SPSO Individual Decisions

Mrs C complained about the care and treatment her late husband (Mr A) received at Galloway Community Hospital after he attended the emergency department (ED) with chest pain. Mr A was diagnosed with gastritis (inflammation of the stomach lining) and was discharged home. He died shortly after from a pulmonary embolism (PE, a blood clot in the blood vessel that carries blood from the heart to the lungs). Mrs C was concerned that Mr A was discharged from the ED without a troponin test (a type of blood test to help confirm or exclude damage to the heart) being carried out. Mrs C also questioned why the ED doctor had not suspected a blood clot when they were aware that Mr A had been treated previously for prostate cancer. The board carried out a critical incident review of Mr A's care and treatment. They found that a repeat electrocardiogram (ECG, a test that records the electrical activity of the heart) should have been performed given abnormalities had been identified and that a troponin test should have been done. In addition, there was no record of family history/other relevant factors. The board said that they would share these findings with the staff involved in order to ensure learning and undertook to source readily available out-of-hours troponin testing at Galloway Community Hospital. We took independent advice from a consultant in emergency medicine. We did not consider that Mr A's symptoms were indicative of a PE, however, we determined that it was unreasonable to discharge him with a diagnosis of gastritis. We found that Mr A should have been admitted to hospital and that a repeat ECG and troponin test should have been undertaken. We, therefore, upheld Mrs C's complaint. However, we considered that it was unlikely Mr A's outcome would have been different because ECG and troponin testing is not a test for PE.

Mrs C complained about the care her daughter (Miss A) received at Midpark Hospital. Miss A has Asperger’s (a form of autism, in which people may find difficulty in social relationships and in communication) and suffers from depression, attention deficit disorder and personality disorder. She was admitted informally to the hospital for assessment and help. Mrs C complained that both the standard of psychiatric care and mental health nursing care Miss A received was unreasonable. Mrs C raised a number of concerns in relation to communication and the management, supervision and diagnosis of Miss A. We took independent advice from a psychiatrist and a mental health nurse. We found that the standard of psychiatric care and mental health nursing in relation to communication, management, supervision and diagnosis was reasonable. We did not uphold Mrs C's complaints. Related reading View Decision Report 201702769 as a PDF (10.99 KB) Updated: December 2, 2018

Mr C complained about the care and treatment his late wife (Mrs A) received from Dumfries and Galloway Royal Infirmary in relation to the decision and communication about de-activating her implantable cardioverter defibrillator (ICD - a device designed to treat abnormal heart rhythms). Mr C also raised concerns that no discussions took place with Mrs A about a 'do not attempt cardiopulmonary resuscitation' (DNACPR - a decision taken that means a healthcare professional is not required to resuscitate the patient if their heart or breathing stops) order being put in place until after the decision had been taken by medical staff. In addition, he was dissatisfied that staff had not clearly communicated that Mrs A's condition had worsened to the point that she was in the end of life stage. We took independent advice from a consultant cardiologist. We found that there was sufficient evidence to show that discussions had taken place about the DNACPR order on two separate occasions. We also considered that it was appropriate clinical practice to de-activate Mrs C's ICD given that her condition had significantly deteriorated and there were no other treatment options possible. Whilst we did not uphold these aspects of Mr C's complaint, we welcomed that the board have taken steps to improve how conversations about de-activating ICDs are carried out. In terms of Mr C's concerns about communication regarding end of life, we found that there was evidence to demonstrate that conversations took place about the reasons why there were no treatment options possible, and that palliative (end of life) care was Mrs A's only option. Whilst palliative care had been started, we found that there was no indication at the time of discharge from hospital that Mrs A would die as soon as she did afterwards. We, therefore, did not uphold this part of the complaint. Related reading View Decision Report 201701697 as a PDF (11.51 KB) Updated: December 2, 2018

