SPSO Individual Decisions

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 late spouse (A). A was suffering from facial pain and numbness and underwent an MRI scan. The MRI reported a benign slow growing tumour at the base of A's skull which can usually be managed with pain killers or sometimes stereotactic radiosurgery (SRS, a high dose of radiotherapy to a small area) is considered. Shortly after, A's local health board referred A to Lothian NHS Board for treatment. A attended a telephone consultation with a neurosurgery consultant (specialist in surgery on the nervous system, especially the brain and spinal cord). A was not considered to have a diagnosis of cancer given the findings of the MRI scan and was referred on a routine basis for consideration of SRS treatment. A's case was subsequently reviewed at a multidisciplinary team meeting by clinicians at Lothian NHS board. It was identified from a review of the MRI report received from A's local health board, that there were other not previously identified lesions in A's brain, which were in keeping with metastases (cancer that has spread from other areas of the body). A was referred on an urgent basis to their local health board for further investigations including an MRI scan and CT scan. A was diagnosed with cancer and died shortly after. We took independent advice from a consultant neurosurgeon. We found that the MRI report did not show any sinister findings which required urgent intervention and that the board took appropriate action. However, the review of the MRI at the subsequent multidisciplinary team meeting identified metastatic lesions. We considered that the review of the MRI took place within a reasonable timeframe. We took additional advice from a consultant radiologist (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) about the findings of the MRI performed by A's local board. We found that the report had not detected tiny abn

C complained on behalf of their spouse (A) about the care and treatment they received from the board. A was reviewed by the vascular surgery service (specialists in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels) after sustaining an injury to one of their fingers. The injury initially caused some infection which progressed to gangrene (a serious condition where a loss of blood supply causes body tissue to die). A's finger was amputated but the wound did not heal and deteriorated further, leading to the amputation of A's hand. C raised concerns about the timeliness of A's initial finger amputation and that had this been done before the infection progressed, this would have avoided the need for full amputation of A's hand. We took independent advice from a vascular surgeon. We found that the decision to admit A to hospital and treat with intravenous antibiotics was timely and appropriate. There was evidence of regular review and high quality multi-disciplinary working. We also found that the finger amputation was performed in a timely manner and that there were no published guidelines that were not followed. We considered there was no indication that performing the finger amputation earlier would have prevented the need for hand amputation. Therefore, we did not uphold C's complaint. Related reading View Decision Report 202003174 as a PDF (24.5 KB) Updated: May 24, 2023

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

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 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 that the board failed to provide appropriate care for their parent (A) when they were admitted to A&E. A had a cut on their leg which was not treated because the board said they had not been made aware of it. C said that this was not acceptable, noting that patients are not always able to make staff aware of their symptoms. We reviewed the medical records and took independent advice from a consultant in emergency and retrieval medicine. We noted that the explanations provided by the board as to why they were not aware of the wound, and did not treat it at the time, did not tally with the information in the medical records, where it was noted that A had been admitted with a cut to the knee. We progressed the complaint to investigation and asked the board to comment on the initial findings and suggested a resolution approach would be welcome. The board responded, stating they wished to move to resolution and would meet the outcomes asked for. We accepted this outcome. Related reading View Decision Report 202106164 as a PDF (24.27 KB) Updated: March 22, 2023

C complained about the care and treatment provided to their late adult child (A). A had been admitted to hospital from police custody due to cellulitis in their hand. A was monitored overnight and discharged the following day. A was readmitted several days later following a cardiac arrest. On resuscitation, a cannula (a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of samples) was found in A’s arm dated the day of their initial admission. A’s condition deteriorated and they died a few days later. C was concerned that A’s mental health issues were not taken into consideration and that it had been unreasonable to discharge A without these being assessed. C also believed it was unacceptable for A to have been discharged with a cannula in place given A’s known drug misuse. C believed that these failings led directly to A’s death as they had used the cannula to administer drugs immediately before suffering a cardiac arrest. The board had carried out an Adverse Event Review (AER) following C’s complaint. This found a number of failings in A’s care. It made recommendations to try and address these. We took independent medical advice from a consultant in emergency medicine. We found that there had been a full investigation of the case. The key learning points had been identified and actions were being taken to reduce the likelihood of a similar incident occurring in future. There was no evidence of failings which had not been addressed by the AER. We upheld C’s complaints due to the acknowledged failings in A’s care.

