SPSO Individual Decisions

Miss C had been experiencing poor health over a number of months and made a suicide attempt by medication overdose. She contacted NHS 24 and was taken to University Hospital Ayr. Miss C's symptoms included slurred speech and problems with walking. Miss C was assessed by nursing, medical and psychiatric staff and was later discharged. The following day, she attended with the same symptoms and was again discharged home. The next day, Miss C's GP arranged for her to attend University Hospital Crosshouse. A scan confirmed Miss C had a brain tumour, which was subsequently operated on. Miss C complained that, despite her presenting symptoms, she was not properly assessed or treated when she attended at University Hospital Ayr. We took independent advice from a specialist in emergency medicine. We found that at the initial admission, the focus of attention had been on the immediate presenting problems of Miss C's mental health and the effects of the overdose and that the assessment and treatment provided that day were appropriate and reasonable. The adviser said that in normal circumstances, the symptoms Miss C presented with on her second attendance at the hospital should have resulted in further investigation. In this case, however, the adviser noted that the doctors involved had felt it was likely that Miss C's presenting symptoms were related to the overdose the previous day and that it was reasonable that they reached this conclusion. Therefore, we concluded that the assessment was reasonable. We also reviewed Miss C's records and were satisfied that the treatment she received was appropriate. Therefore we did not uphold Miss C's complaint. Related reading View Decision Report 201601919 as a PDF (11.41 KB) Updated: March 13, 2018

Mr and Mrs C complained to us about the treatment they received at an out-of-hours centre where they took their baby on the advice of NHS 24 as he was not feeding well and was blue around his lips. There was a wait to see a GP and the baby went pale and struggled to breathe. The baby was seen urgently by a GP who examined him through his clothing and told Mr and Mrs C to take the baby to the A&E department at Crosshouse Hospital in their car. On arrival at the hospital, the baby stopped breathing and had to be resuscitated. The baby remained in hospital for three days. Mr and Mrs C felt that the GP should have given their baby oxygen and arranged for an ambulance transfer to hospital. We took independent advice from an adviser in general practice medicine and concluded that the GP had carried out an inadequate examination of the baby as they did not remove the baby's clothing. In addition, we noted that the GP had maintained that they did not administer oxygen to the baby as it would have delayed the referral to hospital. We found that as oxygen was available at the out-of-hours centre, the GP should have administered it to the baby. We also found that it was inappropriate to have asked Mr and Mrs C to have transported their baby to hospital without clinical support. We upheld the complaint.

Ms C complained about the care and treatment her late father (Mr A) received from the board's out-of-hours service shortly before his death. Mr A had been diagnosed with bladder cancer and was receiving palliative care. On the day Mr A died he was in severe pain in the early hours of the morning and Ms C's mother (Mrs A) contacted NHS 24. Mr A was seen by a doctor from the out-of-hours service and was given morphine for the pain. He remained in pain and another out-of-hours doctor was asked to attend but they felt they would not be able to attend before their shift ended, so asked that Mr A's GP attend instead. Mr A was told the GP would attend at 08:00 however the GP was not contacted until 08:05 and did not attend until 08:45. Mr A died in the early afternoon. Ms C complained that the actions of the out-of-hours doctors prolonged Mr A's severe pain during the final hours of his life. We took independent advice on Ms C's complaint from a GP adviser. We found that the first out-of-hours doctor attended in good time but provided a dosage of morphine that was too low to improve Mr A's pain and did not take into account the medication he had already been taking which had little effect. We found there was a similar failure to look into Mr A's recent history by the second out-of-hours doctor as there was no evidence of this second doctor speaking to either Mr or Mrs A to assess Mr A's condition at that time nor of them making their decision with reference to the earlier out-of-hours attendance. We were critical that the decision to refer Mr A to his GP practice was taken without taking into account his needs. The second call to the out-of-hours doctor was given a one hour priority, but passing the call on to Mr A's GP practice (which had not yet opened at the time of the call being passed on) meant it was not possible for the one hour timescale to be met. We noted that the board's out-of-hours policy recognised situations like this and provided scope for the

