SPSO Individual Decisions

C, a support and advocacy worker, complained on behalf of their client (B) about the care and treatment their child (A) received in the early months of their life. A was born prematurely, suffered a number of medical problems following their birth and died a few years later. A was initially cared for in Aberdeen Maternity Hospital's neonatal unit. A was transferred for treatment in the High Dependency Unit (HDU) at Royal Aberdeen Children's Hospital. C asked us to investigate the standard of care and treatment that A received at Royal Aberdeen Children's Hospital. B said that A suffered a number of desaturation episodes which caused A to turn blue. They attributed this to staff being slow to react. A's feeds were increased upon admission to Royal Aberdeen Children's Hospital. B said that A's health began to deteriorate from this point. B said that A should have remained in Aberdeen Maternity Hospital's neonatal unit given A's weight at five months was still below that of many neonates, or else transferred to another neonatal unit elsewhere in Scotland. They complained that, whilst A was in Royal Aberdeen Children's Hospital, the level of supervision was insufficient, particularly over weekends. We took independent advice from a consultant paediatrician and a paediatric nurse. We found that, while A's condition was complex, there was nothing to suggest that moving A to the HDU at Royal Aberdeen Children's Hospital resulted in a drop in the level of care and support available. We also found that the overall approach to managing and monitoring A's weight was reasonable. We did not uphold these aspects of C's complaint. In relation to nursing supervision, we found that nursing staff reasonably monitored A throughout their time in the HDU, maintaining detailed and thorough records and appropriately escalating any issues identified to the medical team. We did not uphold this aspect of C's complaint. In relation to medical supervision, while the nursing staff

C complained to us, on behalf of A, that the board failed to appropriately diagnose and treat A during their attendances at Aberdeen Royal Infirmary. A had chronic obstructive pulmonary disease (COPD, a disease of the lungs in which the airways become narrowed) and had also previously been diagnosed with probable left sided lung cancer several years earlier. At that time, it was agreed that A would receive high dose palliative radiotherapy (a treatment using high-energy radiation). Over a period of eight months, A was admitted to hospital nine times. The first five of these admissions were to a respiratory ward and the last four to a general medical ward. They were treated for worsening of COPD and increasing frailty. A had a fall during one of the admissions, but was subsequently discharged home. C said that at that time, A was not fit for discharge as they required to be readmitted again a few days later when they were told that they had terminal cancer. A's condition subsequently deteriorated further and they died the following month. We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly). Although the board had acknowledged that the clinical records did not show that A's underlying diagnosis of cancer was discussed with them in appointments in the final two years of their life, we found that there was no evidence that the board failed to properly diagnose and treat A during the relevant hospital admissions. We did not uphold this complaint. C also complained that the board failed to communicate appropriately with A during this period, despite them having power of attorney for A. We found that A's care and treatment were discussed reasonably with both C and A and we therefore, did not uphold this complaint. C complained that the board failed to handle A's complaint in line with their obligations. We were satisfied that the board dealt with A's complaint in accordance with their complaints handl

C complained to the board about the treatment which they received when they attended the out of hours service (OOHS) at Aberdeen Royal Infirmary. C said that they had already reported problems with back pain and loss of feeling to their GP practice. However, the OOHS doctor who attended to C did not conduct examinations or arrange investigations such as a scan, and told C to see their GP the following day. C was taken by ambulance to hospital the following day and, after a CT scan, they were diagnosed as having cauda equina syndrome. C felt that the doctor at the OOHS should have completed a more thorough examination and that the correct diagnosis would have been reached sooner and would not have had such a drastic effect on their health. We took independent advice from a GP. We found that that although the OOHS doctor obtained a good history from C and conducted a reasonable examination, they failed to action C's progressive neurological symptoms and new onset bladder problems. These required referral for an orthopaedic (conditions involving the musculoskeletal system) opinion or further investigations that day. Therefore, we upheld the complaint.

