SPSO Individual Decisions

C complained about the care and treatment that they received from the practice prior to their diagnosis of an abdominal cyst, which was surgically removed some years after C first attended the practice with symptoms. C complained that they did not receive a referral for an ultrasound scan until many months after first attending the practice with symptoms. C also complained that four different doctors were involved in their care and that the practice’s complaint handling was unreasonable. We took independent GP advice. C’s case was complex and challenging due to the nature of C’s cyst, C’s other diagnoses and the timing of C’s consultations during the COVID-19 pandemic. Nevertheless, we found that there was a missed opportunity for the practice to refer C to the colorectal service based on the positive result of a qFIT test (a test to detect blood in the stool) when C first attended the practice with symptoms, based on the National Institute for Health and Care Excellence (NICE) guidance. We found that there was a further missed opportunity for the practice to consider referring C to secondary care based on C’s subsequent positive qFIT test result, which was taken many months after the first positive qFIT test. We also found that there were delays in the practice contacting C after receiving the result of the subsequent qFIT test and when the practice received the result of C’s ultrasound. We found that, given the state of NHS services at the time C attended the practice, there was not likely a significant delay in C receiving a diagnosis or surgery for their cyst. On balance, we upheld C’s complaint about their care and treatment from the practice. We found that the practice’s complaints handling was unreasonable, because the first complaint response did not address the issues C raised as a complaint. We upheld C’s complaint about the practice’s complaints handling.

C submitted a complaint on behalf of their relative (A) who received treatment at hospital. A had previously suffered a stroke (causing left sided weakness) and was admitted after being unwell for a few days. C complained about the nursing care provided to A while they were in hospital. We took independent advice from a nursing adviser. We found that there were failings in relation to nursing documentation, moving and handling practices, a lack of equipment, and a lack of assessments as to A’s needs. In particular, there was no falls assessment and appropriate action and recording did not take place after A’s fall. In relation to moving and handling, we found that glide sheets should have been utilised and that appropriate equipment should have been available in the ward. The board failed to reasonably record the care that they provided, or carried out appropriate assessments to ensure person-centred care to confirm that A’s needs were met. As such, we upheld this complaint.

A’s spouse (B) was admitted to hospital for a knee replacement. The operation went well but during B’s recovery their condition began to deteriorate and B was transferred to the High Dependency Unit. B went into cardiac arrest, CPR was administered but it was unsuccessful and B died. C raised complaints on A’s behalf about B’s treatment during their admission. The board undertook a Local Adverse Event Review (LAER), identified issues with B’s care and treatment and made recommendations to address these issues. The board also responded to the complaints raised by C regarding B’s treatment. In their response the board reiterated the conclusions of the LAER, their recommendations made in relation to some aspects of B's treatment, and concluded that other aspects complained of by C had been reasonable. In relation to specific questions about B’s admission that C had shared, the board indicated that responses to most of these had been provided at a meeting that had taken place between B’s family and a consultant orthopaedic surgeon (branch of surgery concerned with conditions involving the musculoskeletal system) or in the LAER report. The board provided a response to one other question in the response to C. We took independent advice from a specialist in orthopaedic surgery. We found that observations of B should have been increased, their care escalated and that antibiotics should also have been commenced sooner. We upheld this aspect of the complaint. In relation to the provision of answers to questions raised in the complaints submitted, we found that clear responses from a clinician were available to the board’s complaints team within a month of the questions having been raised. The board provided answers to some of the questions at a meeting the following month but clear answers to the remaining questions were not provided until SPSO became involved and specifically asked for them almost two years later. Given this, we upheld this aspect of the complaint.

