SPSO Individual Decisions

C complained on behalf of a family member (A) who was diagnosed with breast cancer and died less than two years later. C complained that during a consultation the consultant oncologist (specialist in the treatment of cancer) treating A had given the impression that despite having a condition that was treatable but not curable, A was likely to live for many more years. C noted that they had been present when this had been explained, and that it was evident that A had made important life decisions based on what C considered, in light of subsequent events, to be have been highly misleading communication. C also noted a lack of documentation relating to the initial consultation. In response, the board stated that the oncologist treating A was clear that it had been explained that they had metastatic, stage four cancer. The consultant was also certain that they had not stated that the treatment would definitely work in an on-going sense and life-expectancy would be unchanged. The board apologised if this has been the impression formed by A. We took independent advice from an oncologist. We found that the board’s position that it was not the oncologist’s custom to discuss life expectancy at the first meeting in order not to overwhelm a patient, and that such predictions can be very difficult to make was reasonable. Additionally, we noted that a letter had been sent to A’s GP following the initial consultation. We found it was not unreasonable for a letter to be in lieu of additional notes in a paperless system, and that it is not a requirement for a copy to also be sent to the patient. We also noted that this was one of a number of records and communications with A’s GP that were somewhat generic in nature, noting that while a further letter referenced discussions of palliative options, which implied a discussion about the seriousness of A’s condition, this letter could have been more specific in relation to what exactly was discussed. Overall, we found that while communi

C complained about arterial surgery. The board accepted that there were issues related to the systems in place at the time for the sharing of information between board sites and communication, and apologised for this. We took independent advice from a cardiology adviser. We found that there was nothing to suggest that there was poor clinical practice or decision making and found that, the issues related to the sharing of information between board sites and communication meant that aspects of the care and treatment C received fell below the standard C could reasonably expect. We upheld C’s complaint.

C complained about the care and treatment that they received from the board following a stillbirth. C complained that the board had failed to provide them with adequate support following the birth of their child. C also complained that a consultant had acted unreasonably by discussing their child’s post mortem results with them, without prior warning and without the presence of their partner, during a consultation several months later to discuss the progress of a new pregnancy. The board did not identify any failings with the support provided to C. However, they apologised for the distress caused to C during the meeting with the consultant. They said that the consultant was required to make a plan of care for the new pregnancy and that this inadvertently led to the discussion and counselling of C’s previous pregnancy. The Board said that C’s partner was unable to attend the meeting due to restrictions on hospital visiting in force at the time due to the pandemic. C remained unhappy and asked us to investigate. C complained that the support provided to them was inadequate. C also complained that the consultant had acted unreasonably. We took independent advice from a consultant obstetrician. We found that inpatient care discharge arrangements, including handover of C’s care to community midwives was as expected. We did not uphold this complaint. However, we found that there had been a failure to adequately prepare for C’s consultation. In the circumstances, we found that it was unreasonable to have progressed with C’s consultation without offering them the choice of re-scheduling so that consideration could have been made to their partner attending, or offering a remote appointment. We upheld this complaint.

C complained about the care and treatment that their late parent (A) received from the board. C complained that the board failed to reasonably treat an ulcer on A’s toe or manage their related pain. C also complained that A was unreasonably transferred to a nursing home from the ward when they were too frail and unwell to leave the care of the hospital. C advised that the communication with them in relation to A’s transfer was unreasonable, both in the way the matter was discussed with them by the social worker and as the ward failed to explain that their parent was nearing the end of his life. C said that they were only made aware of this by a GP at the nursing home who explained A was receiving end of life care. The board's response to C’s complaint confirmed that A had received treatment for their toe ulcer during their inpatient admission, with follow-up treatment planned following their discharge to the nursing home. On the matter of A’s referral to nursing home care, the board advised that this had been discussed with C by phone. The board said that the documentation of the phone call reflected that C was in agreement with the plan, with the purpose of the referral being to arrange long term care for A. Prior to discharge, A was reviewed by a ward doctor and it was determined that they were fit for discharge based on their improving blood results following a recent chest infection and as their observations were stable. The board expressed regret that A returned to hospital 10 days later having deteriorated since leaving hospital. We took independent advice from a consultant physician and geriatrician. We found that a plan to manage A’s toe ulcer had been put in place and that they advised that A had received pain relief as required. We considered that the plan of care made by the board was reasonable. In reference to A’s discharge to the nursing home, we found that this had been arranged in discussion with C, noting that A was not suitable for further