C complained to the practice about the treatment that they received when they contacted the practice with back problems. C spoke to a GP and an advanced nurse practitioner (ANP) by telephone during that period due to the COVID-19 restrictions and C was advised to make further contact should their situation worsen. C was taken by ambulance to hospital and after a CT scan was diagnosed as having cauda equine syndrome (a disorder that affects the nerves). C felt that the GP and the ANP should have seen them in person for an examination and that had this been the case, the correct diagnosis of cauda equine syndrome would have been reached sooner and would not have had such a drastic effect on their health. We took independent advice from a GP and an ANP. We found that C had a previous history of back problems over a number of years which were felt to be sciatica (back and leg pain caused by irritation or compression of the sciatic nerve) and musculo-skeletal in nature and that it was not unreasonable to attribute C's reported symptoms to those conditions. However, when C attended hospital their condition had deteriorated and they had reported new symptoms which were red flag signs of cauda equine syndrome. We did not uphold the complaint. Related reading View Decision Report 202004100 as a PDF (24.37 KB) Updated: June 23, 2021

C complained on behalf of their parent (A). A had a fall at home and was admitted to hospital due to a fractured hip. C was concerned that A was discharged from hospital only a few days after they had surgery. We took independent advice from an orthopaedic surgeon (specialist in diagnosing and treating conditions involving the musculoskeletal system) and an occupational therapist. We found that a comprehensive occupational therapy assessment was carried out prior to A's discharge which fully considered A's home environment and that the decision to discharge A four days after surgery was reasonable and met the targets set out in the Scottish Standards of Care for Hip Fracture Patients. We also found that the discharge and medications were discussed with A. We, therefore, did not uphold C's complaint about A's discharge from hospital. C also complained about the way the board handled their complaint. We found that the board did not always proactively update C or provide a revised timescale when they could expect to receive the response to their complaint. Therefore, we upheld C's complaint in this regard.

C complained about the care and treatment the board provided to their parent (A) after they stepped on a rusty nail and it penetrated their foot. A was initially seen at their GP practice and was then referred to the board. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). C said that the board failed to provide A with appropriate care and treatment at Woodend Hospital for their painful toe. We found that A should have been seen in hospital within 12 weeks of referral, but was not seen until nearly eight months later, and after a second referral was sent by A's GP. C also said that the surgeon planned to amputate A's fifth toe during surgery, when it should have been their fourth toe. While the decision to amputate the fourth toe was reasonable, we noted that there was nothing in the medical records recording the misunderstanding about which toe was to be amputated. We also found that the specific risks of the amputation surgery were not mentioned to A at the clinic appointment at which the proposed surgery was discussed. Therefore, we upheld this part of the complaint. C also complained that the board failed to provide A with appropriate care and treatment after their toe surgery. They said that, when A's surgical wound was not healing, the consultant failed to carry out a pulse test (test of the peripheral vascular system) on A and failed to refer them to the vascular surgeons (specialists in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels) sooner. We found that A's pulses should have been assessed at the clinic appointment at which amputation surgery was discussed, and this should then have led to investigations and vascular input prior to surgery, if an abnormality had been detected. We considered that the failure to carry out this assessment was unreasonable and we, therefore, up

C complained on behalf of A who has a terminal cancer diagnosis. A was diagnosed with a metastatic carcinoma (a cancer that grows at sites distant from the primary site of origin) of possible colorectal (colon) or ovarian origin and progress lung nodules. C complained that A was misdiagnosed multiple times and given the wrong treatment. The board said that A underwent a number of investigations in order to identify the source of the primary cancer. They explained that surgery was not a viable treatment option. We took independent advice from a consultant clinical oncologist (a doctor who specialises in the diagnosis and treatment of cancer). We found that the investigations carried out were appropriate and the length of time taken reflected the challenges faced in trying to identify the source of the primary cancer. There was no evidence to suggest that A was misdiagnosed or given the wrong treatment. We identified that there was a delay in completing the colorectal investigations however, on balance, we did not consider that this delay was significant as it did not have a detrimental impact on A's prognosis. As such, we concluded that the care and treatment was reasonable and we did not uphold the complaint. Related reading View Decision Report 201908128 as a PDF (24.31 KB) Updated: March 24, 2021