Mr C complained about the treatment which his late brother (Mr A) received when he attended the accident and emergency department at Dumfries and Galloway Royal Infirmary. Mr C had received a phone call from Mr A early one morning saying that he had difficulty breathing. An ambulance was called and took Mr A to the hospital. Later that morning Mr C received a further call from Mr A saying that he was being discharged from the hospital and asking Mr C to pick him up. Mr C ensured that Mr A was settled in his house. However, Mr C later learned that Mr A had died. The cause of death was heart failure and Mr C felt that more care should have been taken at the hospital and that perhaps Mr A should have been admitted for further tests. We took independent advice from a consultant in emergency medicine. We found that the staff at the accident and emergency department had carried out an appropriate examination of Mr A at the time, which included a history of heart problems. They had taken a chest x-ray, electrocardiogram (ECG - a test to check the heart's rhythm) and blood tests. Although there were subtle signs of heart failure from the results, we concluded that it was reasonable for the staff to diagnose that Mr A was suffering from a chest infection rather than heart failure. It was also reasonable that Mr A was prescribed antibiotics and discharged home. We did not uphold the complaint. Related reading View Decision Report 201706917 as a PDF (11.28 KB) Updated: December 2, 2018

Mr C complained about the follow-up care and treament he received at Dumfries and Galloway Royal Infirmary. Mr C underwent surgery for prostate cancer in another NHS board area but follow-up care was to take place within his own area. Mr C complained to the board about the way they handled his follow-up care as there were a number of delays. The board decided to undertake a Significant Adverse Event Review (SAER) as a result. Mr C was provided with a draft copy of the SAER at a meeting, however, the response to his complaint was not supplied until a number of months later with a copy of the finalised SAER report. Mr C complained to us that the board had unreasonably failed to provide him with appropriate follow-up care and treatment. He was also concered that the board had not followed their SAER policy appropriately and that there had been unreasonable failings in the way they handled his complaint. We took independent advice from a consultant urologist. We found that there was a lack of appropriate follow-up care for Mr C and that poor communication between staff caring for him in different board areas had contributed to the issues with his follow-up. We upheld this aspect of Mr C's complaint but noted that the board had acknowledged and apologised for this failing. In relation to the SAER, we found that it was reasonable in its findings. However, it took far longer to complete than Mr C had been advised, and we found a lack of evidence that the board had kept him updated on their progress. We upheld this aspect of Mr C's complaint. In relation to Mr C's complaints handling concerns, we found that there had been significant delays in the investigation process and that the board had acknowledged and apologised for this. We also noted that the SAER was a separate process from the investigation of Mr C's complaints and we considered that it would have been helpful had the board's complaint response more clearly addressed the specific concerns he had raised

Mrs C complained about the management of her husband's (Mr A) insulin after he was admitted to Dumfries and Galloway Royal Infirmary for treatment of a stroke. Mr A has a history of diabetes mellitus (a condition that occurs when the body cannot produce sufficient insulin to absorb blood sugar) for which he administers insulin. In responding to the complaint, the board acknowledged and apologised for a delay in Mr A receiving insulin one evening. The board considered that, during Mr A's admission, staff had followed the correct procedures but more checks of his blood sugar and ketone levels would have allowed staff to act earlier. The board set out a number of measures that they said they had taken regarding staff training and improvements as a result of Mr A's experience. We took independent advice from a consultant physician specialised in diabetes mellitus. We found that management of the insulin was below the expected standard, given the possibility that diabetic ketoacidosis (DKA, a serious complication of diabetes that occurs when the body produces high levels of ketones) could have been prevented by earlier recognition, more frequent monitoring and more aggressive insulin administration. Therefore, we upheld this aspect of Mrs C's complaint. Mrs C also complained that staff did not specifically inform her or Mr A that he had developed DKA and urosepsis (a secondary infection that develops in the urinary tract). Mrs C said they had only been aware that Mr A had low blood sugar levels. We found that when Mr A developed DKA and urosepsis, there was no record of this having been explained to either of them at the time. We upheld this aspect of Mrs C's complaint.

