's preferences in relation to this. The board provided us with the nursing action plan they had developed following C's complaint. We took independent advice from a clinical nurse lead and a consultant geriatrician (specialist in medicine of the elderly). We found that the board's actions and action plan had been reasonable overall but there were some areas where the action plan could be improved. We upheld this part of C's complaint. Similarly, the board accepted that the standard of communication with A and their family fell below a reasonable standard and had apologised for this. We found that the board's verbal and written communication could have been significantly improved, including their record-keeping. While the majority of issues were addressed by the action plan, there were some specific issues where staff could receive further feedback. We upheld this part of C's complaint. C had been specifically concerned about modifications to A's medication and monitoring and treatment of A's feet. We found that the board's actions in relation to these had been reasonable and that A's medical care had been, overall, reasonable. We did not uphold this part of C's complaint. Finally, the board had acknowledged their management of A's discharge and the communications associated with it, fell below a reasonable standard and had taken action with the aim of preventing any recurrence of this. We found that the actions p

C complained about the care and treatment provided to their late parent (A). A felt unwell whilst residing in a care home. They were coughing up blood associated with green phlegm and had chest and abdominal pain. Staff at the care home contacted NHS 24 and were advised that a home visit would be conducted. However, the GP subsequently carried out a telephone consultation due to concerns around the transmission of COVID-19. They diagnosed A with a chest infection. A second GP visited 48 hours later and suspected A had pulmonary embolism (a blocked blood vessel in the lungs) and deep vein thrombosis (a blood clot in a vein). A was admitted to hospital where this was confirmed. A died a few months later and C said that pulmonary embolism was described as a contributing factor on their death certificate. C was concerned that the GP did not conduct a home visit and subsequently failed to correctly diagnose A's condition and instead focused on the transmission of COVID-19 and associated risks. C believes that if a home visit had been conducted, A would have been correctly diagnosed 48 hours earlier and could have received treatment. The board responded and identified some issues in the medical history and documentation taken. C remained dissatisfied with the board's response and brought their complaint to us. We took independent advice from a GP. We found that it was reasonable that no home visit was offered in the context of COVID-19. However, the medical history and particularly the documentation taken by the GP was unreasonable. In particular, there was no documentation to support the consideration of respiratory rate/breathlessness, leg pain/swelling and pulmonary embolism. In view of these failings, we upheld C's complaint that the board failed to provide A with reasonable care and treatment. The board had already apologised for the failings and had highlighted them to relevant staff as a learning point. However, we  provided some further feedback to the board. Rela

C complained about the care and treatment provided to their child (A). A developed facial weakness, which was initially diagnosed and treated as Bell's Palsy (temporary weakness or lack of movement affecting one side of the face). A's condition did not improve and MRI scans revealed a mass. It was considered this was likely a vestibular schwannoma (a rare, non-cancerous tumour) and follow-up in three months was arranged. A later attended hospital with bleeding from the ear. C suspected this was related to the tumour but doctors treated A for an ear infection. A developed further ear symptoms and attended hospital again. Further scans showed significant tumour growth, requiring surgical debulking (removing as much of the tumour as possible). A's diagnosis was revised as para-meningeal rhabdomyosarcoma (a rare and aggressive form of cancer). A was treated with chemotherapy but they continued to deteriorate and died within a few months of this diagnosis. C complained that the board's decision not to remove A's tumour when it was first detected was unreasonable. We took independent advice from four advisers: a paediatric neurologist (specialist in the diagnosis and treatment of disorders of the nervous system), a paediatric emergency medicine consultant, a paediatric neurosurgeon (specialist in surgery on the nervous system, especially the brain and spinal cord) and a paediatric oncologist (specialist in the diagnosis and treatment of cancer). We found that there was inadequate documentation of the risks or benefits to A of performing a biopsy or resection of the tumour when it was initially detected. However, we considered that surgically it would not have been possible to carry out a full resection and that the risks of trying to obtain a biopsy in the specific circumstances were too high. We concluded that the decision not to remove the tumour when it was first detected was reasonable. Therefore, we did not uphold this part of C's complaint. C also complained that th