SPSO Individual Decisions

C complained to us on behalf of their adult child (A). A had several attendances at Victoria Hospital and admissions for further investigation following a period of illness with severe stomach pain, nausea and vomiting. C raised concerns about A's medical care and their nursing care. We took independent advice from a consultant gastroenterologist (a specialist in diagnosing and treating disorders of the stomach and intestines). We found that A was given appropriate medical care and treatment and we did not uphold that aspect of C's complaint. We also took independent advice from an acute nursing specialist. We found that there were delays or issues in getting some of A's prescribed medications. Also, on one occasion, A was given a dose of a medication that was higher than recommended. We found that as A developed a staph aureus bacteraemia (SAB, where a bacteria commonly found on the skin enters the body) infection during their admission, the board appropriately carried out a significant adverse event review and took steps to improve this aspect of care. However, we found that the specific concerns that A's family raised about what caused A's SAB infection should have been addressed in their significant adverse event review. We upheld this aspect of C's complaint.

C's adult child (A) had a history of intravenous drug use and was on a methadone programme. A suffered from osteoarthritis (a condition that causes joints to become painful and stiff) in their knee. A sought surgical treatment for this on a number of occasions. On the latter two occasions, the board determined that A was physically suitable for surgery. Surgery was initially scheduled but it did not take place. A sought surgery again the following year, however, the consultant surgeon did not consider A would cope with the possible postoperative pain of a total knee replacement (TKR) and decided not to schedule any surgery. C complained to the the board about this decision. The board's response noted recent x-rays showed A was physically suitable for surgery but that the board was concerned about how A would cope with the postoperative pain, and noted the likelihood that A would be in more pain following the surgery than previously. The board said that pain control following this operation can be exceptionally difficult and that this, coupled with the high doses of methadone A was prescribed and any heroin injections they may have been taking, meant that there was a risk of A's pain becoming chronic and untreatable after the operation. Clinicians recommended that A's chronic pain be managed, A's dose of methadone reduced and A be free of heroin before surgery be considered. The board said that clinicians intended to await a multidisciplinary team meeting outcome and liaise with A's psychiatrist before discussing options with other colleagues. The board said that A's GP would be updated with information about these outcomes and the board's recommendations at that point. We took independent advice from an orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the board's reasons for caution regarding A's TKR were well documented and their decisions were reasonable. In considering the compla

C complained about the treatment for a leg wound which they had received from a podiatrist (a physician who specialises in the study and medical treatment of disorders of the foot, ankle and lower extremity). C felt that the podiatrist was rough and that they had provided inappropriate treatment as the wound had increased in size. C, who has a history of cardiovascular disease (disorders of the heart) and other health issues, required regular podiatry treatment to treat their toes and feet for ulcers. C began to have concerns about a number of podiatrists who had treated them. In particular, C felt that one podiatrist was irate when they had to wait a time for C to answer the door due to their poor mobility. C also found that the wound appeared to worsen after the podiatrist's care. We took independent advice from an adviser and found that from a clinical perspective, the treatment provided by the podiatrist was reasonable. There was evidence that informed consent for treatment was obtained from C and that their leg wound was treated in accordance with recognised procedures. We did not uphold the complaint. Related reading View Decision Report 202003093 as a PDF (24.26 KB) Updated: August 18, 2021

C complained that the care and treatment provided to their partner (A) was unreasonable. During a routine scan around 20 weeks into A's pregnancy, their cervix was found to be short, putting them at risk of miscarriage. A suture (a stitch or row of stitches holding together the edges of a wound or surgical incision) was inserted in their cervix that day. In hospital the following day, it appeared that A's membranes had ruptured and that the decision was taken to remove the suture. A and C were advised their baby was unlikely to survive. They were offered medication to abort the foetus and condolences were given. They chose to continue with the pregnancy and as time passed it appeared that the initial diagnosis had been incorrect. A was monitored for a few days on the ward and was discharged with follow-up arrangements when their condition was deemed to be stable. At a follow-up appointment a few days after discharge from hospital, the consultant advised that a further suture was required to protect the pregnancy. The procedure was carried out that day. A few weeks after the second suture was inserted, A went into labour and their baby was born three months prematurely. C complained that the decision to remove the first suture was unreasonable. They also complained that they had been told their unborn baby was dead. We took independent clinical advice from a consultant obstetrician and gynaecologist (specialist in pregnancy, childbirth and the female reproductive system). We found that in deciding to remove the suture the clinicians were acting in good faith with the information available and in the best interests of the mother, at a stage when the foetus could not survive if delivered. Appropriate discussion took place with the on-call consultant who was in agreement with the instruction that the suture should be removed if there was any sign of ruptured membranes. This is a recognised indication for removal of a cervical suture as it increases the risk