C complained on behalf of their parent (A) about the care and treatment provided by the board. A was scheduled for a hip operation after experiencing increased pain which was affecting their daily function. The operation was cancelled on the day as the anaesthetist was not prepared to go ahead due to the high level of risk associated with the procedure and significant concerns about complications. C complained about the hospital’s process which they said caused great distress. We took independent advice from a registered consultant physician. We found that there was a failure by the surgeon to share their concerns about A’s surgery with clinical colleagues in a timely way. There was also a break-down in communication between the key teams involved in the pre-assessment, resulting in failures in process and cancellation of surgery on the day. We also found that there was a lack of coordination in arranging A’s discharge home when the operation did not go ahead. We also found failings in the board’s handling of the complaint, such as the complaint not addressing all the issues raised by C. We therefore upheld the complaint.

C complained about the care and treatment provided to their adult child (A). C complained that actions taken shortly before and after A’s discharges were unreasonable as was the board’s response to the complaint. We took independent advice from a consultant in general medicine and a registered general nurse. We found that appropriate assessments were carried out prior to discharge and that the board reasonably discharged A. As such, we did not uphold these parts of C’s complaint. We considered C’s complaint regarding the level of support offered after A’s falls. We found that the board’s response to these falls were reasonable. Action taken after the fall in the car park were in line with policy and the level of staffing available on the day, and in relation to the fall while being admitted, the care as documented was considered to be reasonable. As such, we did not uphold these parts of C’s complaint. In relation to the complaints handling, we found that there were failings in the response to C’s verbal and written complaints, with no response issued to the verbal complaint, and not providing a full response to the written complaint. While there were some aspects of the board’s response which were reasonable, overall we upheld this part of C’s complaint.

C complained on behalf of their partner (A) that their initial CT scan was misread and their symptoms misdiagnosed as ischaemic colitis (injury to the colon as a result of reduced blood flow), leading to a delay in treatment and diagnosis of a bowel obstruction. C felt as A’s condition deteriorated, further investigation should have taken place to identify the cause of A’s symptoms. The board maintained that there was no misdiagnosis as the first CT scan showed the appearance of ischaemic colitis, with no obstruction reported. A was treated appropriately with antibiotics and there was no evidence of deterioration during the period of observation. When A developed symptoms after the reintroduction of food, a second CT scan was ordered and the bowel obstruction identified. The board considered that A had an incomplete or evolving obstruction on admission, which was not picked up by the CT scan. We took independent advice from an experienced general and colorectal surgeon. We found that while the reading of the scan was reasonable, the failure to consider clinical presentation alongside the scan was unreasonable. We found that this led to a focus on treating ischaemic colitis and no consideration was given to identifying the underlying cause. There was minimal investigation carried out to identify the cause and consideration should have been given to endoscopic investigation, a contrast enema, a colonoscopy and listening to bowel sounds. All would have identified a bowel obstruction, resulting in the correct diagnosis and earlier treatment for A. We also found that as the delay led to A’s deterioration and an increase in treatment, the incident met the Duty of Candour threshold, which the board failed to identify. As such, we upheld C’s complaint.

C complained about the care and treatment they received by the board. C was pregnant and called triage as they thought their mucus plug (a protective collection of mucus in the cervical canal) had passed and that they noticed green discharge. C was advised to stay at home and call back if they had further concerns. C went to hospital later that day and underwent an emergency caesarean section to deliver their baby (A). A appeared well following birth, but soon deteriorated. A was initially diagnosed with hypoxic ischaemic encephalopathy (a type of brain damage), and then subsequently diagnosed with quadriplegic cerebral palsy (a lifelong condition that affect movement and co-ordination). C complained to the board about the advice provided not to attend hospital during the initial call to triage, and about the care and treatment during delivery and immediately afterwards. C believed that clinicians delayed in taking appropriate action in response to A's symptoms and considered this may have impacted their health. In response to the complaint, the board recognised that C's recollection of the call to triage differed from the notes taken but concluded on the basis of the information available, that the assessment and advice was appropriate. The board gave a detailed account of the care and treatment provided to C and A from C's attendance at hospital, through to delivery and in the period following A's birth. The board explained the decision to proceed to an emergency caesarean section and concluded that this was appropriate and timely. The board also concluded that it was impossible to say if the outcome for A would have been different had C attended hospital earlier, and it was unlikely an earlier birth from the time of admission would have altered the outcomes. C was dissatisfied with the board's response and brought their complaints to our office. We took independent advice from an obstetrician (specialist in pregnancy and childbirth) and from a consultant neonatol