Miss C complained to her mother (Mrs A)'s medical practice about how they dealt with Mrs A in the last two days of her life. Miss C then complained to us that a GP failed to diagnose and treat Mrs A's condition; that reception staff wrongly referred her mother to NHS 24 rather than arranging for a house call from a GP; and about the practice's handling of her complaint. We looked at the practice's file on Miss C's complaint and at Mrs A's medical records, and we took independent advice from one of our GP advisers. We found that Mrs A had a number of risk factors for a heart condition, and we decided that the GP should have taken these into account by reviewing Mrs A's blood pressure and pulse, given the possibility of a heart-related cause for her symptoms. We concluded that the assessment and treatment provided by the GP was not of a reasonable standard. We also concluded, on the balance of the available evidence, that reception staff were wrong to refer Mrs A to NHS 24, rather than offering an emergency appointment at the practice or a home visit from the on-call GP. We also found that the practice's handling of Miss C's complaint was not in keeping with the principles set out in the national NHS complaints handling guidance. We upheld Miss C's complaints.

Mrs C complained that the board had delayed in arranging an appointment for her to have a tooth extracted. She had seen a dentist from the board about the tooth and the dentist considered that the tooth needed to be taken out. Mrs C wanted to know if there was any way that the tooth could be saved and the dentist referred her to a consultant in restorative dentistry to discuss this. The consultant examined the tooth and then wrote to the dentist to say that the tooth should be taken out as soon as possible. After receiving the letter, the dentist contacted Mrs C to say that the tooth would be extracted at her next arranged appointment, a few weeks later. Mrs C considered that the tooth should have been extracted without delay. She contacted NHS 24 for advice over the following weekend and an emergency hospital appointment was arranged for her to have the tooth extracted. We took independent advice on the complaint from a dental adviser. We found that it had been reasonable for the dentist to decide to wait until Mrs C's next appointment to extract the tooth. There was no evidence in the records to suggest that Mrs C was in such pain that an emergency appointment was required. We did not uphold this aspect of her complaint. Mrs C also complained that the board had failed to phone her back when she contacted them for advice after the tooth had been taken out. There was no evidence that staff did call Mrs C back about this and we upheld this aspect of her complaint. We also upheld Mrs C's complaint about how the board had handled her complaint. However, we were satisfied that the board had apologised and learned lessons from these failings, and we did not make any recommendations. Related reading View Decision Report 201406408 as a PDF (11.36 KB) Updated: March 13, 2018

Ms C complained on behalf of her mother (Mrs A), who lived in a nursing home. Ms C complained about a home visit by an out-of-hours GP, and that they were unwilling to provide a second home visit to give a second opinion on the GP's assessment. Ms C was concerned that her mother had a chest and urine infection, and requested a GP home visit, via NHS 24. A GP assessed Mrs A and found no signs of infection. The following evening Ms C again requested a GP home visit, and another GP visited Mrs A at the nursing home. Following a full assessment and discussion with the nursing home staff and with Ms C, the GP confirmed that there were no signs of infection and no need for treatment. Later that evening Ms C phoned NHS 24 again, and requested a second opinion of her mother, as she had concerns that her mother was distressed. NHS 24 referred Ms C on to the out-of-hours service, where a GP explained that they would not be able to provide a second opinion as the GP had made a full assessment earlier that evening. We took independent advice from one of our GP advisers who said that the second home visit (the focus of Ms C’s complaint) was thorough and reasonable. Our adviser said that the observations indicated that there was no sign of infection, and the GP's conclusions that there was no need for treatment or hospital admission were appropriate. Our adviser also confirmed that it was not the role of the out-of-hours service to provide a second opinion. On this basis, we did not uphold the complaint. Related reading View Decision Report 201403967 as a PDF (11.28 KB) Updated: March 13, 2018