C complained on behalf of their client (B) about the care and treatment provided to B’s late sibling (A). A had attended the A&E in mental distress, had attended their GP the same day, and had a hospital appointment with the crisis team a few days later. At this appointment it was considered that hospital admission was not required. A completed suicide a short time later. B felt that the board had failed to provide reasonable care and treatment to A. We took independent advice from a mental health nursing adviser. We found that the board had carried out a detailed review of A’s care and had taken some action which was reasonable. However, we found that the risk assessment carried out by the board when A presented at A&E lacked transparency and rigour. The assessment carried out a few days later provided more detail, however, it lacked a structured risk assessment and the clinical reasoning behind not offering any ongoing planned follow-up and the weighing of current and historical risk indicators against protective factors was not fully transparent. The record keeping of the risk management decisions was also not sufficient to show the way in which risks factors and protective factors were balanced. We also found that it was unreasonable that the board’s administrative systems resulted in an erroneous early diagnosis of borderline personality disorder being recorded. We found that the Adverse Event Review process did not appear to attempt to establish why things occurred as they did, rather than simply establishing what occurred. Therefore, we upheld the complaint

C complained on behalf of their partner (A) about the care and treatment provided by the board when A had hip replacement surgery. Specifically, C complained about the management of A’s pain in the post-operative period. The board acknowledged the discomfort experienced by A, but when it became apparent that surgeons could not manage A’s pain effectively, the Pain Management Team was involved. The board considered the care delivered following surgery, and in reducing medication after discharge, was reasonable. We took independent advice from an anaesthetics and pain management adviser. We found that whilst pain management in the post-operative period is challenging, the board’s management of A’s pain was reasonable following surgery. We did not uphold this aspect of the complaint. Additionally, we found that, with respect to reducing A’s medication, the advice provided by the board to A following discharge was appropriate. On this basis, we did not uphold this aspect of the complaint. Related reading View Decision Report 201911968 as a PDF (24.23 KB) Updated: December 21, 2022

C complained about the care and treatment that their grandparent (A) received at the Royal Infirmary Edinburgh (RIE). A was admitted to the RIE following a fall. Following a period of recovery, A was discharged to their home. A was subsequently readmitted to the RIE a short time later and died in hospital following this second admission. C complained to the board about aspects of A’s care during their first admission to RIE, including the board’s management of A’s nutrition and hydration, the physiotherapy A received, and the planning for A’s discharge, but the board did not identify any failings. We took independent advice from a geriatrician adviser. We found that the management of A’s nutrition and hydration, the provision of physiotherapy to A, and the planning for A’s discharge was reasonable. We did not uphold C’s complaints. Related reading View Decision Report 202000048 as a PDF (24.18 KB) Updated: December 21, 2022

C attended the A&E department at the Royal Infirmary of Edinburgh having suffered a fall and was diagnosed with muscular pain. They re-attended four months later, when a diagnosis of fractured vertebrae was made. C complained to the board that there were failures to fully investigate their symptoms and arrange appropriate x-ray imaging at the initial attendance. When responding to the complaint, the board had initially concluded that a ‘red-flag’ symptom had been missed which should have prompted imaging. They upheld C’s complaint, apologised and outlined the steps that they would take to learn from this. They subsequently reviewed their position with neurosurgery colleagues and decided that C had been managed appropriately. We took advice independent advice from an emergency medicine consultant. We found that C was appropriately assessed and did not meet the criteria in the relevant guidelines for their injury to have been considered high-risk and requiring imaging. We did not uphold the complaint. We found that we weren’t critical of the board for reviewing and revising their decision. However, we were critical that they had not communicated this to C and shared recommendations.