C complained about the care and treatment provided to their parent (A) who had been admitted to hospital with an infection of the gallbladder. A Magnetic Resonance Cholangiopancreatography (MRCP, an MRI scan of the gall bladder) was ordered and gallstones were found to be present. However, A did not hear from the hospital for several months following the scan until they proactively chased up a response. The board later confirmed that the MRCP report had not been provided to the consultant who had ordered the test causing the delay. A was subsequently admitted for an Endoscopic Retrograde Cholangiopancreatography (ERCP, a procedure combining an endoscopy and X-rays to examine and treat conditions of the bile and pancreatic ducts) and discharged the following day. A was admitted again a few weeks later suffering from a complication of pancreatitis and a drain was inserted. A was discharged to be seen again as an out-patient. However, a few days later A was readmitted as an emergency patient suffering from a significant infection and died shortly after. C complained about the delay between the MRCP and ERCP procedure and questioned whether this had led to A's death. C also complained about the general standard of care provided to A. We took independent advice from a consultant general surgeon with a specialist interest in upper gastrointestinal problems. We found that there had been a failing in both the board's paper and electronic reporting systems. Despite these failings, we were of the view that the delay did not, on this occasion, lead to a worse outcome for A clinically. However, we were critical of the care provided to A following the ERCP procedure. We also found that A was discharged too soon, despite having developed pancreatitis, against both local policies and clinical best practice. We considered that A should have been admitted for longer, under the care of the original consultant, and that better initial care for A may have facilitated earlier interventi

C complained about the standard of medical care and treatment provided to their spouse (A). A was diagnosed with, and treated for, advanced breast cancer. A’s condition deteriorated and they later died. C complained that clinicians failed to, amongst other things, act upon A's worsening symptoms or their concerns that their cancer may be spreading. C also raised concerns about the end of life care A had received from the board. The board, in responding to C’s concerns, did not consider that there had been a failure to act on A’s worsening symptoms. However, they acknowledged incidences where A had not been given the opportunity to bring support to out-patient appointments where clinicians reported a deterioration in their symptoms. They apologised to C for A's poor experiences and agreed to take a number of improvement actions in response. They acknowledged A’s end of life care had been highly distressing for C and their family but did not consider that this had fallen below a reasonable standard. We took independent advice from a consultation clinical oncologist. We found that the communication surrounding A’s diagnosis and progressive disease could have been better. We also noted a lack of documented Clinical Nurse Specialist support, but overall felt A’s treatment following metastatic (when cancer cells spread to other parts of the body) diagnosis had been appropriate. We did not uphold this aspect of the complaint. With regards to A’s end of life care, we found that although the board’s handling of A’s DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) and discussions around their deterioration were appropriately documented, the communication around this did not meet C’s own expectations or needs. However, we found no evidence to support that decisions taken in respect of A’s end of life treatment, including their nursing care, had been unreasonable. For these reasons, we did not uphold this aspect of the complaint. We did, however, provide feedba