C's parent (A) had complained for a number of years about pain in their legs. They considered that their concerns had been dismissed and that they weren't reasonably responded to. A later required a stent and an angioplasty (a procedure to widen narrowed or obstructed arteries or veins) after they experienced a blockage of an artery in their leg. While initially successful, the stent then blocked, leading to a second procedure. A later had their leg amputated. C considers this could have been avoided with earlier treatment. C complained that the board failed to reasonably respond to issues regarding A's feet and legs. We took independent advice from a vascular adviser (treats disorders of the circulatory system). We found that prior to the severe blockage experienced by A, the actions taken by the board in response to their symptoms of pain and numbness were reasonable. We found that these symptoms were unrelated to the sudden onset situation where A had blockage of the external iliac vessel (relating to the large broad bone forming the upper part of each half of the pelvis or the nearby regions of the lower body) on the left side, and we found that the response to this blockage was reasonable. When the stent then became blocked, we found that the response to this was also reasonable. However, communication with A and their family could have been better in terms of explaining A's symptoms, how A was followed up after the procedure and the possibility that the initial stent could fail. While there were some communication issues and there should have been further follow-up after the first stent was placed, we found that the overall the treatment provided by the board was reasonable. Therefore, we did not uphold this complaint. Related reading View Decision Report 202004831 as a PDF (24.56 KB) Updated: June 23, 2021

C complained about the length of time they waited for gallbladder surgery. They had two emergency admissions to hospital without surgery being carried out and had been placed on the waiting list for surgery after their second admission. C said that they were left in chronic and excruciating pain and considered the surgery should have been carried out on an emergency basis. They considered the length of time that they were waiting was unreasonable. As a result, C had the surgery carried out privately. The board said that it was reasonable to postpone surgery each time C was admitted to hospital because their gallbladder had been inflamed. C was seen and allocated to the surgery waiting list. C's surgery would have been carried out within current NHS waiting times. We took independent advice from a colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found that C should have been regarded as a high priority case given their symptoms had led to two emergency admissions and, after each admission, they should have been offered an early appointment for surgery once the inflammation settled. Instead, due to an administrative error, an initial follow-up appointment was not offered after the first admission. After the second admission, C was added to the waiting list with no indication as to when their surgery would take place. We found that the board had failed to arrange C's gallbladder surgery within a reasonable timeframe and, therefore, we upheld C's complaint. We took into account that the cost of the private treatment was partly due to the board's failings and also partly due to a private decision by C. In the specific circumstances, we recommended that C be reimbursed to the extent which the surgery would have cost the board.

C complained about the care and treatment provided to their late spouse (A) by the board in relation to the diagnosis, treatment, and management of A's cancer, especially regarding a delay in A receiving a Positron Emission Tomography scan (PET, a scan that produces detailed 3D images of the inside of the body). We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines). We found that A's cancer pathway took 17 months, which was significantly longer than it should have taken. We found that the most significant issue for the delay in the process was the error which resulted in the PET scan not being booked, as requested by the multi-disciplinary team (MDT). Additionally, the PET scan should have been requested on a suspected cancer pathway and we were critical that this was not the case. We found that the delay in A's diagnosis was unreasonable and on balance, due to the increase in size of A's tumour during the delay, it is likely this negatively impacted on their outcome. We considered that the care and treatment A received from the board was unreasonable and upheld this aspect of C's complaint. C also complained about the out-of-hours service (OOHS). A developed a postoperative wound infection, and was admitted to hospital. C complained that the OOHS, who saw A prior to admission, requested a non-life-threatening response from the Scottish Ambulance Service (SAS), rather than a life-threatening ambulance. We took independent advice from a GP. We found that the OOHS GP requested the ambulance in line with the SAS guidance, and any delays in the ambulance attending were outwith the GP's control. Therefore, we did not uphold this aspect of C's complaint.