C complained about the care and treatment provided to their parent (A) by the board. A was admitted to the hospital due to a catheter blockage. On examination, it was determined that A required specialist treatment and an ambulance transfer to another hospital within the board was arranged. It took approximately six hours for the ambulance to arrive by which time A was showing signs of sepsis (a life-threatening reaction to an infection). Antibiotics treatment was initiated on A’s arrival and they had regular washouts of their catheter and continuous irrigation due to blockages and bleeding. A had ongoing uro-sepsis and required blood transfusions. A suffered a heart attack during their admission and blood-thinning medication was prescribed. However, this made the bleeding at the catheter site increase. A died in hospital several days later. C complained to the board about A’s care and treatment but the board did not identify any failings. The board did identify and apologise for failure in communication with C. C remained unhappy and asked us to investigate. C complained that the staff in the first hospital had unreasonably delayed in treating A with antibiotics. C complained that staff in the second hospital subjected A to unnecessary pain while irrigating their catheter. C also complained that staff failed to identify that A’s catheter had been incorrectly placed. C complained about a decision to prescribe A with the anti-coagulant. C also complained about the palliative care given to A. We took independent advice from a consultant in emergency medicine and a consultant urological surgeon (specialist in the male and female urinary tract, and the male reproductive organs). We found that staff in the first hospital had unreasonably delayed in treating A with antibiotics and we upheld this aspect of C’s complaint. We found that the care and treatment given to A in the second hospital was reasonable. However, we considered that staff had failed to re

C complained about the standard of medical treatment provided to their late spouse (A) by the board following diagnosis and treatment of upper tract urothelial cancer (a type of kidney cancer). A’s condition deteriorated and they died. C complained that clinicians failed to, amongst other things, communicate with them in a reasonable way about treatment options and take reasonable action in response to A’s clinical condition. We took independent advice from a urology specialist (concerning the male and female urinary tract, and the male reproductive organs) and a renal specialist (concerning the kidneys). We found that A’s cancer had likely been more aggressive than originally suspected. However, given the information available at the time, the option of treatment offered to A had been a reasonable approach. We also found that the board had failed to adequately document that all treatment options had been discussed with A, and that a specialist renal cancer nurse should have been available to the family sooner. We found that had A’s treatment been carried out sooner (and in line with cancer waiting time standards), it may have improved their health outcomes. For these reasons, we upheld this aspect of C’s complaint. C also complained that during a hospital admission the board had failed to reasonably manage the removal of A’s nephrostomy tube (a catheter inserted through the skin and into the kidney) causing them to suffer an arterial trauma (or bleed). We found that bleeding is a recognised complication of such a procedure and there was no evidence to indicate any failings in the removal of the tube. We did not uphold this aspect of C’s complaint. C further complained that when A’s condition deteriorated following dialysis, unit staff advised the family to take A home, or to take them to the emergency department themselves. C also complained that there had been no end-of-life plan in place for A. We found that there was insufficient evidence to determine

C, an advocate for A, complained about the way A was treated by the board for their chronic psychotic illness. A experienced a relapse when administration of their medication was changed from a depot injection (a slow release method) to an oral route. A subsequently required two in-patient admissions. C complained the second admission only occurred due to a failure by the board to manage A's medication properly, and to being discharged from their first admission when they were still experiencing psychotic symptoms. We took independent clinical advice from a consultant psychiatrist on the board’s management of A's medication and the circumstances of their discharge from hospital during their first in-patient admission. In reference to the board managing A's transition back onto their medication by depot injection, we found that this had been managed appropriately, and in agreement with A. However, we noted that the documentation of this could have been better. While we did not uphold this aspect of the complaint, we gave feedback to the board in respect of record-keeping. Regarding the timing of A's discharge from hospital, we found that this had been reasonable and person-centred in approach, noting there was no reference in the medical records to A experiencing psychotic symptoms at the time of their discharge. As such, we did not uphold this aspect of the complaint. Related reading View Decision Report 202103398 as a PDF (24.38 KB) Updated: July 20, 2022