C complained about the practice's care and treatment of their parent (A) who died as a result of sepsis several days after being admitted to hospital. According to the death certificate, one of the underlying causes of A's death from sepsis was an infected grade four sacral ulcer (an injury that breaks down the skin and underlying tissue, grade 4 is the most severe type) that had been there for several months. C complained that in the period preceding admission to hospital, GPs from the practice never assessed A's sacral ulcer, despite C's requests for them to do so. C complained about a house visit consultation carried out by a GP (GP1) when the family suspected A may have sepsis. They complained about GP1's decision to prescribe oral antibiotics even though A was known to have swallowing problems. C also complained about the GP's refusal to assess the ulcer visually and their decision not to arrange admission to hospital. C also complained about a telephone consultation a few days later, in which a GP (GP 2) declined to carry out a house visit and arranged admission to hospital on a non-urgent basis. We took independent advice from a GP. We accepted GP1's clinical assessment that oral antibiotics were appropriate. However, we were critical of GP1's failure to record observations during the house visit, noting that in the absence of these records it was not possible to establish the basis on which GP1 concluded A did not have sepsis. We found it unreasonable that GP2 declined to carry out a house visit or arrange urgent admission to hospital, even though this may not have changed the ultimate outcome for A. We found there were omissions in the records in relation to anticipatory care/palliative care planning. There was also a lack of recorded discussions with A's family. Taking all of this into account we upheld C's complaint.

C complained about the care and treatment they received from the board in relation to an incident of extravasation (the leakage into surrounding tissue of medication administered intravenously) of chemotherapy into their arm. C told us that following the incident, their arm became painful and swollen and that they were left with loss of function in their hand and arm, despite being referred to the board's orthopaedic, plastic surgery and physiotherapy departments for further treatment. C considered that the aftercare they had received had been unreasonable and that there had been a lack of diagnosis in relation to the injury to their arm. C also complained about the attitude of nursing staff after the incident, which they felt lacked compassion. The board told us that extravasation is a known risk of chemotherapy treatment but that once the extravasation was noticed, chemotherapy treatment was stopped immediately and that attempts were made to aspirate the fluid from C's arm. The board also noted that C was reviewed by an on-call plastic surgeon, all in accordance with their extravasation policy. The board acknowledged that, while C was subsequently seen by specialist in orthopaedics and physiotherapy, their recovery appeared to be slower than would normally be expected and that the long term implications were unclear. We took independent advice from an oncologist and a nurse. We found that the board's response to the extravasation incident, both immediately and in the months that followed, was in keeping with their extravasation policy and established good practice. However, on review of the available documentation, there was no evidence to show that nursing staff had completed the necessary hourly checks of C's peripheral vascular cannula (through which the chemotherapy was administered) or that the extravasation incident had been discovered as a result of monitoring by nursing staff. This was unreasonable and contrary to professional nursing standards in relation

C complained about the care and treatment provided to their adult child (A) by the board. A had an extensive history of epilepsy and was diagnosed with ictal asystole (a rare but potentially devastating complication of epileptic seizures). A was referred by the board's neurology service (specialists in disorders of the nervous system) to the cardiology service due to ongoing seizures with loss of consciousness which could not be controlled with medication. A was fitted with a pacemaker but later developed severe headaches and a rash. A was advised to stop taking recently prescribed tablets and that the rash was likely caused by the ointment used when the pacemaker was fitted. A few days later, A was finding it difficult to breathe and called NHS 24. Paramedics attended A at home but A was not admitted to hospital. A phoned NHS 24 again the following day and when paramedics attended, they took advice from an emergency medical consultant at the hospital who advised that A should take paracetamol and see the GP the following morning. A was advised by the GP to attend the COVID-19 hub where A collapsed and was taken to hospital. A was admitted to hospital and died the following day from sepsis (a life-threatening reaction to an infection). C complained that the board's cardiology service failed to provide reasonable care and treatment to A. We took independent advice from a consultant cardiologist. We found that there was a failure to provide a clear timeframe on the day of the pacemaker implantation and a failure to take reasonable action when A developed a rash following the procedure. We also found that the board failed to identify the asystole earlier but had already acknowledged this in their complaint response to C. Given these failings, we upheld this part of C's complaint. C complained that an emergency medical consultant unreasonably told the paramedic that A should take paracetamol and see the GP the following morning. We took independent advice from a consult