Mrs C attended A&E at Monklands Hospital in the early hours of the morning with her daughter (Miss A), who was given a liquid steroid to treat croup (an infection of the voice box and windpipe) before being discharged. Later that same day, and after speaking with NHS 24, Mrs C returned to A&E because she felt that Miss A's condition had not improved. Mrs C said she was advised that an out-of-hours (OOH) appointment had been booked for her daughter that evening but that she did not know about it. A nurse examined Miss A, and after a discussion with the duty consultant, advised Mrs C that she could take her daughter home. The following day, Mrs C visited her doctor for an unrelated issue and whilst there, the doctor examined Miss A and confirmed there was a slight wheeze so prescribed steroids. Because of this, Mrs C complained that the care and treatment provided to her daughter in A&E was unreasonable. The board told Mrs C that because Miss A was well and had a normal set of observations, the duty consultant felt it would be best if she was allowed to attend her booked OOH appointment. They said this was because it was unlikely that she would be seen by an A&E doctor earlier than the time of the scheduled appointment later that evening. However, when we examined the evidence, we identified that the scheduled appointment had already been cancelled because Miss A was seen in A&E. When we asked the board about this, they told us that the appointment with the OOH service would have been cancelled when Mrs C arrived at reception in the A&E department. The board said the receptionists for both services sat side by side and would have liaised with each other about this. We took independent advice from one of our medical advisers, but he said he was unable to say whether the care and treatment provided to Miss A by the A&E department was reasonable, given that the duty consultant made an incorrect assumption that her OOH appointment was still booked for later in the evening

Ms C was the carer for her late employer (Ms A). When Ms A became unwell late at night with nausea, diarrhoea and abdominal (stomach) pains, Ms C requested an ambulance. She was referred to NHS 24 and a nurse called back and arranged for an out-of-hours (OOH) GP visit. About an hour and a half later, Ms C called NHS 24 again as Ms A's pain was worsening, at which point the OOH doctors arrived. They examined Ms A, provided medication and advised Ms C and Ms A to call back should Ms A's condition worsen. When Ms C's colleague took over caring for Ms A in the morning, she contacted NHS 24 and was told to call Ms A's medical practice. Ms A's GP visited, after which Ms A was admitted to hospital, where she later died. Ms C complained about the care and treatment that Ms A received from both the OOH GP service and NHS 24. Ms C was of the view that if Ms A had been taken to hospital sooner, the outcome might have been better. She also thought that the OOH doctors provided inadequate pain relief, and was unhappy that she had to contact NHS 24 again (rather than being able to contact the doctor directly). Our role was to consider whether – on the basis of the available evidence - the care provided to Ms A was reasonable. We took independent advice on the case from one of our medical advisers, who is a GP. The adviser reviewed the evidence, and explained that NHS 24 had not acted unreasonably in arranging for the OOH GPs to attend. He said that the records showed that the doctors examined Ms A and appeared to have discussed a possible hospital admission with her. The adviser was also satisfied that the OOH doctor gave appropriate advice by advising Ms A to call back should her condition worsen. His overall view was that the care provided was of a reasonable standard. Although we recognised how difficult and distressing this had been for Ms C, in the light of the advice we received we did not uphold her complaints. Related reading View Decision Report 201304590 a

Ms C was the carer for her late employer (Ms A). When Ms A became unwell late at night with nausea, diarrhoea and abdominal (stomach) pains, Ms C requested an ambulance. She was referred to NHS 24 and a nurse called back and arranged for an out-of-hours (OOH) GP visit. About an hour and a half later, Ms C called NHS 24 again as Ms A's pain was worsening, at which point the OOH doctors arrived. They examined Ms A, provided medication and advised Ms C and Ms A to call back should Ms A's condition worsen. When Ms C's colleague took over caring for Ms A in the morning, she contacted NHS 24 and was told to call Ms A's medical practice. Ms A's GP visited, after which Ms A was admitted to hospital, where she later died. Ms C complained about the care and treatment that Ms A received from both the OOH GP service and NHS 24. Ms C was of the view that if Ms A had been taken to hospital sooner, the outcome might have been better. She also thought that the OOH doctors provided inadequate pain relief, and was unhappy that she had to contact NHS 24 again (rather than being able to contact the doctor directly). Our role was to consider whether – on the basis of the available evidence - the care provided to Ms A was reasonable. We took independent advice on the case from one of our medical advisers, who is a GP. The adviser reviewed the evidence, and explained that NHS 24 had not acted unreasonably in arranging for the OOH doctors to attend. He said that the records showed that the doctors examined Ms A and appeared to have discussed a possible hospital admission with her. The adviser was also satisfied that the OOH doctor gave appropriate advice by advising Ms A to call back should her condition worsen. His overall view was that the care provided was of a reasonable standard. Although we recognised how difficult and distressing this had been for Ms C, in the light of the advice we received we did not uphold her complaints. Related reading View Decision Report 2013040