Miss C was due to have surgery on her leg at Dumfries and Galloway Royal Hospital but this was cancelled shortly before the scheduled time. Miss C complained that the board did not carry out her surgery and that the reasons for this were not properly explained to her. While the board apologised for the confusion surrounding the decision to cancel Miss C's surgery, they felt that the decision was appropriate as it was a major operation with significant risks and she had shown some recent improvement. Miss C was unhappy with this response and brought her complaint to us. We took independent advice from a consultant vascular surgeon. We found that it was reasonable for the operation not to have been performed, but we considered that the decision-making process surrounding this could have been clearer. We found that the entries made at the time in Miss C's medical records indicated that the reasons for not going ahead with the surgery had been explained to her. We did not uphold Miss C's complaints but provided feedback to the board regarding their decision-making process for surgery in complex cases. Related reading View Decision Report 201701656 as a PDF (11.1 KB) Updated: December 2, 2018

Mr C attended his GP practice with symptoms of fatigue, reduced appetite and night sweats. Tests indicated an infection and Mr C was prescribed antibiotics and referred to hospital. Several weeks later, after discussing the matter with the GP, Mr C decided to cancel the hospital appointment offered. However, Mr C was unaware that the referral to hospital mentioned the possibility of serious pathology (red flag symptoms). When Mr C had the same symptoms a year later, an x-ray showed suspected cancer in his right lung and further tests showed stomach cancer. Mr C complained that failings by the practice meant that he had been unable to make an informed decision about the initial referral the year before and that his life had been shortened considerably. Mr C complained that the practice failed to provide him with a reasonable standard of medical care. We took independent advice from a GP. Overall, we found that the standard of medical care and treatment provided was reasonable. We were satisfied that Mr C had been investigated appropriately and that the tests taken were thorough. Therefore, we did not uphold the complaint. Related reading View Decision Report 201700272 as a PDF (11.19 KB) Updated: December 2, 2018

Mrs C complained on behalf of her husband (Mr A) about the care and treatment he received at Dumfries and Galloway Royal Infirmary. Mr A became unwell and was admitted to hospital. A heart scan identified that he had a gathering of fluid around his heart. Staff inserted a chest drain (a tube to remove fluid) but the next day staff discovered that the drain had become blocked. They made multiple unsuccessful attempts to insert another chest drain which resulted in significant bleeding. A decision was made to transfer Mr A to a hospital out with the board, which took place late in the evening. Mrs C complained that the board failed to provide Mr A with appropriate medical care and treatment. She raised particular concerns about the actions of the staff in inserting chest drains and about the time taken to transfer Mr A to the other hospital. Mrs C also complained that the board failed to communicate appropriately regarding Mr A's condition. We took independent advice from a consultant cardiologist. We found that bleeding is a recognised complication of the chest drain procedure and that it appeared reasonable. However, we found that records showed evidence of poor communication between staff and concerns about skills in relation to some members of staff. Regarding the transfer of hospitals, we found that the time taken to transfer Mr A to the hospital outside the board was unreasonable. We also found that the discharge arrangements were inadequate, given the complicated nature of Mr A's admission. Therefore, we upheld this aspect of Mrs C's complaint. In relation to communication with Mrs C, we found that there was evidence of poor and limited communication with both her and Mr A, particularly surrounding the procedure to insert the chest drain and the transfer of hospitals. We upheld this aspect of Mrs C's complaint. However, we noted that the board had taken action to address a number of these problems.

Ms C complained about the care that her late mother (Mrs A) received at Dumfries and Galloway Royal Infirmary. Mrs A was admitted for emergency treatment of a bowel issue and after some time in the intensive care unit, she was moved to the high dependency unit (HDU). Mrs A's condition deteriorated while she was in the HDU and she later died. Ms C was concerned about the standard of both medical and nursing care that Mrs A received. Ms C also complained about the level of communication with family members and the way that the board dealt with her concerns. We took independent advice from a critical care consultant and a nursing adviser. We found that the care and treatment provided to Mrs A by both medical and nursing staff was appropriate and reasonable. Therefore, we did not uphold these aspects of Ms C's complaint. However, we found communication with the family during Mrs A's time in hospital to be unreasonable. The nursing adviser noted that staff will refer to the 'ceiling of care' indicating the level of intervention that is appropriate for that particular patient. We considered that the records made of discussions with Mrs A's family were insufficient as they did not document enough information about ceiling of care and to what extent this was discussed. Therefore, we upheld this aspect of Ms C's complaint. However, we noted that the board had already identified areas for improvement. In relation to complaints handling, we found that there had been a short delay in issuing a final response to Ms C and that the board had not arranged an extension or apologised for this. Therefore, we upheld this aspect of Ms C's complaint. However, we noted that the board had acknowledged this failing and had made improvements to their approach to complaints handling.