C complained that they did not receive appropriate care and treatment from their GP practice in relation to the diagnosis and treatment of menopause symptoms. C felt the practice did not take their menopause symptoms seriously and that GPs were not up to date with current guidance when C was offered antidepressants in response to menopause symptoms. As such, C complained that the practice failed to recognise and appropriately treat the symptoms of menopause, leading to a delay in diagnosis and treatment. The practice considered that the care and treatment provided to C had been reasonable. We took independent advice from a GP. We found that there had been a number of missed opportunities to diagnose menopause, that consideration had not been given to the relevant NICE Guideline NG23 (National Institute for Health and Care Excellence guideline on Menopause: Diagnosis and Management), and that GPs had failed to consider alternative hormone replacement treatment (HRT) preparations during a period of national shortage. This led to a delay in the diagnosis and treatment of C's menopause. As such, we upheld C's complaint.

C, an adult with attention deficit hyperactivity disorder (ADHD), autism, and pathological demand avoidance (PDA) complained that the board failed to diagnose their conditions when they should have done. C told us that the board said they stopped considering diagnosis of conditions such as ADHD and autism when a patient reached the age of 25 years old. C complained that this practice led to them being misdiagnosed which prevented them from obtaining access to appropriate medication, particularly, medication to help with the management of ADHD. The board said that the understanding of developmental disorders in adulthood, including high functioning autism and ADHD was very limited during the mid 1990s (when C felt they should have been diagnosed). The board felt any potential delay in diagnosis should be considered in line with the expectations and understanding of psychiatric practice at the time. In C's case, it appears C experienced a number of other physical and mental health problems that would not be solely accounted for by diagnoses of autism and/or ADHD, although these conditions may have been predisposing factors. We took independent advice from a general adult consultant psychiatrist. We found that the timing of the recognition and diagnoses made were reasonable and that there was no evidence to suggest that the recommended treatment for ADHD was delayed or withheld because of prescriptions of other medications. We also noted, at this point in time, there are appropriate guidelines and clinical guidance for clinicians to follow, in relation to pervasive developmental disorders in adults. Whilst we recognise that C was not diagnosed with ADHD and autism until relatively recently, we consider that the care and treatment provided to C was reasonable in the circumstances at that time. We also consider treatment provided for other diagnosed conditions was reasonable and did not prevent or delay C's later diagnoses of ADHD and autism. We noted that the board may

C complained about medical treatment provided to their late spouse (A) following their transfer to a community hospital from a regional hospital, where A had been treated for a heart attack. C raised concern about several aspects of the care provided, including the frequency of medical reviews and communication with A’s family about their condition. We took independent advice from a consultant in care of the elderly. We found that A had been suffering from hypernatraemia (high sodium levels in the blood) at the time of their hospital transfer and that this condition required careful monitoring of A’s fluid balance, planned daily medical reviews and frequent blood tests. Despite this, we noted that A had not been medically reviewed daily at the community hospital. Weekend medical cover was provided by an out-of-hours GP service, which would only attend if required. Given this, we found that the decision to transfer A to this hospital had been unreasonable. We also found that the frequency of blood tests carried out was insufficient and that no medical review was carried out despite rising sodium levels in A’s blood. We noted that A had not received intravenous fluids over a period of three days despite their oral intake documented as poor and that, when intravenous fluids had been administered, the particular type of fluids given had been inappropriate to treat hypernatraemia and may have worsened A’s condition. However, it was not possible to say how this might have affected A's outcome given the generally poor prognosis associated with the condition and A’s significant comorbidities. For these reasons, we upheld C's complaint.

C complained that the board failed to provide reasonable care and dental treatment to them over a period of several months. During clinical examinations, C raised concerns about experiencing pain from a particular tooth. We took independent advice from a dentist. We found that while treatment provided by the dental practice was, in general, reasonable, there were some missed opportunities to further investigate the condition of the tooth in question. Further investigations would have been appropriate to help determine whether the tooth was the actual cause of the pain. We found that further information obtained at subsequent appointments would have helped confirm that C’s pain was the result of a localised infection. The board accepted that in retrospect, the pain was due to the tooth that was ultimately extracted. Given the missed opportunities to further investigate the condition of the tooth in question, develop a more appropriate diagnosis and potentially reduce prolonging C’s pain and discomfort, we upheld the complaint.