C, a patient adviser, complained on behalf of their client (A) in relation to the care and treatment provided to A's child (B) by the board. B was diagnosed with a type of slow growing brain tumour and subsequently underwent a surgical procedure to treat build-up of fluid in the brain. B experienced a neurological deficit following the procedure and the surgeons identified that the burr hole (a small hole drilled into the skull) was not placed at the intended site. Over the following months, the neurological deficit improved but B continued to experience severe headaches following the procedure. Follow-up care was provided by paediatric oncology (specialists in treating children with cancer) and paediatric neurology (specialists in treating children with disorders of the nervous system) as well as other specialties over the following years. We took independent advice from a consultant paediatric neurosurgeon and a consultant paediatric neurologist. Firstly, C raised concern that the board did not obtain informed consent for the surgery and that the surgery was not performed to a reasonable standard. We found that there was limited reference to complications within the consent form and the written notes, whilst a number of known serious complications were not included in the consent form. We also found that the incorrect placement of the burr hole was unreasonable and that this likely caused the neurological deficit that B experienced. We upheld these aspects of C's complaint. C also complained that the board did not manage B's pain reasonably following the surgery. We found that this aspect of B's care had been reasonable, with close involvement from both a consultant paediatric oncologist and a consultant paediatric neurologist over a number of years. We did not uphold this aspect of C's complaint. Finally, C raised concern about the communication between the board and the family about B's care. We found that the documentation of discussion with B's paren

C attended the board in relation to concerns about swelling to their neck area. C was eventually diagnosed with differentiated carcinoma (type of cancer) of the left parotid (salivary gland situated just in front of the ear) with extension to regional nodes and infiltration of the skin. C said that the board, in particular the ear, nose and throat (ENT) department, failed to provide them with reasonable care and treatment in that the board failed to take their concerns seriously and there was a delay in their diagnosis. The board’s position was that as soon as the ENT department were presented with symptoms which raised concern, these were acted upon immediately and appropriately to ensure that C was diagnosed quickly and that a plan for further treatment could be developed with C. We took independent advice from an ENT adviser. We found that there had been failures in the care and treatment C received which led to a delay in diagnosis and treatment, including: a delay between having an ultrasound scan and C being seen in clinic; interpretation of that ultrasound scan and a failure to appreciate the relevance of the time delay to the scan appearances; the classification of C’s referral which should have been classed as urgent; and C’s discharge from clinic and lack of follow-up appointment. We found that the board did not provide reasonable care and treatment to C and upheld this complaint.

C attended Dr Gray's Hospital after experiencing sudden pain in their knee. C said that, on both occasions, they advised hospital staff they had extreme heat and swelling on the front of their leg. C had a history of varicose veins (swollen and enlarged veins that usually occur on the legs and feet) and requested that their leg be scanned on both occasions, but this did not happen. C later travelled abroad. Whilst abroad, C was diagnosed with a deep-vein thrombosis (DVT, a blood clot in a vein). They underwent emergency surgery and had stent filters inserted to prevent the clots reaching their lungs, heart or brain. C said that they and their family suffered extreme trauma and worry about the expense of being hospitalised abroad and C has suffered mental and physical health issues since returning home. C complained that the board failed to carry out a reasonable assessment of their leg symptoms during their two hospital attendances. We took independent advice from a consultant in emergency medicine. We found that C was appropriately reviewed during their hospital attendances. We noted that whilst it was possible that a DVT was present at this point, it was more likely that it developed during C’s long-haul flight. There was no indication during C’s hospital attendances that a scan or x-ray of their legs should have been carried out. We did not uphold C's complaint. Related reading View Decision Report 201905266 as a PDF (24.45 KB) Updated: February 17, 2021

C’s sibling (A) received care and treatment from the board in response to symptoms of pain and urinary issues. A was later diagnosed with bladder cancer and died. C complained that the treatment provided to A prior to their diagnosis was unreasonable. Dissatisfied with the board’s response to their complaint, C brought their complaint to our office. We took independent advice from a consultant urological surgeon (a doctor who specialises in the male and female urinary tract, and the male reproductive organs). We found that the board failed to carry out a general anaesthetic cystoscopy (passing a thin viewing tube called a cystoscope along the urethra (the tube that carries urine out of the body) and into the bladder) in a reasonable timescale. This was accepted in the board’s own complaint investigation. However, we considered that there were opportunities to pick up and correct the delay which were missed. As such, we upheld the complaint. In relation to a complaint about pain management, we found that while there were elements which could have been improved, overall the board reasonably managed A’s pain. We considered that the board could have enquired about pain with A and did not do so, however, there was also no record that A had reported pain which had not been responded to. As such, we did not uphold this complaint. We considered that the board had failed to diagnose A in a reasonable timescale. We found, which the board had previously acknowledged, that due to the delay in carrying out the general anaesthetic cystoscopy there was an unreasonable delay in diagnosing A with cancer. We also considered that the lack of follow-up for one of A’s symptoms following a botox injection was a failing. As such, we upheld this complaint. Finally, C complained that the board had failed to reasonably respond to their complaint. We found that, overall, the board’s responses to C’s complaint were accurate and the board took action to discuss C’s concerns at a meeting and pro