Mr C raised a complaint about the care and treatment he had received from his dentist when he had two teeth removed and two new teeth added to his existing denture. Mr C later found his denture to be too loose fitting and returned to his dentist. Mr C had clips fitted to make his denture more secure, however, he still felt that it was too loose and was advised by his dentist that a new denture was the only other option. Mr C was unhappy with his treatment and brought his complaint to us. We took independent advice from a dentist. We found that the dental treatment Mr C received was reasonable and in accordance with usual practice. However, we found issues with patient communication and record-keeping. Mr C was not given a full explanation of his treatment at the outset or advised of the all the possible options and outcomes. We also found that dental records did not mention the advice that the dentist had given to Mr C. On balance, we found Mr C's treatment to be unreasonable and upheld his complaint.

Mrs C complained on behalf of her husband (Mr A) about the care and treatment he received from the board at Dumfries and Galloway Royal Infirmary. Mrs C complained that there was an unreasonable delay in diagnosing that Mr A was suffering from renal cancer, that there was an unreasonable delay in providing him with treatment and that staff had failed to communicate appropriately with Mr A and his family about his diagnosis and treatment. We took independent advice from a consultant urologist who said that there was a severe failure to follow-up on a radiologist's report of a scan. The radiologist had suspected that an area of abnormality which showed in Mr A's kidney was renal cancer and had made a recommendation that the scan should be discussed at a urology multi-disciplinary team meeting (MDT). The radiologist's recommendation to discuss this at MDT was not actioned. There was also a failure to mention the scan finding in any of the correspondence on Mr A's discharge from the hospital. As a result, the suspected renal cancer was neglected until the same renal mass was found, by chance, a number of months later when Mr A had a scan to investigate a problem that was unrelated to his renal cancer. While it appeared that Mr A's tumour had not progressed when found, we found that the delay was unacceptable and that the diagnosis, management and treatment of his renal cancer was well below an expected standard. We upheld Mrs C's complaints about delays in diagnosis and treatment. We also took independent advice from the consultant urologist, as well as a nursing adviser, about how staff communicated with Mr A and his family about his diagnosis and treatment. We did not find any reference in Mr A's medical records of medical staff having a discussion with him about his cancer diagnosis and treatment. We found that the actions taken by nursing staff had fallen short of the standard expected and needed for Mr A and his family at the time. We upheld this aspect o

Miss C's mother (Miss A) had lung cancer which had spread to her brain. The steroid medication she was taking to alleviate the symptoms caused psychotic symptoms, requiring an admission to Dumfries and Galloway Royal Infirmary. One day when her family went to visit they were unable to find her. They subsequently found her in a stairwell, disorientated and upset. Miss C complained about the board's failure to ensure that Miss A did not leave the ward. She also complained that the board's complaints handling was unreasonable. We took independent advice from a nursing adviser. The adviser highlighted the importance of the balance to be struck between weighing the risks of staff monitoring patients and promoting some independence and dignity. In their response to the complaint the board said that the ward was extremely busy and that, although staff did their best to ensure that vulnerable patients were monitored, they were extremely sorry and disappointed that on this occasion they were unable to prevent Miss A from leaving. We considered the board's response to the complaint to have been reasonable and did not consider that Miss A should have been under closer supervision. We did not uphold this aspect of Miss C's complaint. We found the board's complaints handling to have been poor. The family's complaint was initially not taken forward because it was believed that Miss A's consent was required, and she lacked capacity to give consent. We found that the board failed to communicate their reasons for not taking the complaint forward, and did not investigate until the Patient Advice and Support Service became involved. We upheld this aspect of Miss C's complaint.