C, an advocacy worker, complained on behalf of A about the care and treatment they received from the board. A had been referred to the Ear, Nose and Throat (ENT) department when they noticed a growth on their neck. A was diagnosed with a positive squamous cell cancer (type of cancer that starts as a growth of cells on the skin) in their left tonsil which had spread to their neck lymph nodes. C complained about the standard of communication from the ENT department and a failure to provide appropriate treatment which they considered led to A's terminal diagnosis. The board provided an overview of the care and treatment provided and were satisfied that appropriate care was provided. Due to the metastatic nature (spread) of A's cancer, the only treatment available was palliative. The board also noted there was regular communication with A and they were copied into letters that were sent to A's GP. We took independent advice from a consultant ENT surgeon. We found that the clinical decision making with regards to treatment for A's cancer was appropriate and clearly set out in the records. While we recognised that A may have been under the impression that their cancer had been successfully treated, we were satisfied that the records documented detailed discussions which took place between clinical staff and A on multiple occasions regarding their diagnosis and treatment plan. We acknowledged it was possible that A may not have understood the complex and technical terminology used, however overall, we did not find that the clinical team failed to communicate with A. As such, we did not uphold C's complaints. Related reading View Decision Report 202300410 as a PDF (24.65 KB) Updated: November 22, 2023

C complained about the care and treatment provided to their infant (A). C's concerns related to A's urinary function. C had concerns about the monitoring they had received whilst pregnant with A, the care provided to them and A immediately post- birth as well as during A's early years. C raised issues about the assessment of A's bladder function, A's renal health and the pain and discomfort A was suffering. C also felt that the family had not been listened to and their concerns dismissed or minimised. C had sought a second opinion at a hospital in England and believed board medical staff criticised the family for taking this step. They also said that the board failed to liaise with the hospital in England, resulting in A not receiving treatment or care for an extended period. The board had accepted that communication with the family could have been better but considered the standard of care and treatment provided to A was reasonable. We took independent advice from a consultant paediatrician. We found that A's symptoms were reasonably investigated initially and that they were referred to urology timeously. We also found no clear evidence that A's bladder had been damaged by failings on the part of the board. Therefore, we did not uphold these parts of C's complaint. We found that the impact on A and their family of their condition was not adequately acknowledged and that the board had failed to communicate appropriately with C and their family. We also found that the board did not act when it became apparent that A was no longer being cared for by a hospital in England, resulting in avoidable delays in their care. Finally, we considered that the board failed to handle C's complaint reasonably. We upheld these parts of C's complaint.

C complained about the care and treatment that they received during their labour and delivery of their baby (A). In particular, C complained that the standard of care and treatment they received had been unsafe, that there had been a lack of communication in relation to their requested position during labour, the use of forceps and the provision of pain relief. C also complained that they had been unable to give their informed consent for the use of forceps. The board, when responding to C’s complaint, accepted that some aspects of C’s care did not meet the standard that they would expect in terms of communication and C’s requested positioning throughout the labour and delivery of A. As a result of C’s complaint, the board had shared the complaint with the midwifery staff responsible for C’s care. The board asked them to reflect on C’s experience and consider ways of improving care for the purpose of providing person centred care. The board also accepted that they had failed to arrange C's postnatal review clinical appointment. The board said they had taken action to review and amend the process for appointing consultant led postnatal follow-up. The board indicated that, while the event had not been recorded as an adverse incident and a Datix (an incident/risk management reporting system to collect and manage data on adverse events) had not been submitted, a review had been carried out and action had been taken as a result of that review. We took independent advice from a consultant obstetrician (a doctor who specialises in care during pregnancy, labour and after birth). We found that during C’s labour there were significant periods of loss of contact (LOC) during the recording of the foetal heart rate. However, we also found that, while labour would have been complicated by the LOC there was no evidence that C or A were put at risk. We also found that the actions of staff during this period were reasonable and proportionate to the needs of C and the clini