C complained about the care and treatment their late parent (A) received. A had a diagnosis of small cell lung cancer and was transferred to the Western General Hospital for urgent treatment of metastatic lung cancer. This was during the first year of the COVID-19 pandemic. Shortly after A's admission, the patient in the bay beside A was confirmed positive for COVID-19. A received a test for COVID-19 and was discharged home. A was then made aware that they had COVID-19. A's condition deteriorated and they died. C complained about the placement of A within an amber zone, rather than a green zone at the hospital. C was also concerned that A was placed in a bay beside the other patient, who subsequently tested positive for COVID-19. We sought independent advice from a consultant oncologist (a specialist in the diagnosis and treatment of cancer). We noted that the COVID-19 guidance in place at the time required NHS Boards to have COVID/Non-COVID areas and provided examples of pathways for how NHS Boards might separate patients. The guidance was not prescriptive and each NHS Board had to decide how to apply the guidance to the different hospital environments within their area. We found that the board’s internal pathways were consistent with the pathways set out in the guidance. Given that A did not meet the criteria for a low risk/green zone within the hospital, we found it was reasonable to place A in an amber zone based on the information known at the time. We therefore did not uphold this aspect of the complaint. We recognised how distressing it must have been for C to learn that their parent had contracted COVID-19 while in hospital. To assess this aspect of C's complaint we obtained the relevant clinical records for the other patient and shared these with the independent adviser. We found that the symptoms the other patient was exhibiting were not thought to be due to COVID-19 and we did not identify any failure regarding the placement of A beside this

A was admitted to A&E at the Royal Hospital for Sick Children with symptoms including retching, a purple rash on their leg and feeling agitated. A had a diagnosis of quadriplegic cerebral palsy (form of cerebral palsy in which all four limbs are affected), was non-verbal and received PEG feeding (passing a thin tube through the skin to give food, fluids and medicines directly into the stomach). A was subsequently admitted to hospital after assessment. A was observed in hospital and underwent a number of investigations. A gastrojejunal tube (when a thin, long tube is threaded into the jejunal portion of the small intestine) was inserted to address concerns about A's nutrition. A became increasingly distressed following the procedure and their condition deteriorated. A underwent emergency surgery where a caecal volvulus (obstruction of the bowel) was diagnosed. C complained to the board that they had missed several opportunities to diagnose and treat the bowel obstruction which was causing A's symptoms. The board produced a report detailing the history of A's care and decision making during the period. The main finding was that there were no identified failings in the care provided to A and that there was no misdiagnosis of A's condition. Dissatisfied with the board's response to the complaint, C brought their complaint to our office. We took independent advice from a paediatric gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas) and a paediatric radiologist (a specialist in the analysis of images of the body). We found that the investigations and treatment provided were appropriate. There was a delay in obtaining a CT scan, however the delay was relatively small in the context of the period of A's admission. As such, we found that the care and treatment provided to A was reasonable and we did not uphold the complaint. There were some aspects of care which we identified as being suitable to f

C has Asperger's Syndrome (a form of autism, in which people may find difficulty in social relationships and in communicating) / Autistic Spectrum Disorder and a diagnosis of chronic fatigue and Functional Neurological Symptom Disorder (symptoms in the body which appear to be caused by problems in the nervous system but which are not caused by a physical neurological disease or disorder). They were referred by their GP to neurology (specialists in the nervous system) to explore a possible neurological basis for their pain symptoms. C raised a number of concerns about this consultation. C complained that no meaningful assessment took place, that the conclusions were unreasonable and that the consultant neurologist wrongly stated a psychiatric opinion by stating that they had a complex personality disorder. C also noted that there were inaccuracies in the board's response to their complaint. The board responded to C's individual concerns and concluded that overall, they considered the assessment was reasonable. We reviewed the relevant medical records, evidence provided by C and took independent advice from a consultant neurologist adviser. We found that there were not any significant failings and that the assessment was of a reasonable standard, consistent with General Medical Council guidelines and that the reasons for the referral were reasonably addressed. We did not uphold the complaint. Related reading View Decision Report 202005840 as a PDF (24.45 KB) Updated: June 22, 2022