Mrs C complained to the board about the care and treatment she received when she was admitted for elective hip replacement surgery at Dumfries and Galloway Royal Infirmary. Mrs C recalled feeling pain before the procedure finished, known as breakthrough pain, and complained to us about the level of anaesthesia she was given during surgery. We took independent advice from an anaesthetic adviser, who was satisfied that that both the type and dose of anaesthetic and sedative drugs used were appropriate in this case. They did not find a record of breakthrough pain in the notes, and they could not confirm what action might have been taken in response to this. As the evidence available was not conclusive about the reported episode of breakthrough pain, we could not conclude that there was a failure to document pain and the use of top-up anaesthetic. We did not uphold this complaint. Mrs C also raised concerns that staff did not maintain reasonable records following the operation, and that the records failed to reflect that she was in pain. We received independent advice from an adviser in general medicine and a nursing adviser. The general medicine adviser was satisfied that the frequency and detail of the entries in the records by medical staff was in accordance with normal practice, and they considered that the record-keeping was reasonable. The nursing adviser found that the nursing records had been maintained to a reasonable standard and were in accordance with the professional code of practice. We concluded that the record-keeping was reasonable and we did not uphold this complaint. Related reading View Decision Report 201605471 as a PDF (11.3 KB) Updated: March 13, 2018

Ms C complained about an appointment she had attended with a psychiatrist to explore her possible learning difficulties. In particular, she complained that she had not properly consented to discussing the matters raised with her, that the questions asked of her were unreasonable given the stated purpose of the meeting, and that her privacy was ignored as these questions were asked in front of others. We took independent advice from a mental health adviser and found that while the psychiatrist had acted reasonably in the matter of consent, they should have enquired further about Ms C's understanding of the appointment. We found that the questions asked were not unreasonable, but it should have been made clear to Ms C that she could decline to answer. We did not uphold these aspects of the complaint, but made a recommendation to address this. In relation to Ms C's privacy concerns, we found that she should not have been asked any personal questions in the presence of others. We, therefore, upheld this aspect of the complaint.

Mr C complained about various aspects of the treatment he received at the prison health centre. He complained that the board failed to carry out an appropriate assessment of him, and failed to adequately manage his pain. During the course of our investigation, Mr C was liberated from prison. He did not provide us with a forwarding address so we were unable to communicate with him. In the circumstances, we discontinued our investigation. Related reading View Decision Report 201605508 as a PDF (10.81 KB) Updated: March 13, 2018

Ms C complained about a transvaginal ultrasound scan (an internal pelvic scan used for examination of a woman's reproductive organs) carried out at Dumfries and Galloway Royal Infirmary. Ms C complained that she was kept waiting unnecessarily, that inappropriate and unclean equipment was used and that the procedure was carried out in an overly rough manner which she felt led to vaginal and bladder infections. Ms C also complained about the way her complaint was handled. During our investigation we took independent medical advice from a consultant obstetrician and gynaecologist with a special interest in ultrasound scanning. We found that a member of staff should have checked on Ms C's wellbeing while she waited for her scan so we upheld that aspect of her complaint. We found that there was no evidence that the equipment was inappropriate or unclean so we did not uphold those aspects of the complaint. We found that while these types of scans can sometimes cause vaginal or bladder infections, this would not necessarily indicate that the scan was carried out improperly or in too rough a manner, so we did not uphold this aspect of the complaint. In relation to complaints handling, we found that there was a delay in responding to Ms C's complaint which the board did not acknowledge, and we therefore upheld this aspect of the complaint.

Mr C complained to us about the care and treatment provided to him by the board in relation to treatment for his leg problems, and their communication with him. Mr C said that after a course of foam sclerotherapy (a procedure where medicine is injected into the blood vessels, making them shrink) for varicose veins in his legs, he was in a lot of discomfort. He said that he was told at a scan a month later that he had deep vein thrombosis (a condition when a blood clot forms in a vein located deep inside the body) but that he was not given appropriate treatment for this. He also said that he had been told contradictory things regarding the clot in his leg. During our investigation, we took independent medical advice from a consultant vascular surgeon. We found that although the treatment that was given to Mr C was reasonable, there were two occasions on which follow-up scans should have been arranged but were not. We upheld this aspect of Mr C's complaint. We also found that the board had acknowledged that communication with Mr C had been poor, and that the lack of documentation of communication evidenced this. We upheld this aspect of Mr C's complaint. Mr C also complained to us about the board's complaints handling, specifically that it took a long time for them to issue their final response to his complaint. The board accepted that they had failed to respond to Mr C's complaint in a timely manner and we therefore upheld this aspect of Mr C's complaint.