C complained about the care and treatment they received at Victoria Hospital for their broken wrist. C had surgery on their wrist but developed swelling and pain two months later. C's GP referred them back to the board but C felt that they could not wait for 12 or more weeks to see an orthopaedic doctor (a specialist in the treatment of diseases and injuries of the musculoskeletal system) on the NHS, so obtained private treatment. We took independent advice on this complaint from a consultant in emergency medicine and a consultant orthopaedic surgeon. C said that they were not given adequate pain relief when they first attended the hospital. We found that the timing and type of pain relief given to C appeared reasonable, but the board failed to record pain scores for C and this was unreasonable. As there was no record of C's level of pain, we were unable to conclude with certainty that C's pain was adequately controlled. C complained that the board failed to contact them about surgery after they were sent home and advised to wait to be contacted. We found that the board failed to contact C in a timely way to advise them when their surgery would take place. C also complained that there was a delay in the surgery taking place. We concluded that the ten day delay in C's surgery taking place was unreasonable. However, whilst acknowledging the significant pain and uncertainty experienced by patients in such cases, we found no evidence that the delay had been ultimately detrimental to C's clinical outcome. C said that they felt they could not wait for 12 or more weeks to see an orthopaedic doctor on the NHS, so had to obtain private treatment. We did not conclude that C had no choice but to obtain private treatment, as it could not be assumed that C would have been back to driving and other manual tasks more quickly, if they had been seen sooner. However, we noted that C's GP referral should have resulted in C being reviewed within four weeks at the fracture clin

C submitted a complaint on behalf of their late sibling (A) about the treatment A had received by the board over a five-month period. A had a mass in their abdomen which led to a referral to urology (specialists in the male and female urinary tract, and the male reproductive organs) and later gynaecology (specialists in the female reproductive systems). A was initially diagnosed with pedunculated fibroids (noncancerous growths in the uterus) but it was later found by a different health board that A had cancer. C considered that the treatment provided by the board was unreasonable and led to a delay in A receiving the correct diagnosis. C complained that the board failed to reasonably diagnose A after they were referred by their GP. We took independent advice from a specialist. We considered that the initial investigations carried out were reasonable, however, after the MRI results were received, the board failed to reasonably respond to this. The MRI result did not match with A's clinical picture and we considered that there was an unreasonable failure that this was not recognised and steps taken to investigate it further in a reasonable timescale. We considered that there was a failure in clinical judgement relating to this. Therefore, we upheld this aspect of C's complaint. C also complained that the board failed to provide reasonable treatment when A attended A&E. We took independent advice about this complaint. We found that the investigations carried out were reasonable; we noted that further actions could have been taken, but the lack thereof was not in itself unreasonable, given the remit of A&E to only deal with emergency presentations. On balance, we did not uphold this aspect of C's complaint.

C had experienced pain and numbness in their hands over a period of years and was referred to the board for treatment. C underwent some tests and was offered repeat carpal tunnel surgery. C complained that the board failed to provide reasonable care and treatment. Unhappy with the board's response to their complaint, C brought the complaint to our office. We took independent advice about all the complaints raised with us. C complained that the board failed to carry out reasonable tests and investigations prior to their surgery. While we considered that the rationale provided by the surgeon in relation to what tests were carried out was reasonable, we questioned whether this was reasonably explained to C. We considered that the contemporaneous records did not evidence a thorough assessment of C's condition prior to the surgery being carried out. Therefore, we upheld this aspect of C's complaint. C complained that the board unreasonably carried out surgery to their hands. We considered that the decision to undertake the revision surgery was reasonable, albeit that further investigations could have been carried out prior to this. C had previously had carpal tunnel surgery. We noted carpal tunnel can recur and it was reasonable for a second operation to be considered. On that basis the offer of surgery was reasonable. We did not uphold this aspect of C's complaint. C complained that the board failed to offer a reasonable treatment plan after their surgery. We considered that after it was found the surgery had been unsuccessful, the actions recommended by the surgical team were reasonable. They offered to refer C back to the pain clinic and, after this was declined, discharged C back to the care of their GP. We concluded the board's treatment plan and actions regarding pain management were reasonable. We did not uphold this aspect of C's complaint.