C complained about delays in treatment that was meant to be provided to their late spouse (A). They told us that A had been referred to the board from another area for heart surgery, but that this took so long to arrange, A's condition deteriorated to a point that surgery was no longer viable and they subsequently died. C was also concerned about the board's handling of their complaints about the matter. We took independent advice from a cardiology consultant (a specialist in diseases and abnormalities of the heart). We found that, while there were delays in arranging scans, these were the responsibility of the board in A's home area, so Lothian NHS Board could not be said to be responsible for this. With regards to C's concerns about complaints handling, we found that the board's approach had been reasonable, with appropriately empathetic language used throughout and regular updates provided. Given these points, we did not uphold C's complaints. Related reading View Decision Report 201907379 as a PDF (24.23 KB) Updated: May 18, 2022

C complained about the care and treatment provided to their late parent (A) when they were admitted to hospital for investigations of lung cancer. A had an out-patient appointment for a CT scan, however, the day before this appointment, A was admitted to hospital due to increased haemoptysis (coughing up of blood). There was a delay in performing the CT scan due to miscommunication between the clinical team and radiology, which the board have acknowledged. When A was taken for the scan, they suffered a massive haemoptysis and a subsequent cardiac arrest and died. C complained about the communication failures which led to a delay in arranging the CT scan and that insufficient efforts were made to resuscitate A. To investigate C's complaint, we reviewed the clinical records and sought independent advice from a consultant radiologist (a specialist in the analysis of images of the body). Our investigation found that while there were communication failures in arranging A's CT scan on an in-patient basis, we did not consider the delay caused to be unreasonable as A's condition was stable and there were no further episodes of haemoptysis. We did however, uphold the complaint on the basis that there were communication failings. We made no recommendations due to action already taken by the board. Our investigation also found that reasonable attempts were made at resuscitation when A suffered the cardiac arrest. We did not uphold this aspect of the complaint. Related reading View Decision Report 202008128 as a PDF (24.42 KB) Updated: May 18, 2022

C complained on behalf of their late partner (A) about the care and treatment they received at the Royal Infirmary of Edinburgh for heart disease. A’s condition deteriorated and they were transferred to the intensive care unit and then ultimately referred to another health board for a heart transplant. A died five days later. C said that the board did not treat the left side of A’s heart which resulted in a grave outcome for A. C also said that the board did not notice that A was deteriorating and that A should have been transferred to the other health board earlier. The board said that when A was admitted they had a blocked right coronary artery and treatment was given for this. They explained that there was no viability in the left side of A’s heart (due to damage caused by a previous heart attack) and therefore, to treat that side would have subjected A to additional risk. The board said that A was very unwell, but reasonably stable until their sudden deterioration. They said that there was no indication that an earlier referral outwith the health board was warranted or would have altered the outcome. We took independent clinical advice from a consultant cardiologist (a doctor that that deals with diseases and abnormalities of the heart). We found that it was reasonable for the board not to have a treatment plan for the left side of A’s heart as it would have exposed A to increased risk and there would have been no benefit to A (due to irreversible damage caused by a previous heart attack). The board reasonably monitored A’s condition and provided appropriate care and treatment in response to their deteriorating condition. We also found that the board’s decision to refer A to another heath board was reasonable and that there was no indication this should have been done earlier. As such, we did not uphold this complaint. We did, however, provide feedback to the board regarding their communication with A. Related reading View Decision Report 202005961 as a PDF (24.