C complained about the care and treatment that they received in relation to their mental health from the board over the course of just over a year. C was also concerned about the treatment that they received from a psychiatric consultant including consideration of referring C to a different health board and dealing with complexities in the case, such as C’s parent being employed by the board. We took advice from an independent psychiatric nursing adviser. We found that the overall standard of treatment provided to C was reasonable and did not uphold this complaint. C was also concerned that the board unreasonably delayed the organisation of community mental health care to them due to concerns over safety and risk. Although C was ultimately referred to the specific community mental health team outwith the area that they had requested from early in the process, we found that the board’s regard for the potential risks of such an arrangement were reasonable and that, overall, there was no unreasonable delay due to the board’s action and that the standard of care provided was reasonable. We did not uphold this complaint. C was further concerned that the psychiatric consultant did not reasonably record their assessment and reasoning of decisions to hospitalise C, to prescribe medicine to C or to refer C to a psychologist. We found that record keeping over the relevant period had been reasonable and that, taking all of the available evidence, the psychiatric consultant had reasonably recorded their assessments and reasoning regarding C’s treatment. We did not uphold this complaint. C was concerned about delays in the board responding to complaints about their care and treatment, the board’s inability to explain the reasons for those delays and the board’s failure to provide a copy of a response to an elected representative as C had requested. While the board had accepted some of these failures during their consideration of the complaints submitted or while responding to ou

C complained about the care and treatment that they received from Tayside NHS Board following treatment in the A&E of Ninewells Hospital. C attended the A&E after sustaining an injury to the little finger of their right hand caused by a serrated knife. They were diagnosed and treated for mallet finger (a deformity of the finger when the tendon that straightens the finger is damaged at the fingertip), of which treatment involved the application of a splint to the injured finger. C complained to the board that their injury had failed to heal correctly. C complained that they were not given an x-ray, that the splint was too big and that they were given insufficient information to allow them to care for their injury. C also complained that they had not been provided with a face-to-face physiotherapy appointment timeously. We took independent advice from an emergency medicine adviser. We found that C's injury was wrongly diagnosed and that, consequently, the application of a splint in C's case was not the appropriate treatment. We found that the A&E should have referred C to a hand surgeon. We upheld this aspect of C's complaint. We found that it was the responsibility of C's GP practice to arrange a timeous referral to physiotherapy. We, therefore, did not uphold this aspect of C's complaint.

C complained about the board's decision to discontinue the prescription for gluten free foods for their adult child (A). The board explained that as A did not have a confirmed diagnosis of coeliac disease, that they would not be expected to prescribe gluten free foods. To make a diagnosis, a patient would be required to include gluten in their diet for a number of weeks prior to testing. C said that due to A's additional needs and the distress that they would suffer from the symptoms associated with taking gluten, it would be reasonable for the board to take a flexible approach when applying their policy on the matter. We took independent advice from both a GP adviser and a gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas). It was noted that it was agreed by all parties that it would be distressing to A to require them to include gluten in their diet in preparation for testing. We considered that a more flexible approach should be taken to the application of the relevant policies and guidance and that a diagnosis could be made by probability. We found that principles of realistic medicine and patient-centred care should be applied and we recommended that consideration is given to other means of non-invasive tests to determine the presence or absence of coeliac disease in A's case. As such, we upheld the complaint.