C complained that their partner (A) was inappropriately prescribed a strong opiate painkiller by their GP, that they developed severe mental and physical health problems as a result of being kept on this medication for too long, that A was not appropriately reviewed while on this medication, and that their requests for help were not acted upon. We took independent advice from a GP, who considered whether the prescribing to A was reasonable in the circumstances. They found no evidence to support that the long-term prescribing of the medication contributed to the deterioration in A's mental and physical health. They noted there was evidence of regular review and discussion of A's pain and pain relief. We accepted this advice and did not uphold this complaint. However, we noted some complaint handling issues. The practice did not initially request consent from A to enable them to take C's complaint forward. Additionally, there were subsequent delays in preparing their response and they did not keep C updated or agree an extension to the target timeframe. We advised the practice to review their handling of C's complaint and ensure mechanisms are in place to ensure compliance with the NHS Scotland Complaints Handling Procedure. Related reading View Decision Report 201902396 as a PDF (24.36 KB) Updated: May 19, 2021

C, a support and advocacy worker, complained about the standard of medical and nursing care and treatment provided to their client (A) during A's hospital admissions at Victoria Hospital and Cameron Hospital over 11 months. The concerns raised cover numerous aspects of the care and treatment provided by clinicians at A&E and the intensive care unit at Victoria Hospital, and clinical staff at Cameron Hospital. These include unreasonable failures in relation to the response to A's deterioration, medication including dosage, communication, bedsores, rehabilitation, and discharge. C also said that the board failed to handle A's complaint in a reasonable way. C told us that as a result of the failings, A developed complications which have had a profound impact on them and their spouse's life. We took independent advice from four advisers: consultants in emergency medicine, psychiatry and anaesthesia, and a nurse specialist in tissue viability. We found that A had not been regularly reassessed as they should have been in A&E for a number of hours during which time their condition deteriorated and their transfer to the intensive care unit was delayed, and that staff in A&E failed to communicate with A's spouse in a reasonable way. We found that clinicians failed to take reasonable action to prevent hospital-acquired pressure damage to A and then failed to investigate and treat A's pressure ulcers, which led to severe and extensive pressure damage to a degree rarely seen in today's healthcare setting. We noted that this was avoidable and that the board's failure to identify these failings in their subsequent review was very concerning. We also found that the board's response to the complaint about A's condition and its cause did not reflect the evidence from the clinical records and advice obtained from specialists. We upheld five of C's complaints. We did not find failings in relation to medications, communication from clinical staff in intensive care, transfer, h

Mr C complained about the board's weight management service at Queen Margaret Hospital. In the course of our investigation, we took independent advice from a bariatric surgeon (a doctor who specialises in the causes, prevention and treatment of obesity). Mr C complained that the service refused to offer him bariatric surgery after he attended a weight management programme. We found that the board provided an inadequate reason for not progressing Mr C to the next stage of the pathway, where patients are considered for surgery, and considered that this decision was unreasonable. We found that the board did not give appropriate consideration to Mr C's individual circumstances in making their decision and had failed to offer a second opinion or appeal process. We upheld Mr C's complaint and made a number of recommendations. Mr C also complained that the board had informed him of their decision not to progress in a public setting, where other patients could overhear. We carefully considered Mr C's account and the board's account of what happened. We were unable to reconcile the differences, and we did not find evidence to conclude that clinicians had failed in their duty to maintain patient confidentiality. Therefore, we did not uphold this complaint. Finally, Mr C was also unhappy with the way the board handled his complaint. We found that there were short delays in the board informing Mr C about the timescales for responding to the complaint. We also found that the board had not communicated accurately with Mr C about a case conference that was initially offered to him. We noted that the board had apologised for the confusion in relation to this. We upheld this complaint and provided feedback to the board about complaint handling.