Mrs C cared for her late husband (Mr C) at home with assistance from carers, district nurses, Mr C's GP and the board's palliative care (care provided solely to prevent or relieve suffering) team when necessary. On the day Mr C died, Mrs C had phoned the board's palliative care line as her husband was in severe pain. An out-of-hours (OOH) GP arrived within 47 minutes of her call to provide pain relief to Mr C, who died around an hour later. Mrs C complained about the length of time it took for the OOH GP to attend and administer the pain relief. The palliative care line is part of the board's OOH service and it helps palliative care patients to get help without having to go through NHS 24. It is not an emergency service but the board aims to respond to priority calls within one hour. Mr C was visited within 47 minutes of Mrs C's phone call and, even although Mr C was in a lot of pain, we concluded that this was within a reasonable timescale. We noted that when a palliative care patient is nearing the end of their life, an anticipatory pack of medication is often provided to help with distressing symptoms, such as pain, nausea, agitation and breathlessness. This is, however, a decision for the primary care team involved in the patient's care, not the OOH service. Although we did not uphold the complaint, we made recommendations to address our concerns about this.

Mr C was unhappy with the care and treatment he received when he attended A&E at Aberdeen Royal Infirmary. He said that NHS 24 had told him to attend a primary care service next to A&E, and an appointment had been made for him to be seen just under two hours later. He cancelled this, however, and instead called an ambulance to take him to A&E. He said the care and treatment he received was unreasonable, that a senior charge nurse had assessed him as only being 'in some discomfort' and he was escorted from A&E to the primary care department. We obtained Mr C's medical records and after taking independent advice from one of our medical advisers, who is a hospital doctor, we did not uphold the complaint. We found that staff had accurately assessed Mr C's pain and discomfort, had correctly followed their triage policy (triage is the process of deciding which patients should be treated first, based on how sick or seriously injured they are) and referred him appropriately to the primary care department. Related reading View Decision Report 201304311 as a PDF (11.11 KB) Updated: March 13, 2018

Mr C, who is a doctor, complained on behalf of his friend (Mr A). Mr A had phoned Mr C because he had pain in his chest and arm. Mr C was concerned that his friend was having a heart attack, so he phoned for an ambulance. The crew assessed Mr A, including carrying out an electrocardiograph (ECG - a test that records the electrical activity of the heart). They found no indicators of a heart attack, and Mr A decided not to go to hospital. When Mr C heard this, he was very concerned and phoned for another ambulance. At this point his call was transferred to NHS 24, who went on to speak to Mr A before sending another ambulance. Mr A was taken to hospital and was found to have had a heart attack. Mr C then complained that the first crew did not assess Mr A properly and take him to hospital. The Scottish Ambulance Service said that Mr A had not been taken to hospital in the first ambulance at his own request. However, they also noted that the crew did not make sufficiently thorough records of the tests they carried out and their visit. We sought independent advice from a paramedic, who said that the first call was taken and prioritised appropriately, and that the service appropriately sent an emergency ambulance. He also considered that, given the finding of the tests when they assessed Mr A, it was reasonable for the crew's assessment to override Mr C's phone assessment. Mr C's second phone call was also appropriately handled, given the evidence available. We did not uphold the complaint, as although we found that the first crew were not told that a doctor had assessed Mr A by phone, and did not keep sufficient records of their interaction with Mr A, we were satisfied that they appropriately assessed his condition. We also noted that the service had reminded ambulance crews that they should make sure they evidence all of their clinical actions, particularly where a patient is not being taken to hospital. Related reading View Decision Report 201303126 as a PD