C attended hospital for gastroenterology procedures (medicine of the digestive system and its disorders). Upon waking from the procedures, C reported experiencing a painful tingling sensation in their mouth, left hand and foot. C informed the nurses of their symptoms and a consultant carried out an assessment. Following the assessment, C was deemed fit for discharge as no clinical concerns were identified. However, C's symptoms persisted upon returning home. They attended an emergency GP appointment the following morning and the GP concluded that C had had a stroke. C was readmitted to hospital for further investigations. A CT scan confirmed that C had suffered a stroke. C complained that the board's staff unreasonably failed to identify that they had had a stroke following their procedure. We found that, whilst staff identified that C's symptoms indicated they may have had a stroke and an assessment was carried out with this in mind, the assessment was insufficiently detailed and, in light of C's presenting symptoms, further investigation by a neurologist (specialist of the nerves and the nervous system, especially of the diseases affecting them) should have been arranged. Therefore, we upheld the complaint.

C complained to the practice about a delay in prescribing them with medication for high blood pressure, and as a result C suffered a heart attack. C said that they had attended the practice on a number of occasions within a few months with recurring chest pains, breathlessness and dizziness. C had their blood pressure read and electrocardiograms (ECGs) taken a number of times. C saw a GP and reported chest pain and dizziness. The GP put this down to muscle spasm and arranged another ECG and blood pressure reading. C was then given tablets for their blood pressure. The following day, C was admitted to hospital to have a stent inserted as they had suffered a heart attack. The practice explained that C had had a number of contacts within a few months, and was seen by 11 GPs. Most of the contacts related to C's respiratory problems of Chronic Obstructive Pulmonary Disease (COPD). C's blood pressure was discussed with a GP and further readings were arranged either at the practice or read by C at their home and telephoned to the practice. It was when C reported chest pain a few months later that further investigations were conducted and the decision was taken to provide antihypertensive medication (used to lower high blood pressure). We took independent clinical advice from a GP. We found that the practice had provided a reasonable standard of treatment to C. Their blood pressure readings were monitored both in the practice and at home and subsequently, arrangements were made to prescribe medication when it was appropriate to do so. We did not uphold the complaint. Related reading View Decision Report 202000476 as a PDF (24.52 KB) Updated: April 20, 2022

C complained to us regarding the treatment that they had received from the board relating to a diagnosis of liver cancer. They told us that there had been significant delays in carrying out appropriate tests and that they considered that their care had been very self-driven, stating that they had to chase up and request treatment on a number of occasions. They told us that they had received an unreasonable prognosis when being given their cancer diagnosis, being told that they were terminally ill with only months to live. They told us that they were only referred to a liver surgeon at their request, who was subsequently able to operate successfully. They also complained that a consultant had written an unreasonable letter to their GP about one consultation, suggesting that their appearance had given cause for concern. We took independent advice from a consultant oncologist (cancer specialist). We found that there had been unreasonable delays in carrying out C's tests. In particular, a failure to appropriately refer on the results of a scan, resulting in C having to chase this up and request a referral through their GP, and, a failure to mark the request to carry out a biopsy as urgent, resulting in a further delay. These failures contributed to a delay in providing both diagnosis and treatment for C which was well out with normal guidelines for cancer treatment. In addition, the fact that C was required to seek a referral from their GP to further consider the results of their scan was considered to be evidence that their care had been unreasonably self-driven. We also found that an unreasonable prognosis had been given to C, as it was clear that the consultant in question was not best placed to provide a prognosis and further consultations were required before an accurate prognosis could be given. We therefore upheld these aspects of C's complaint. However, while we noted C's strongly held view that the consultant's assessment of their appearance had been un