C told us that their spouse (A) had been under the care of a cardiologist (a specialist that deals with diseases and abnormalities of the heart) who saw them at least once a year for review appointments following surgery, until their death twenty years later. A scan taken six years before their death showed a chronic dissection of the descending thoracic aorta (a serious condition in which there is a tear in the wall of the major artery carrying blood out of the heart). Clinicians decided to manage A's condition conservatively, but C told us neither they nor A were aware of this or the findings of the scan. C was also concerned that clinicians failed to carry out regular scans to monitor A's condition until shortly before their death and that communication between different specialists had been poor. We took independent advice from a consultant cardiologist. We found a number of failings that had an impact on the board's ability to monitor A's condition which in turn meant that their treatment plan was not fully informed. These failings included: lack of records relating to A's operation and x-rays which made interpretation of later scans more difficult; lack of follow-up on whether additional imaging and/or cardiac opinion was needed following the scan showing the dissection; results of a CT colonoscopy (a procedure that uses a CT scanner to produce detailed images of the colon and rectum) were not shared or acted upon. We also found that communication between the relevant healthcare professionals was not as effective as it should have been given A's complex clinical condition. We upheld both of C's complaints.

C complained about the consent process and the standard of surgery for a procedure they had received from the board. C was listed for a surgical procedure with the aim of removing a stoma (an opening in the abdomen formed during a colostomy procedure) and a para-stomal hernia (a weakness in the abdominal wall beside a stoma which allows the bowel to protrude outwards). The surgeon was unable to safely perform the procedure as planned and the decision was made to create a new stoma site. C experienced complications with the wound following surgery and was unhappy with the outcome. We took independent advice from a consultant colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found that C should have been informed about the risk that it might not be possible to complete the intended procedure successfully and the implications of this. In the absence of evidence that C was informed of this, we concluded that the board had failed to obtain appropriate consent for the procedure, in line with recognised guidance. We upheld this aspect of C's complaint. In relation to the surgical procedure, we found that this was performed to a reasonable standard and the decisions made by the surgeon during the operation were reasonable. Given the findings, we did not uphold this aspect of C's complaint.

C complained about matters relating to their previous GP practice. C had been removed from the practice list as in the practice's view there had been a complete breakdown in the doctor/patient relationship due to the way C was using a prescribed antibiotic medication. The practice wrote to C to inform them of their decision. C had concerns about the practice's decision to remove them from the list. We found that the practice had failed to provide C with a warning before removing them from the practice list. Therefore, we upheld this aspect of the complaint. C was also unhappy with the factual accuracy of a letter sent by the practice regarding the removal decision. We did not find that the practice's letter contained inaccuracies and we were unable to conclude that it was unreasonable. We did not uphold this aspect of the complaint.

C complained that the practice failed to provide them with effective treatment for a skin complaint and that they waited an unreasonable length of time before they saw a doctor. We took independent advice from a nurse adviser and a GP adviser. C had first attended two nurse consultations, a week apart, as they had developed an itchy rash on their back. We noted that the initial working diagnoses (insect bites/fungal infection) and the care and treatment provided at this point was reasonable. Ten days after C's first consultation, they contacted the practice again. As the triage telephone call mentioned 'shingles' as another possible diagnosis, a referral to see a GP should have been made at this time. However, C was given an appointment with an advanced nurse practitioner. Although C was being treated with an allergy tablet, there was no documented working diagnosis of what was causing the itch. We found that the management of C at this time was not reasonable. C contacted the practice again the following day and requested to be seen by a GP. This was the fourth time C had contact with the practice in eleven days since the onset of the rash, which was getting worse and becoming painful. Although the advanced paramedic practitioner who saw C on this occasion sought advice of a GP regarding treatment, we considered that it was unreasonable that C was not referred to be seen by a GP at this time. C made a further request for a GP appointment two weeks later and again was given an appointment with an advanced paramedic practitioner. We found that this was unreasonable given that this was C's second request for a GP appointment, they had seen nurse and paramedic practitioners four times over a period of several weeks and had attended the out-of-hours service, during which time their rash was getting worse/not responding to prescribed treatment and was painful. Due to their ongoing symptoms, C attended again at the out-of-hours service when they were prescribed