Mr C complained about the board's treatment of his wife (Mrs C) when she was admitted to the Royal Infirmary of Edinburgh. Mrs C, who had a history of severe renal (kidney) failure, had hip replacement surgery and was kept in for five days. During that time she experienced constipation and although she asked staff for laxatives, these were not provided before she was discharged home. Mrs C continued to suffer from constipation there. She developed a sore, swollen stomach and began vomiting black liquid. Concerned about her condition, Mr C phoned NHS 24 and requested a home visit from an out-of-hours GP. The GP examined Mrs C and prescribed two enemas and laxatives. He advised Mr C to monitor her overnight and to call Mrs C's own GP in the morning if she did not improve. As she did not improve, Mr C called the GP, who examined her and immediately referred her to hospital, where she was diagnosed with a perforated bowel and had emergency surgery. Mr C complained that this could have been avoided had his wife been given laxatives in the hospital and had the out-of-hours GP recognised the seriousness of her condition. We upheld the complaint about Mrs C's hospital treatment, as we found that that staff clearly failed to provide her with laxatives during her admission, despite her requests. We accepted independent medical advice that patients with renal failure are particularly sensitive to medications and their side effects, noting that Mrs C was on pain medication containing codeine, which is known to cause constipation. Staff should have been aware of the increased risk of constipation and should have closely monitored her for this. Although tools were available to prompt them to ask patients about their bowel movements, staff did not use these and Mrs C was discharged without a proper assessment of her bowel activity. We did not, however, uphold the complaint about the out-of-hour GP's examination of Mrs C, as we found that medical records showed that he

Mr C's wife (Mrs C) had hip replacement surgery. She recovered well, but suffered constipation afterwards because of the painkilling medication she was prescribed. After having had no significant bowel movements for more than a week, Mrs C began vomiting and had a painful, hard stomach. Mr C phoned NHS 24 and asked for a home visit from a GP. Mrs C's case was prioritised as serious and urgent and Mr C was told that a district nurse would come within two hours. When the nurse did not arrive, Mr C called NHS 24 again. They investigated and learned that the district nurse would not visit new patients with constipation. Instead it had been arranged for a GP to call Mrs C for a further phone assessment. Mr C was not happy with this, and was then told that NHS 24 would request an out-of-hours GP to visit within two hours. The out-of-hours GP was, however, required for another more serious call, and arrived about six hours after Mr C's initial call to NHS 24. He gave Mrs C two enemas and a prescription for laxatives. Mr C was advised to monitor his wife overnight and contact her own GP in the morning if she did not improve. As Mrs C did not improve, her own GP visited and immediately referred her to hospital, where she was diagnosed with a perforated bowel that needed emergency surgery. Mr C complained that NHS 24 did not prioritise Mrs C's case appropriately and that she could have been admitted to hospital more quickly had the out-of-hours GP attended sooner. After taking independent advice on this case from one of our medical advisers, who is a GP, we upheld Mr C's complaint. We found that Mrs C's case was treated seriously and given the highest priority, but that NHS 24 should have requested a GP visit rather than a district nurse visit at the start. We were critical of NHS 24 for not gathering relevant information about Mrs C's bowel habits and pre-existing kidney failure, which would have helped staff decide the action to take. We concluded that, althou

Ms C, who is an advocacy worker, complained on behalf of her client, Mrs A. Mrs A went to her dentist with toothache. She was examined, but decided not to have treatment because of the complexity of the problems. Early the next month, the dentist referred Mrs A to the dental hospital. They referred her there again about two weeks later for an emergency appointment, and made a further referral some four days after that. The assessment consultation for this last referral was not until two months after the date of referral. Mrs A said that despite then going to the dental hospital a number of times, she did not receive appropriate treatment until some eight months after she first went to her dentist with toothache. Throughout this period, she made a number of calls to NHS 24 because she was in considerable pain. Mrs A complained about the delay in treatment, and said her dentist provided all relevant information to allow treatment to proceed at the time of the third referral. She said that the delay was particularly unreasonable because she was pregnant and in pain. We took independent advice on this case from one of our dental advisers. They said that while the board failed to meet the national 18-week target in relation to the third referral, they did tell Mrs A of the likely delays, and provided advice about what she could do to be treated more quickly. The adviser also said that Mrs A's pregnancy did not necessarily mean that she was a priority patient, and that it was the responsibility of her dentist to manage her pain while waiting for treatment. In light of the board's failure to meet the target, we upheld the complaint but we did not make any recommendations as the board have introduced a new system for appointments, with the aim of ensuring that target times are met in future. Related reading View Decision Report 201302916 as a PDF (11.48 KB) Updated: March 13, 2018