C's child (A) had complex needs as a result of a brain injury sustained when they were four years old. Given A's care needs, they had an Anticipatory Care Plan (ACP) in place which was reviewed regularly. A was admitted to a general ward at Ninewells Hospital with a high temperature and was subsequently moved to a high dependency unit. A died three days following admission. C complained about the inappropriate use of Hi-Flo Nasal Cannula Oxygen (high-flow oxygen, a form of respiratory support) despite concerns raised at the time. C complained that incorrect decisions were taken with respect to A's care and treatment, including that clinicians did not have appropriate regard to the ACP that was in place. In response to the complaint, the health board carried out a Mortality Review and shared its findings with C. The findings were that care was maximised in the High Dependency Unit as it was not felt A would survive admission to Paediatric Intensive Care Unit, and that this decision together with the decision not to intubate was made with C's input. The variation in care from the ACP was discussed with C and highlights plans are flexible. C complained to our office that clinicians failed to follow the ACP, that they did not take their views into consideration and that A died of carbon monoxide poisoning as a result of the decisions made in relation to A's treatment and care. We took independent advice from a consultant paediatrician. We found that there was good documentation evidencing that clinicians had discussed A's care with C, including decisions not to intubate A. We considered treatment with high-flow oxygen was reasonable in the circumstances. Whilst the ACP was not followed, and the board identified this, the ACP is not a legally binding document and the decisions to deviate from the ACP were reasonable in the circumstances. A's cause of death is consistent with the evidence within the medical records. We concluded that A's care and treatment was r

C attended the A&E at Ninewells Hospital with back pain and leg weakness, and was discharged with a diagnosis of suspected sciatica (back and leg pain caused by irritation or compression of the sciatic nerve). C had attended a neurology (the science of the nerves and the nervous system, especially of the diseases affecting them) out-patient clinic earlier that day regarding a separate matter, and the neurologist had noted a foot drop (a muscular weakness or paralysis that makes it difficult to lift the front part of the foot). C complained that the A&E failed to accurately assess them and refer them on to neurosurgery (surgery of the brain or other nerve tissue). C was assessed by neurosurgery four days later, following an urgent GP referral, and was diagnosed with disc prolapse (ruptured disc in the spine) and nerve compression (direct pressure on a nerve) requiring surgery that same day. The board advised that, while the A&E doctor noted reduced power in C's left leg, they did not feel that foot drop was present and that they felt that sciatica was the most likely diagnosis. The board noted that the neurologist's observation that C had foot drop was not based on a physical examination, whereas the A&E doctor documented a physical examination. The board also noted that local neurosurgical referral guidelines state patients with back pain and sciatica with neurological deficit should be referred to physiotherapy prior to referral to neurosurgery. They concluded that C received appropriate care that was in keeping with relevant guidelines. We took independent advice from a consultant in emergency medicine. We found that C's assessment and management in the A&E was reasonable and appropriate. We found that the mild weakness documented on assessment in the A&E was not in keeping with a foot drop and that it did not indicate that a neurosurgical referral was required at that time. The A&E discharge letter documented that C was advised to see their GP, and we no

C complained about the care and treatment they received from the board. C experienced pain and discomfort when eating and suffered from gastro-oesophageal reflux (stomach acid travelling up towards the throat). C's gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines) ordered a barium swallow test (BST, a special type of X-ray test where barium is swallowed which shows up clearly on an x-ray to help diagnose problems with swallowing and the oesophagus). The radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) who reviewed the images reported them as normal. C complained about the care and treatment provided by the gastroenterologist and the radiologist's interpretation of the BST. We took independent advice from a consultant radiologist and a consultant gastroenterologist. We found that there were small osteophytes (bony lumps that grow on the bones of the spine or around the joints) in the spine on the BST images. However, these were small and insignificant. We found that images had been thoroughly reviewed by the radiologists and that there was no demonstrable compression of or leakage from the oesophagus. We also considered that the suggestion to change C's medications was reasonable and good clinical practice. The BST showed that no further investigations were required. Therefore, we did not uphold this aspect of C's complaint. C also complained about how the board responded to their complaint. We found that the complaint response may not have been as in depth as C would have preferred, and that the conclusions of the medical staff were not what C was hoping for, however that did not mean the response was unreasonable. There was a delay in providing a complaint response to C, however we found that these were caused by the COVID-19 pandemic and from a further submission of inf