C complained on behalf of their sibling (A) after A was admitted to hospital with a history of progressive vomiting and nausea. The dietetics team (specialists in the scientific study of the food that people eat and its effects on health) asked for A to be prescribed thiamine (vitamin B1) for malnutrition as A had recently lost ten percent of their body weight. The prescription was not made and A did not receive the thiamine supplements. A was discharged several days later as their symptoms had improved and investigations had been generally reassuring. Several weeks later, A suffered a collapse and was readmitted to hospital with confusion and reduced mobility. After extensive investigations, A was diagnosed with Wernicke's encephalopathy (a condition which affects the brain, caused by lack of thiamine). C complained that the board had failed to provide reasonable care and treatment to A in relation to the failure to prescribe thiamine, and that discharging A had been unreasonable. 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 noted that the board had previously acknowledged that there was a failure to give A thiamine when originally recommended by the dietetic team, and they had apologised for this. They had also implemented a ward round checklist to prevent similar failings recurring. However, based on the advice we received, we were concerned that the board had not fully considered or accepted the potential impact of this failure, as we considered that thiamine supplements may have at the very least lessened the severity of the Wernicke's that subsequently developed. We upheld C's complaint.

C had been in contact with a number of specialists at the health board as C suspected they were symptomatic of lung cancer. C said that a tumour in their lung was visible from a number of tests carried out by hospital specialists, but that this was unreasonably missed. C also said that treatment decisions and management were not reasonable and that the failure to diagnose them with lung cancer within a reasonable time had catastrophic consequences for their prognosis. C was also concerned about the way the health board dealt with their complaint. We took independent advice from three advisers: from a consultant 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), a respiratory physician (a doctor who specialises in treating and managing patients with conditions affecting their lungs) and from an orthopaedic specialist (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that C's treatment was reasonable. C was regularly reviewed and their antibiotics were changed in order to try and improve their outcome. However, we found that there was a significant delay in the diagnosis of lung cancer resulting from an unreasonable failure of radiological interpretation which lead to significant injustice to C; this failure would shorten C's life. We also found an unreasonable failure to follow up test results or to carry out a further scan, although we concluded that in themselves this would not have changed the outcome for C. In relation to the standard of respiratory care and treatment provided, we found that the diagnostic process and treatment decisions were reasonable. Finally, we found significant failings in the health board's investigation of C's complaint. While the health board identified radiological errors, they did not apologise for these or explain how they occurred and what action the health board were ta

C complained about the care and treatment provided to their late parent (A) during an admission to Aberdeen Royal Infirmary. C complained that during the admission, they did not see A being provided with nebulisers (a device which helps to moisten the airways; or allow medicine to be administered as a vapour) or oxygen therapy. C also felt that A was not given appropriate pain relief, particularly towards the end of their life, and that A’s condition and potential outcome were not explained to C and their family. We took independent advice from a consultant in acute medicine. We found that the management of A’s need for oxygen was reasonable. The evidence that had been provided suggested that A was receiving regular nebulisers, however there was no medication record to confirm this and this was unreasonable. There was no evidence that A was in unrelieved pain towards the end of their life and the prescription of medication and documentation regarding this matter was reasonable. We considered the timing of the conversation with A’s family regarding Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) was likely reasonable, but some of the documentation around this conversation was not reasonable. On the basis of the lack of evidence regarding the prescription of nebulisers, and poor documentation of the initial DNACPR conversation, we upheld C’s complaints.