Mrs C went to her medical practice because she had been having headaches for a few months. She was given migraine medication to try, and an appointment was made for her to come back a week later. Mrs C did not go to the appointment but had called NHS 24, where the on-call doctor thought she might have acute sinusitis (inflammation causing facial pain). Later that month, Mrs C went back to the practice with her sister. She said the medication had not worked. She also had other problems, including being increasingly unable to socialise or attend to her personal hygiene. She was treated for sinusitis, but her symptoms became even worse, and she went back to the practice at the end of the month. She described increasing withdrawal, problems with her eyesight and that she had been off work for a number of weeks. The day after this appointment, NHS 24 were called again, and Mrs C was immediately admitted to hospital for a scan. She was diagnosed with a brain tumour and had an operation to remove it. Mrs C complained that the GP at the practice failed to pick up on her serious illness and refer her to hospital. She said that as a consequence her life had been put at risk. We obtained all the complaints correspondence and Mrs C's relevant clinical records and took independent advice from one of our medical advisers, who is a GP. Our investigation found that the GP missed a number of classic features associated with brain tumours. The adviser said that on her second visit to the practice Mrs C was demonstrating enough of these to merit urgent referral. He said that although some of the changes could be interpreted as being associated with depression, in his opinion that would be a secondary consideration in a patient with persistent headache and such a significant change in personality. The symptoms should have alerted the GP to a possible serious diagnosis and she should have made a comprehensive assessment including a detailed clinical examination, then refer

Mr C said that he had suffered from repeated bouts of sinusitis (inflammation of the lining of the sinuses, causing facial pain) since he was a teenager. He said that he had tried a variety of different treatments, but the only one that had consistently worked for him was a short course of antibiotics. Mr C complained that when he contacted his medical practice suffering from sinusitis, he was not initially given an appointment but told to contact his pharmacist. He then called NHS 24 and was referred back to the practice, where he was given an appointment that day. Mr C was unhappy that when he went there he was seen by the practice nurse, rather than a doctor. The nurse did not accept that Mr C needed antibiotics, and refused to prescribe them. Mr C said that he was forced to return to his previous medical practice to get them. He said that the practice nurse refused to allow him to see a doctor and inaccurately recorded his symptoms to support her diagnosis. We took independent advice on this complaint from one of our medical advisers, a specialist in general practice medicine. He said that Mr C had symptoms that corresponded with acute sinusitis, but that current guidance was not to prescribe antibiotics for this condition, as research suggested they were ineffective. He also said that it was standard practice in busy surgeries for patients to be seen initially by a practice nurse. He found no evidence of the notes being altered, or of Mr C having asked to see a doctor. Having taken this advice into account, we did not uphold Mr C's complaint. Related reading View Decision Report 201301507 as a PDF (11.37 KB) Updated: March 13, 2018

Ms C, who is an advice worker, complained to us on behalf of Ms B about the care and treatment of her late father (Mr A) during an out-of-hours GP visit. This visit came shortly after Mr A had been diagnosed with lung cancer. Ms B said that her father had become increasingly short of breath and was looking very unwell. The family called NHS 24 and requested a home visit. Mr A spoke to a nurse on the phone, and was assessed as needing a home visit within an hour. Ms B asked that the GP not mention the new cancer diagnosis to her father, as he was not fully aware of it. About half an hour after the call, a GP arrived. She assessed Mr A's condition, and listened to his chest. She noted his vital signs, and as not all her equipment was working fully, she judged his temperature by touch and found that he did not have a fever. Following discussion with the family, Mr A was not transferred to hospital, but was given medication for his cough and to reduce pain. Shortly after the GP left, Mr A collapsed and had to be resuscitated by his family until an ambulance came. He was taken to hospital, where he died the following afternoon. We took independent advice from one of our medical advisers, who based their findings on the notes made by the GP at the time. We noted, however, that the accounts given by the GP and Ms B in relation to what happened during the visit were somewhat different. Our adviser said that during the consultation the GP took appropriate action in relation to her assessment of Mr A's condition. She had taken account of Mr A's medical history, and took the family's views into consideration in suggesting that he remain at home and be reviewed by his GP the following morning. However, the adviser was slightly critical of the level of detail in the GP's notes. In coming to a decision on this complaint, we were not able to determine what exactly happened during the consultation, given the conflicting accounts. However, based on the clinical record