C complained about the care and treatment provided to their late relative (A). A was admitted to hospital with an ongoing Clostridium difficile infection (bacteria that can infect the bowel and cause diarrhoea). A remained in hospital until their death. C raised concerns with the board about the level of clinical and nursing care provided to A. The family were particularly concerned that staff took the decision to implement the nil by mouth protocol, meaning A would not be given any foods or fluids. The board acknowledged failings and agreed to review relevant practice. We took independent advice from appropriately qualified advisers. In relation to the clinical care provided, we found that clinical staff took detailed consideration of A’s health and were aware how frail they were when admitted to hospital. The records indicated that a good level of investigation took place along with frequent blood tests and x-rays, when appropriate. We considered that the clinical care A received was reasonable. We did not uphold this aspect of C's complaint. In relation to the nursing care, we found that important information from A’s family with regards to the requirement to provide thickened fluids was handled poorly by nursing staff. We found that it was unreasonable to carry out the appropriate swallow test with A using water instead of thickened fluid. In addition to this, risk assessments and person-centred documentation were never completed throughout A’s time in hospital. Had this documentation been completed, then failings might have been avoided in A’s case, meaning medications and fluids would have been provided. We upheld this aspect of C's complaint.

C complained about a consultation with a consultant psychiatrist. During the consultation, C discussed a previous incident where their GP prescribed medication without carrying out a review of C's medical records. Following the consultation, the consultant psychiatrist recommended C be prescribed Mirtazapine (antidepressant medicine). C experienced side effects from the medication and subsequently discovered that their GP's records showed they had been prescribed this medication a number of years previously and had experienced adverse side effects. In light of this, C complained as they did not feel the consultant psychiatrist carried out an appropriate check of C's medication history before recommending that Mirtazapine was prescribed. C also complained about the time taken by the board to investigate their complaint and the thoroughness of their investigation. In respect of C's first complaint, we took advice from an appropriately qualified independent adviser with a background as a consultant psychiatrist. We found that the course of action taken by the consultant psychiatrist was appropriate and reasonable. We recognised that the decision to recommend Mirtazapine ultimately had a negative outcome for C, but we concluded that the decision-making and process leading to this recommendation was reasonable. We considered the consultant psychiatrist took appropriate action to ensure they had enough information to make an informed decision. In light of this, we did not uphold this complaint. In respect of the C's second complaint, we concluded that the board had carried out an appropriately thorough investigation, but their responses could have been clearer and more detailed. We also considered the time taken for the board to provide both a stage 1 and stage 2 response was unreasonable. As such, we upheld this complaint.

Ms C was referred to the ophthalmology department (the branch of medicine concerned with disorders and diseases of the eye) by her optician after she became concerned about the vision in her eye. She attended several appointments with a consultant ophthalmologist but was unhappy with the care and treatment provided. In particular, Ms C felt that the consultant did not take her seriously at her initial appointment. She was also unhappy that the treatments given and tests carried out did not give her a definitive diagnosis or improve the vision in her eye. We took independent advice from a consultant ophthalmologist. We found that the consultant's assessment, management and onward referral for tests were reasonable. Therefore, we did not uphold Ms C's complaint. Related reading View Decision Report 201804515 as a PDF (24.06 KB) Updated: February 17, 2021

C was admitted to the Queen Margaret Hospital where they were detained under an Emergency Detention Certificate (EDC). C complained about the nursing care provided during their admission. They said that staff did not interact with them or show them around the ward; they did not receive adequate food; they did not have clothes or toiletries; and that staff searched their bag and removed medication. The board said there were attempts to offer food to C, however this was sometimes refused. They said there was evidence of good nursing care provided to C and that they did attend for meals. The board confirmed C’s bag was not searched and that they do not hold a supply of clothing for patients. We took independent advice from a mental health nurse. We found that, while some aspects of the nursing care provided to C were reasonable, there was no evidence that a nutritional screening tool was used to assess C’s nutritional state, and this should have been done within the first 24 hours of admission. We concluded the board failed to adequately assess and record C’s nutritional needs and, as such, the nursing care was below the standard expected. We upheld C's complaint.