Mrs C complained about the care and treatment provided to her late husband (Mr A). Mr A was admitted to hospital after he attended A&E complaining of abdominal pain with a background of hiatus hernia (where part of the stomach pushes up into the lower chest). Mr A had a nasogastric tube (where a tube is placed through the nose into the stomach) inserted to decompress the hiatus hernia, however on one occasion it fell out and a number attempts had to be made before it was reinserted. During this procedure, Mr A suffered a cardiac arrest and died. Mrs C complained that the board inappropriately handled the insertion of his nasogastric tube and raised concerns that it may have caused Mr A's cardiac arrest. Mrs C also complained that insufficient attempts were made to resuscitate Mr A when he suffered cardiac arrest. The board explained that nursing staff escalated the procedure for passing the nasogastric tube appropriately and that Mr A arrested before any further escalation could happen. The board also explained that Mr A’s cardiac rhythm was asystole (unshockable) therefore attempts to prolong resuscitation would be ineffective. We took independent advice from a consultant general surgeon and from a consultant in acute medicine. We found that reasonable action was taken by the nursing staff in escalating the reinsertion of the nasogastric tube and there was no evidence that the procedure was inappropriately handled. We also found that the decision to stop resuscitation was made in consultation with the clinical staff present and the decision was reasonable in light of his additional conditions and the fact that his heart rhythm was asystole. Therefore, we did not uphold Mrs C's complaints. Related reading View Decision Report 201809447 as a PDF (24.56 KB) Updated: November 18, 2020

C complained that the board failed properly to investigate the causes of their neck and shoulder pain. As a result, they said that they experienced up to 20 migraines a month and spent a large part of time in bed. C said that they regularly asked for an x-ray but were told that it would not be appropriate and were prescribed a number of medications and botox, none of which had effect. Because they were struggling with their quality of life, C attended a private chiropractor (a person who treats diseases by pressing a person's joints, especially those in the back) who took x-rays which revealed that the vertebrae at the top of their spine were out of alignment. The chiropractor then carried out a procedure to address this, as a consequence of which, C said, their migraines largely disappeared. C believed that the board ignored their concerns about neck and shoulder pain and said that had they been addressed when requested, they would have had a better quality of life. The board’s view was that, throughout, C had been treated appropriately and in line with clinical guidance; x-rays were not normally recommended in migraine diagnosis and management and were not standard practice. They also said that clinicians were not trained in alternative procedures and were unable to recommend them. We took independent clinical advice. We found that x-rays were not part of the normal practice in the diagnosis and management of migraine and that neck and shoulder pain can occur in 90% of patients with migraine. We also found that the alternative procedure given to C was not an approach offered by the NHS and that C had been treated in line with clinical best practice. We did not uphold the complaint. Related reading View Decision Report 201905636 as a PDF (24.55 KB) Updated: November 18, 2020

Mr C complained about the care and treatment provided to his partner (Miss A) at Aberdeen Maternity Hospital. Mr C said that when Miss A attended a pre-caesarean section assessment, the doctor failed to identify that she was in the early stages of labour. Mr C also complained that the board failed to explain why their baby required antibiotics and a breathing tube after they were born, and that the board's handling of his complaint was unreasonable. The board acknowledged that the doctor assessing Miss A had failed to carry out a full assessment. The board noted that the reasons why their baby required antibiotics and a breathing tube had been explained to Mr C by hospital staff and later in email correspondence. The board also carried out a comprehensive review of their handling of the complaint and identified areas for learning and improvement. We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in the female reproductive system, pregnancy and childbirth). We accepted the board's view that the doctor failed to carry out a full of assessment of Miss A's condition when she attended for the pre-caesarean section appointment and that their handling of the complaint was unreasonable. We upheld these complaints on that basis and made further recommendations for learning and improvement. We concluded that there was reasonable evidence it had been explained to Mr C why his baby required antibiotics and a breathing tube at the time of the event and later in email correspondence. Therefore, we did not uphold this aspect of the complaint.