C complained about the care and treatment their parent (A) had received from the board. A had a terminal cancer diagnosis and severe arthritis. C complained about a series of admissions A had to hospital. C said A had been discharged without C being consulted, even though they were A’s main carer. This meant A was discharged to a potentially unsafe environment, and did not receive the necessary levels of care. C said A was readmitted to hospital. A was then discharged to a care home, but was not provided with oxygen. C said that A had required oxygen in hospital and the failure to accept that A required long term oxygen support or to provide A with oxygen meant that A required a further hospital admission. C said that when A was readmitted to hospital, they received substandard care. A was put on a busy ward, that did not specialise in palliative care or geriatric medicine (medicine of the elderly) and that this type of care was only provided once C intervened. We took independent advice from a consultant geriatrician. We found that A’s discharge planning was carried out to a reasonable standard. A had capacity and the board’s actions took into account their wishes and included a reasonable assessment of A’s home environment. We found A was very ill during their final admission and that at times A was dehydrated and eating very little and that this would have been very distressing for C and other family members to have witnessed. We noted that dehydration and low food intake were a common feature of this stage of A’s illness and were not evidence of neglect on the part of staff. We found, based on the advice we received, that communication with A was of a reasonable standard and that their pain and condition was monitored and acted on appropriately. In terms of A’s discharge without oxygen support, we found that staff gave appropriate consideration how best to manage A’s low oxygen saturation levels and that on discharge A’s own preference was a factor in the decisi

C complained about various aspects of the care and treatment their late spouse (A) received from the board. A had a history of vascular (relating to a vessel or vessels, especially those which carry blood) surgery and was admitted to hospital for the removal of a benign tumour. The procedure took place, however, A’s condition deteriorated and they were moved to an infectious diseases unit with suspected sepsis (blood infection). A’s condition deteriorated further and they were transferred to a vascular and critical care ward in a different hospital on an emergency basis. Later that day, A underwent surgery to remove an infected synthetic artery graft (a piece of living tissue that is transplanted surgically). A experienced an abdominal bleed and was transferred to a critical care unit. After treatment, A was reviewed by a consultant and returned to the vascular and critical care ward. A experienced a fall on the ward. A later developed a lung infection/sepsis and died. C complained that the board failed to screen, manage or treat A’s infection. C said that A had been discharged from the critical care unit onto the ward too soon. C also complained that the board had failed to properly assess A’s fall risk or treat A properly after their fall. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a registered nurse. We found that the screening, management and treatment of A’s infection and their discharge from the critical care unit was reasonable. We did not uphold these complaints. However, we found that the board had failed to adequately complete risk assessments, including a falls risk assessment, for A. We upheld this complaint. We also considered that the board made an error of communication while responding to C’s complaint when they referred to MRSA (a bacterial infection that is resistant to a number of widely used antibiotics) instead of MSSA (a bacterial infection which is not resistant to certai

C complained to the board about surgery they received on a semi-urgent basis. C complained that the surgery had been inadequate and that they had been unable to fully consent to it due to time pressure and a lack of information. C also complained that the board’s subsequent management of their pain medication was unreasonable. In particular, C complained that they had not been informed of the potential for opiate pain relief to become habit-forming. The board responded that the surgery had been performed correctly and that a lengthy consultation had been held with C prior to surgery by the operating consultant neurosurgeon (a surgeon who specialises in surgery on the nervous system, especially the brain and spinal cord). We took independent advice from a consultant neurosurgeon. We found that the surgery had been performed to a reasonable standard and that the board’s management of C’s pain medication was also reasonable. However, we identified a lack of records illustrating any discussion with C about the potential benefits, risks or complications of surgery prior to the operation. We also identified a lack of records illustrating any discussion with C regarding the potential for opiates to become habit-forming. In the absence of such records we were unable to say whether C received appropriate information. Therefore, on balance, we upheld both complaints.