C complained to the practice about a consultation they had. They said that they reported symptoms of severe pain and swelling of the abdomen and that they were grey in colour and had difficulty standing up. C said the practice prescribed them with laxatives (medication to help increase bowel movements). C continued to deteriorate and days later was admitted to hospital as an emergency, where it was found they had perforated diverticular (diverticula are small bulges or pockets that can develop in the lining of the intestine as you get older) disease. C said they had to undergo emergency surgery and were an inpatient for a month. C felt that the practice should have diagnosed their serious condition and arranged an urgent hospital admission. We took independent advice from a medical practitioner. We found that the GP involved had carried out an appropriate examination based on C’s presenting symptoms and that a diagnosis of constipation was reasonable. There was no clinical indication that C’s health was going to suddenly deteriorate with severe diverticular disease and that they would require a hospital admission. We did not uphold the complaint. Related reading View Decision Report 202001802 as a PDF (24.32 KB) Updated: December 16, 2020

C complained about the care and treatment they received from the board. C received a positive bowel screening result and attended a screening clinic shortly after. A colonoscopy (an exam used to detect changes or abnormalities in the large intestine (colon) and rectum) was arranged but was unsuccessful. C later underwent a successful colonoscopy which identified a rectal polyp (a small cell clump that grows within your body). C’s polyp was initially considered to be benign (not harmful). They were referred for an endoscopic ultrasound (EUS) scan in another NHS board area. This identified that C had type two rectal cancer. C complained about what they considered to be a misdiagnosis by the board. They also complained about delays in the board carrying out a successful colonoscopy and arranging for an EUS to be carried out. We took independent advice from a general and colorectal surgeon (a general surgeon who specialises in conditions in the colon, rectum or anus). In respect of the colonoscopy, we noted that there was a delay of around 24 weeks from C’s positive bowel screening until a successful colonoscopy was carried out. Although the delay was not wholly down to the board, we considered this length of time to be unreasonable. We noted that C was effectively placed at the back of the queue each time an appointment was not successful. We concluded that the board should have done more to progress C’s case following the failed colonoscopy. As such, we upheld this aspect of the complaint. C’s second complaint was that the board unreasonably failed to diagnose that they had cancer following tests. We concluded that the board treated C’s polyp as being suspicious of cancer from the outset. However, we identified clear delays within the treatment pathway, which meant C’s cancer was not identified until later. This meant that cancer was either present during earlier tests, or developed in the months leading up to a later test. We concluded that the overall timescale coul

C complained to us about the board regarding treatment of their child (A). A became unwell and was referred to Victoria Hospital, where they were diagnosed as having gastroenteritis (inflammation of the stomach and intestines) by a paediatric nurse practitioner and discharged home. Three days later, A suffered a seizure and was readmitted to the hospital. They were transferred to a hospital in another health board area and diagnosed as having pneumococcal meningitis (a life-threatening infectious disease that causes inflammation of the layers that surround the brain and spinal cord). They remained in hospital where they later died. C complained to the board about their initial assessment and treatment of A. They complained that A was misdiagnosed and that staff did not follow the correct procedures when reviewing their condition. C also felt that A should have been seen by a doctor before the decision was made to discharge them. The board arranged for a Significant Adverse Event Review (SAER) to be carried out by doctors not involved in A’s care. The SAER identified a number of areas where the board could have acted differently in A’s case. However, C still had a number of concerns and asked that we conduct a further review of the case. We took independent advice from a consultant paediatrician. We found that, overall, the SAER had appropriately identified the key failings in the board’s care, including that the original diagnosis of gastroenteritis was unreasonable based on A’s symptoms. However, we found some additional failings in record-keeping, and highlighted that we would have expected the misdiagnosis to have been identified when the nurse practitioner discussed A’s case with a doctor before discharge. We also considered there had been failings in the handling of C’s subsequent complaints. For these reasons, we upheld all of C’s complaints.

C was admitted to Stratheden Hospital following an overdose. C’s complaint is in relation to the care and treatment provided during this admission. C said they were left without medication and discharged without a proper follow-up plan. The board acknowledged that medications were not available when they should have been. They said this was because C’s prescriptions needed to be ordered from the pharmacy and were not stocked on the ward. They said that a senior charge nurse had reminded staff to review prescriptions to ensure they are ordered in time. The board said they provided C with appropriate information about support services. We took independent advice from a consultant psychiatrist. We noted that it was accepted that there was a delay with providing C with their medication. However, we found that the overall management of C’s condition was reasonable, with effective communication between staff and C documented throughout. As such, we did not uphold this complaint. Related reading View Decision Report 201905684 as a PDF (24.23 KB) Updated: November 18, 2020