C complained about the care and treatment that their partner (A) received during an emergency admission to hospital for treatment of a back injury following a fall at home. During admission, C reported that A’s abdomen became very swollen which they were advised by staff was due to constipation and a build-up of faeces, and which was appropriately being treated with laxatives. A’s condition deteriorated and they were subsequently diagnosed with a perforated colon which required emergency surgery. This resulted in a stoma (a surgically made pouch on the outside of the body) and a prolonged period of recovery in hospital. C complained that the board had failed to diagnose and treat A’s abdominal symptoms earlier. They considered that this may have resulted in a better surgical outcome for A, with no stoma being required. C also complained that the board failed to identify or treat a deep laceration on A’s arm, and they complained about the board’s failure to respect A’s dignity by discussing personal matters in the open ward. The board’s response advised that A’s abdominal symptoms were timeously managed and treated, particularly noting that there had been no evidence during the admission assessments of a problem with A’s bowel. The board apologised that A’s arm injury had gone unnoticed and for personal matters being openly discussed, which they had provided as feedback to the ward charge nurse for learning and improvement. We took independent advice from an upper gastrointestinal and general surgeon adviser. We found that A’s bowel perforation had been timeously diagnosed and treated, and the procedure that they received was appropriate to their presenting condition at the time. In relation to A’s arm laceration, we were critical of the board’s failure to identify and treat this as part of the assessment process. In relation to there being open discussion of private matters on the ward, we acknowledged the apology and action taken by the board in response t

C complained about the care and treatment of their late partner (A) during multiple admissions to hospital. C raised concerns that a coronary angiogram (a scan to check for blockages in the blood vessels) was unreasonably delayed, which in turn meant necessary vascular surgery could not take place. C complained about a lack of cohesion between vascular, cardiology and renal teams, and a lack of communication with the family. We took independent clinical advice from a cardiology adviser and a vascular adviser. We found that there was a lack of cohesion and coordination in the management of A’s treatment plan. We considered that multidisciplinary meetings should have taken place to agree a treatment plan, and provide the cohesion that was lacking in the approach to A’s treatment. Overall, however, we found that the clinical decisions made by each team were reasonable and reflected A’s clinical condition at the time. We found nothing to suggest that the lack of cohesion impacted directly on the treatment A received or the eventual outcome for A. In particular, we found that there were good reasons not to proceed with the coronary angiogram, and that it was unlikely any vascular intervention could have been provided due to A’s competing illnesses. On balance, therefore, we did not uphold the complaint that A’s clinical care and treatment was unreasonable. However, we upheld the complaint about the communication with A and their family. The board had already apologised for the poor communication and acknowledged that the multidisciplinary team did not keep the family as informed as they could have. Notwithstanding this, the board considered that A had capacity to make decisions regarding their own care and treatment. However, this assertion did not appear to have been based on any formal assessment. We found that there was evidence only once in the records of a capacity assessment having been undertaken. We found this concerning, particularly as C had raised