C, an advocacy worker, complained to us on behalf of their client (A) about the care and treatment they received at Aberdeen Royal Infirmary. A had an autologous fascia sling procedure (where a strip of tissue from the abdomen is used to create a sling under the urethra) to treat stress urinary incontinence (where urine leaks out of the bladder when it is under pressure). A suffered two complications from the surgery; including a bladder injury and overactive bladder (needing to get to the toilet in a hurry or leaking urine before reaching the toilet). C complained that A was not properly informed about the risks during the consent process. We took independent gynaecology (specialists in the female reproductive system) advice. We found that at A's clinic appointments, they were given appropriate information about the risks involved in the surgical options available. However, a significant period of time passed until A had the surgery. Moreover, surgery had not been A's first choice of treatment, and there was a change to the planned procedure. In the circumstances, we found that it was particularly important to have reiterated all the significant risks of surgery when A signed the consent form. However, we found no evidence that A was advised about the risk of overactive bladder, even though it is a common complication. We upheld C's complaint.

Miss C complained that the board did not provide her with reasonable care and treatment during her admission to Royal Cornhill Hospital. She also complained that the board's staff did not communicate reasonably with her during this admission. Miss C said that she was not given clear information about her condition or possible treatment and that her treatment plan was decided upon before she was assessed. Miss C said that she was prescribed an unreasonable amount of medication and that there was an unreasonable delay before she was seen by the dietician. She also felt that there was a lack of structured therapeutic activity and she was often left for many hours without contact from members of staff. Miss C said that decisions about her discharge and the arrangements put in place were unreasonable. We took independent advice from a consultant psychiatrist. We found that an appropriate management plan for Miss C's care and treatment was put in place which included a care and recovery plan. The evidence showed that the aims of Miss C's admission and the plan of treatment were discussed with her and that the treatment plan was reasonable. There were also timely referrals to the dietician and the medication Miss C was prescribed was in keeping with national guidance. We also found that the approach taken in relation to the management and the arrangements for Miss C's discharge were reasonable, as was communication between staff and Miss C. We did ask the board to provide feedback with regards to an incident during which Miss C was restrained. The evidence showed that staff recorded after the incident that a particular type of restraint was not appropriate for Miss C given her personal circumstances. The board also provided us with further information about their more recent restraint policy and practices which we found to be reasonable. We did not uphold Miss C's complaints. Related reading View Decision Report 201801437 as a PDF (24.58 KB) Updated: September 2

C complained about the care and treatment they received from the practice after attending with concerns relating to swelling of the parotid gland (a salivary gland that lies immediately in front of the ear). C attended the practice several times and was eventually diagnosed with cancer. C later learned that it was terminal. C said that the practice had failed to treat their symptoms appropriately and that it took too long to refer them to the ear, nose and throat (ENT) department. We took independent advice from a GP. We found that the practice had provided reasonable care and treatment to C, that they treated their symptoms appropriately and made appropriate and timely referrals to ENT. Therefore, we did not uphold C's complaint. Related reading View Decision Report 201905692 as a PDF (24.06 KB) Updated: September 23, 2020

C complained about the care provided by the board during their admission to Woodend Hospital. C said that the board unreasonably administered an overdose of an opioid drug. We took independent advice from an appropriately qualified adviser. We found that the board failed to follow local protocol and unreasonably administered an opioid drug to C. We upheld this part of C's complaint. C also complained that the board failed to reasonably monitor them after they underwent an operation. C was being monitored using National Early Warning Score (NEWS). NEWS is a guide used by medical services to quickly determine the degree of illness of a patient. We found that when C triggered a NEWS score of one, they should have been observed every four hours, however C was next observed 11 hours later. This was unreasonable and we upheld this part of C's complaint. C complained that their spouse (B) was unreasonably communicated with after their condition deteriorated. We found that while it was identified in the morning of that day that B should have been contacted, B was not made aware of C's condition until they entered the ward almost eight hours later. This was unreasonable and we upheld this part of C's complaint. The board said that they had already taken action in response to these failings. We asked them to provide evidence of this.