Mr C complained that his dentist did not provide a reasonable standard of treatment. At Mr C's initial appointment, the dentist carried out a detailed examination. She noted that there was extensive decay in one of his lower wisdom teeth and that it might require extraction. When Mr C returned to start the treatment, the tooth was drilled to remove the decay, but this led to exposure of the nerve. The dentist covered the exposed nerve by dressing it with a paste to treat inflammation/infection, and a filling material. She told Mr C that the tooth would need to be extracted at a later appointment. Mr C attended the dentist again two days later as he had pain and swelling around the tooth. The dentist gave him an antibiotic and reduced the filling by cutting it back (this eases symptoms slightly by preventing the patient putting pressure on the tooth when biting). The next day, Mr C contacted NHS 24, as he was concerned about increasing swelling and pain around the tooth. He was referred to an emergency dentist who prescribed a different antibiotic. Mr C saw his dentist again several days later. She was unable to extract the tooth because of the swelling, although she thought that it had gone down slightly. Mr C was later admitted to hospital because the swelling had increased. It was found that he had an abscess and he had an operation to drain the abscess and to extract the tooth. Mr C complained about the dentist's failure to extract the tooth. As part of our investigation we took independent advice from our dental adviser. We found that the decision to delay the extraction of the tooth until such time as it could be fully assessed was reasonable because of the risks associated with extraction of a lower wisdom tooth. However, the dentist had used a substance called glass ionomer to fill the tooth when the nerve was exposed. Our adviser said that this was not an appropriate choice for an exposed nerve and the dentist should have chosen a more approp

Mrs C complained about an out-of-hours hospital consultation with a trainee doctor, which she attended with her four-year-old daughter, Miss A. The appointment was made after Mrs C called NHS 24 to report that Miss A had been unwell for several days and that her condition was worsening. She complained that the doctor did not examine her daughter, and inaccurately concluded that Miss A was suffering from a viral infection. She also complained that he was patronising and condescending. She said she left the examination room and went to the accident and emergency department at another hospital, where Miss A was quickly diagnosed with scarlet fever. In responding to the complaint, the board explained that the doctor was at the beginning of his second year as a general practice registrar and that a fully qualified GP trainer had been on the premises to supervise him. They said it was unfortunate that Mrs C had chosen to leave the premises before the supervisor could intervene. However, they acknowledged that the incident had thrown up a number of training issues that they needed to address with the doctor before he could complete his training and demonstrate his competence as a qualified GP. In particular, they said this would cover the recognition of scarlet fever. In bringing her complaint to us, Mrs C acknowledged that the board had identified training gaps and had undertaken to address these. However, she also felt that the incident had highlighted gaps in the supervision of trainee doctors. She noted that she had been in the examination room for up to ten minutes and considered this too long for a trainee to be left unsupervised. We discussed the case with one of our independent clinical advisers and he had no concerns about the doctor having been left unsupervised for this period of time. He said this was perfectly reasonable for a doctor at this stage of training. We, therefore, did not uphold the complaint. However, we did make recommendations as our

Mr C said that he had to call NHS 24 for assistance twice in two days. He said that he told staff he would not be able to explain his problem and because of this it was incorrectly interpreted that he was complaining about an absent prescription. Mr C said that within hours of his second call he was admitted to intensive care due to the onset of starvation and while there, suffered an unknown cardiac event. Although the first doctor who saw Mr C said that he should be admitted, Mr C said that the second said that he could be discharged. Mr C said that this was unreasonable and likely to cost him his life. Mr C complained to us that staff at the out-of-hours centre failed to provide him with appropriate medical treatment as did staff in the emergency department. He also complained that he was inappropriately discharged from hospital. We did not uphold Mr C's complaints. As part of our investigation, we considered the relevant records and obtained independent advice on the circumstances about which he complained. This confirmed that Mr C was at all times treated appropriately. We found that he had not been admitted to intensive care nor had he been determined to have been suffering from starvation or an unknown heart event. He had been appropriately discharged. Related reading View Decision Report 201204717 as a PDF (11.21 KB) Updated: March 13, 2018