Ms C complained about the treatment she received for an eye infection from the out-of-hours service at Dumfries and Galloway Royal Infirmary. In particular, Ms C complained that a GP wrongly tried to dissuade her from attending the primary care clinic and that when she did attend, she did not receive treatment and was told she needed to give the antibiotics already prescribed more time to work. Ms C also complained about the board's complaints handling. During our investigation we took independent medical advice from a GP. The adviser considered it was reasonable Ms C was told to allow more time for the antibiotics her own GP had given her to work. The adviser did not consider the care provided to be inadequate. We therefore did not uphold Ms C's complaints about the care she received. As we considered there were some errors in the board's complaints handling, we upheld this aspect of Ms C's complaint. The board acknowledged that they were not always efficient in responding to and progressing Ms C's wider concerns and said that they were in the process of making improvements to their complaints handling practices.

An arrangement was in place whereby Mr C received his meals in his prison cell. This was as a result of the anxiety Mr C experienced in attending the prison dining hall due to post-traumatic stress disorder (PTSD). However, the board advised the Scottish Prison Service (SPS) that Mr C could return to the dining hall to have his meals. Mr C complained about the board's decision that he was fit to do so. We took independent medical advice from a consultant forensic psychiatrist who noted that the in-cell dining arrangement did not appear to have been a significant feature of Mr C's historic clinical assessments. They also noted that there was no indication that PTSD was felt to have been a major ongoing issue for Mr C. They considered that Mr C was appropriately reviewed by clinicians before deciding that he was fit to attend the dining hall and that this decision was reasonable. We did not uphold the complaint. However, the adviser considered that the psychiatrist who reviewed Mr C's fitness to attend the dining hall should have provided clearer and more definitive advice to the SPS. As they were still in training, they should have discussed the situation with their supervising consultant if they were unclear on what to advise. There was no evidence that this happened. We noted that the psychiatrist had indicated they would leave it for the SPS to make the final decision, rather than focusing on providing clear and specific advice upon which they could base their decision. We considered that the board's role in such decision-making could benefit from being clarified through the provision of guidance to mental health staff and we made recommendations accordingly.

Mrs C complained about the care and treatment she received when she gave birth at Dumfries and Galloway Royal Infirmary. In particular, she said that a pessary used to induce labour was left in too long, she was unable to use the birthing pool and a tear she suffered was not effectively repaired. We took independent midwifery advice and found that overall, Mrs C's labour and birth had been conducted reasonably. The pessary had been used appropriately and was removed as labour progressed. Stitching of the tear she sustained was completed quickly and though it was recognised that sutures could become loose, Mrs C was referred to an obstetrician as required. However, it was noted that Mrs C either did not receive or did not understand information given about anaesthetic and how its use had repercussions with regard to the use of the birthing pool. Furthermore the clinical records, which were not of the standard required by current guidance, lacked information. For these reasons, we upheld Mrs C's complaint. Mrs C also complained about her aftercare. However, we found no evidence to show that this had not been reasonable.

Miss C, an advocacy and support worker, complained on behalf of Mr A about the care and treatment he received at Dumfries and Galloway Royal Infirmary for the surgical removal of haemorrhoids. Mr A developed a wound infection (a recognised complication of surgery) and he had to have a permanent colostomy. Miss C complained that Mr A had not been fully informed about the risks of the surgery, that his operation was not performed properly, and that care of his wound was poor. We took independent advice from a general and colorectal surgeon. We found evidence to support that the surgery carried out was to a reasonable standard. However, Mr A reattended the hospital by ambulance with post-operation wound-related problems and we considered that the registrar doctor who reviewed Mr A at this point should have contacted the surgeon who had carried out the surgery or the consultant surgeon responsible for admissions that day. We therefore upheld this aspect of Miss C's complaint. We also took independent advice from a nursing adviser and found evidence of appropriate care of Mr A's wound following surgery. We were critical that a full nursing assessment was not carried out at the time Mr A re-attended hospital. However, we did not consider this to have been a failing by the nurses, due to Mr A having been discharged. We found insufficient evidence to show which risks and complications of surgery had been discussed with Mr A prior to him consenting to the operation. We were also critical that the consent form did not include all of the known risks and complications of the surgery. We therefore upheld this aspect of Miss C's complaint.