C was referred to the board's plastic surgery department with a suspected sebaceous cyst (a common non-cancerous cyst of the skin) as a routine referral. It was found that C had a squamous cell carcinoma (a type of skin cancer). After diagnosis of the cancer C subsequently underwent treatment to remove it. After surgery the board's district and community nurses managed C's wound in the community. C complained about the treatment provided by the board and subsequent wound care. We took independent advice from a consultant plastic surgeon. We found that the board's investigation, diagnosis and treatment of C was reasonable and met the waiting times specified by the Scottish Government in 'Better Cancer Care, An Action Plan'. While there had been some communication failings, the treatment provided was reasonable. We did not uphold this aspect of C's complaint. We took independent advice from a nurse regarding C's wound care. We found that the wound care provided by the board was unreasonable. It was not evidenced that C's wound had been seen and assessed by an appropriate clinician before agreeing how the wound would be cared for. The board accepted there was a lack of documentation relating to C's wound care. We upheld this aspect of C's complaint.

Ms C complained that the board delayed in arranging the surgery she needed. She was entered onto the list for surgery at a gynaecology (medicine of the female genital tract and its disorders) out-patient clinic, but said that she was told months later that they were only carrying out surgery for patients entered onto the list in the previous year. She decided that she could not wait for the surgery and had it privately. We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in the female reproductive system, pregnancy and childbirth). We found that there had been a delay in arranging the surgery and we upheld the complaint. However, we also considered that the action the board were taking to reduce waiting times was reasonable. This included addressing their referral pathways and seeking to increase their consultant capacity. In addition, the board had apologised to Ms C that they had failed to meet the treatment time guarantee. When the board had received contact from Ms C's GP about the delay, they had acted on this quickly and a plan for escalation was commenced. We did not, therefore, recommend that Ms C was reimbursed for the costs of the operation, as we were unable to conclude that Ms C had no option but to arrange treatment privately. We did not make any recommendations to the board in relation to Ms C's complaint. Related reading View Decision Report 201900596 as a PDF (24.42 KB) Updated: July 22, 2020

Mrs C, an advice worker, complained on behalf of her client (Ms A) about the treatment which Ms A received following admission to Aberdeen Royal Infirmary with symptoms of right upper quadrant pain and inflammation. Investigations led to a diagnosis of chronic cholecystitis (inflamed gallbladder). Treatment options were considered and it was decided to insert a drain, rather than perform surgery at that time, with a referral to a hepatobiliary surgeon (surgeon specialising in the treatment of the liver, bile duct and pancreas) for ongoing treatment. Ms A was discharged home but was readmitted to hospital as an emergency due to further right upper quadrant pain and required surgery. By the time of readmission, Ms A had not received any correspondence from the surgeon. Ms A said that surgery should have been performed during the initial admission and that the delay in treatment caused her additional health problems. We took independent advice from a consultant in general surgery. We found that Ms A had multiple medical problems and that upon admission to attempt keyhole surgery would be impossible and open surgery would be challenging. It was appropriate to discharge Ms A with a drain in situation for follow-up by specialists at a later date. Although there were gaps in communication with Ms A, this did not impact on her clinical treatment. We did not uphold the complaint. Related reading View Decision Report 201905268 as a PDF (24.44 KB) Updated: July 22, 2020

C attended the practice with a growth on their face. When after initially being prescribed antibiotics the growth remained, the practice referred C to the local NHS board's plastic surgery department as a routine referral. C contacted the practice some months later as the growth had enlarged and C was experiencing other symptoms. The referral was upgraded to urgent and C was seen by the plastic surgery department shortly after. C was subsequently diagnosed with a malignant tumour and underwent further treatment by the board after the diagnosis. C complained to the practice about the treatment that they received. C said that if the malignant tumour had been diagnosed sooner, then the treatment to remove the tumour would have been less invasive and impactful on their appearance. The practice responded via the local NHS board. Dissatisfied with the response, C brought the complaint to our office. We took independent advice from a GP. We found that the practice's working diagnosis of a sebaceous cyst (a common non-cancerous cyst of the skin) was reasonable, with appropriate treatment provided, initially with antibiotics and, when the cyst remained, with a referral to the local NHS board's plastic surgery department. We considered that the skin cancer had presented atypically, and it was therefore reasonable that the practice initially considered the lesion to be a benign lesion, rather than an atypically presenting cancerous lesion. When it was reported that the lesion had grown and C was experiencing other symptoms, the practice reasonably escalated C's referral to urgent. We did not uphold the complaint. Related reading View Decision Report 201906036 as a PDF (24.48 KB) Updated: July 22, 2020