Mr C has a long-standing lung condition. He complained that when he contacted NHS 24 as he was feeling unwell, an out-of-hours GP phoned him back and said that Mr C did not require a home visit and that he was to contact his own GP when the medical practice opened in an hour and a half's time. When Mr C attended the practice, he was prescribed medication and told to return in a week if the symptoms did not resolve. Mr C felt that the out-of-hours GP was wrong to refuse a home visit and complained about this. As part of our investigation we obtained independent advice from a medical adviser, who is an experienced GP. She said that the out-of-hours GP took an appropriate clinical history and that their decision that Mr C should wait until the practice had opened was reasonable. Although Mr C did need to be seen by a doctor, there was no evidence that his condition was unstable or that an urgent house visit was needed before the practice opened. Related reading View Decision Report 201300812 as a PDF (11.07 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment a medical practice provided to her father (Mr A). Mrs C raised concern that the GP had not carried out a physical examination of Mr A when she first raised concern that he was confused. Mrs C said that despite her father living alone and having mobility problems, a phone discussion had only taken place where the GP prescribed antibiotics for a suspected urinary tract infection. Mrs C continued to raise concerns with the medical practice about Mr A’s confusion. The GP then visited Mr A at home and thereafter referred him to a specialist for further assessment as she suspected he was suffering from the onset of dementia. Mrs C remained concerned about Mr A's health and contacted NHS 24. Mr A was subsequently taken to hospital by ambulance and further tests identified that he had suffered a stroke. As part of our investigation we obtained independent advice from a medical adviser. We concluded that the initial phone consultation carried out by the GP was insufficient. We found that the GP, who was in fact a doctor in training, should have organised a home visit when Mrs C first reported her father's symptoms so that he could be fully assessed and his future management discussed with Mrs C.

Miss C, who has a complex eye condition requiring regular ophthalmology (the branch of medicine that deals with the anatomy, physiology and diseases of the eye) interventions, complained about the process for accessing these services. Her condition can flare up at short notice requiring her to seek an urgent ophthalmology appointment. The board's previous process for seeing an ophthalmologist involved attending an eye casualty service which was very busy and could involve waiting the full day to be seen. In order to improve this service, and try to filter out patients whose conditions could be treated by a GP or optometrist (at a community optician practice), the board changed the system. Patients are now required to attend either their GP or optometrist for initial examination and onward ophthalmology referral if required. This should still lead to an ophthalmology appointment within 24 to 48 hours. Miss C complained that she has to re-start this process from the beginning each time, despite her flare ups being regular and onward referral to ophthalmology being inevitable. In responding, the board indicated that, where required, Miss C could obtain repeat appointments by contacting her consultant’s secretary. However, Miss C said that this only applies during normal weekday working hours and only while she was under a specific consultant. Our enquiries revealed that the old eye casualty service was open seven days a week from 09:00 to 16:30. The new clinic hours are the same but it is not open on a Sunday. As prior referral to this clinic is required, this means that Miss C has no direct access to the clinic at weekends when her consultant’s secretary is unavailable. We acknowledged that this might be frustrating for her but noted that the provisions in place will still result in Miss C being seen within the 48 hour target timescale. We also noted that emergency intervention at weekends could still be sought via NHS 24 or direct presentation at an accide

Mrs C complained that the care and treatment provided to her sister (Ms A) was unreasonable. Ms A had a history of chronic obstructive pulmonary disease (a long-term lung condition), osteoporosis (thinning of the bones) and heart problems. A GP from the medical practice visited and, after examining her, prescribed antibiotics and steroids (drugs commonly used to fight infections) in tablet form. Ms A had trouble taking these as she was normally unable to swallow tablets and usually had medication in liquid or powder form. Her condition did not improve. A second GP visited the next day and again examined Ms A but was unable to take her temperature as his thermometer was broken. The GP prescribed a different antibiotic, again in tablet form. Neither GP considered that Ms A's condition warranted emergency admission to hospital and the second GP said that Ms A had specifically told him that she did not want to go to hospital. Ms A's condition continued to deteriorate and Mrs C called NHS 24 (a national advice helpline) later that evening. Ms A was taken by ambulance to hospital where she was found to be suffering from sepsis (serious infection) and hypothermia (where the body temperature falls below the normal range). She was admitted, but died shortly afterwards. We did not uphold any of Mrs C's complaints. Our investigation, which included taking independent advice from a medical adviser, concluded that the examinations and management plan for Ms A had been reasonable. In particular, the adviser said that in light of Ms A's reluctance to go to hospital it was appropriate to take her views into consideration and to manage her condition at home. The family disputed that Ms A did not want to go to hospital, but the records showed that the ambulance paramedics had recorded her reluctance to go there. The practice acknowledged that Ms A had medication in liquid form, but there was nothing specific in her notes to highlight that she had difficulty in swallowing