Mr C complained on behalf of his late father (Mr A). He raised concerns that staff at Dumfries and Galloway Royal Infirmary failed to provide Mr A with appropriate medical treatment and about the board's handling of his complaint. Mr A attended the hospital for a hernia operation. The operation was performed and Mr A was discharged. However, Mr A became unwell and was readmitted to hospital the same day. Mr A's condition continued to deteriorate and he died some months after the operation. The board conducted a significant adverse event review (SAER) and complaints investigation. These processes identified a number of failings, including an error in the prescription of bisoprolol (a beta-blocker, used to treat high blood pressure) and a failure to review blood tests. Mr C questioned whether the board had appropriately identified all the issues in Mr A's care and whether they had appropriately taken action to address these failings. In addition to the issues with the medication and the review of blood tests, Mr C raised concerns about monitoring Mr C's fluid levels, attending to his catheter and the actions of the consultant surgeon and anaesthetist prior to and after Mr A's admission, including whether staff should have undertaken the operation. Mr C also raised concerns about the way the board's investigations had been conducted, including the interaction between the two processes and delays in responding to his correspondence. After receiving independent advice from a consultant in general medicine and a nurse, we upheld Mr C's complaints. We found that the prescription of bisoprolol was unreasonable. We also found the board failed to review Mr C's blood tests. We found the board had subsequently taken appropriate action in relation to these issues. However, we also found there was a lack of specific medical review prior to Mr A's discharge and we were critical of this aspect of Mr A's care. We also found failings in respect of monitoring Mr A and in

Mrs C said her son (Mr A) had bilateral gynaecomastia (swelling of male breast tissue) and was to have surgery at Dumfries and Galloway Royal Infirmary to remove the excess tissue from both breasts. Mrs C complained that on the day of the operation, the board changed the procedure Mr A was to have by operating on one breast instead of both and failed to communicate this to Mr A appropriately. She also said that the operation was not carried out to a reasonable standard and that the board did not reasonably respond to her complaint about the surgery. We obtained independent advice from a consultant breast surgeon. The adviser said it was unreasonable that the decision to operate on Mr A's right breast only was made immediately pre-operatively. We were also concerned that the board did not obtain Mr A's signed consent for the revised procedure and that Mr A did not appear to have been shown photographs of other patients who had had the procedure carried out by the board or been provided with written information on the procedure for him to consider in advance of surgery. Therefore, we upheld this part of Mrs C's complaint. The adviser said it was not possible for them to determine whether Mr A's surgery had been carried out to a reasonable standard or whether the decision to change the surgery had been reasonable as there were no photographs of Mr A's chest before and after surgery and no notes of the surgeon's rationale for making this decision. We therefore did not uphold this part of Mrs C's complaint. The evidence showed that it took the board nearly 11 months to successfully make contact with the surgeon, who had since left their employment, and that when Mrs C first raised issues about Mr A's surgery, the board logged this as a concern rather than a complaint. We upheld this part of Mrs C's complaint.

Mr C complained that a GP practice did not properly maintain the medical records of his wife (Mrs A) and as a consequence, when she was admitted to hospital she was given medication which led to serious side effects. He further complained that a member of staff spoke to him inappropriately and told him that by stopping his wife's medication he could cause Mrs A's death. We took independent general practice advice and noted that while Mrs A's medical records showed that a conversation with Mr C had taken place where he said that he was stopping her medication due to his belief that it caused side effects, they did not record a change to her medication. This was because Mrs A had the capacity to make decisions about her treatment and any changes could only be made after discussion with her. Whilst the records noted a terse conversation with Mr C about his wife's medication, there was no evidence that he had been spoken to inappropriately. It was clear that the repercussions of Mrs A stopping taking her medication had been clearly explained to Mr C. We did not uphold the complaint. Related reading View Decision Report 201508145 as a PDF (11.11 KB) Updated: March 13, 2018