C's late parent (A) was referred by their GP to the board's ear, nose and throat (ENT) department on urgent suspicion of cancer. A's referral was originally vetted and agreed as urgent. In response to the COVID-19 pandemic, significant operational changes were made by the board resulting in A's referral being re-vetted and downgraded to routine the following month. Due to worsening of their symptoms, A contacted the board and it was agreed that A required further investigation by barium swallow (a test to look at the outline of any part of the digestive system). However, as an aerosol generating procedure, these procedures had been suspended by the board and A did not undergo the test until six month's after their initial GP referral. Following the barium swallow and further investigations, A was diagnosed with oesophageal cancer. C complained that the care and treatment provided by the board to A had been unreasonable, noting the delays in investigating A's primary symptom of dysphagia (interference with the swallowing mechanism). C also considered A's age had negatively impacted the decision-making in respect of the investigations and treatment options they were offered, and they advised that A had not known until a month after their barium swallow that cancer had even been considered as the likely cause of their symptoms. We took independent advice from a consultant ENT surgeon. We found that the referral to ENT should not have been downgraded to routine when it was re-vetted given A's symptom of dysphagia. On being seen at the ENT clinic, it was reasonable to refer A for a barium swallow at this stage but only if it had been done urgently. In A's case, the time between the request being made and their appointment was four months, which we considered was unreasonable in light of oesophageal cancer being recorded as a possible differential diagnosis on the referral form. We did not find that A's age had negatively affected the treatment options available to them.

C complained about the care and treatment provided to their late parent (A) by the board's out of hours (OOH) service. A was experiencing worsening symptoms of disorientation, fatigue and abdominal pain. C telephoned NHS 24 and received a call back from an OOH GP who arranged for an ambulance to attend A's home. Paramedics examined A and called the OOH service who agreed that an OOH GP would carry out a home visit to A. Paramedics left the house and the OOH GP attended shortly afterwards. Upon examination, A was found to have a mild fever and fast heart rate, with all other observations recorded as normal. The OOH GP prescribed antibiotics. A died a few days later. We took independent advice from a GP. We found that it was an appropriate course of action to request a paramedic assessment upon receiving C's initial call to the OOH service. We also found that given the observations of the paramedics and the OOH GP, it was appropriate to treat and manage A at home and to take into consideration that A's own GP practice would be open some four hours later. Therefore, we did not uphold C's complaint but did provide feedback to the board in relation to the GP's record-keeping. Related reading View Decision Report 202205600 as a PDF (24.42 KB) Updated: August 16, 2023

C complained that the board failed to adequately investigate and/or treat their late spouse (A)'s condition by failing to follow up their appointment at a gynaecological clinic. A experienced abdominal pain and heavy menstrual bleeding. A's GP referred them to a gynaecology clinic. A attended the clinic and was referred for a scan. A was then discharged back into the care of their GP. A year later, A's GP referred them to gynaecology under a suspicion of cancer. A was subsequently diagnosed with endometrial cancer (a type of cancer that begins in the uterus). A was given various cancer treatments but later died. C complained to the board about A's care and treatment. The board acknowledged that A's care was not to the standard it should have been. They accepted that the gynaecology clinic had failed to follow local treatment guidance in A's case. They apologised for this. C remained unhappy and asked us to investigate. C was concerned that the board had failed to adequately explain events. We took independent advice from a gynaecologist. We found that the board had failed to follow their local clinical guidance in A's case. We welcomed the board's acknowledgement of this failing and their apology. However, given the significance of the failings identified we made additional recommendations for action by the board.

C complained about the care and treatment provided to their late parent (A). A underwent surgery to treat hypertension (high blood pressure). A few days later, A’s condition deteriorated with the cause thought to be sepsis (a life-threatening reaction to an infection). A’s condition worsened further and they were transferred to the High Dependency Unit (HDU). A died later that day. C complained that there had been a failure to administer antibiotics that A had required and that there had been unreasonable delays in transferring A to the HDU, which resulted in A being left in a state of distress. C also complained about the conclusions that the board had reached about A’s care following a Significant Clinical Investigation (SCI). The board stated that A had been monitored every 30 minutes and that there had been no delay in providing antibiotics to A. The board accepted that there had been a failure in communication between nursing and porter staff which had led to a delay in A being transferred to HDU. However, the board considered that this would not have resulted in a different outcome although it was acknowledged that this would have reduced A’s family’s distress. We took independent clinical advice from an acute medicine and nursing adviser. We found that there were a number of failings in the care provided to A following the initial deterioration in their condition. This included failure to initiate tests to identify sepsis, failure to commence intravenous fluids (medical technique that administers fluids, medications and nutrients directly into a person's vein) and failure to perform necessary blood tests, as had been outlined by A’s consultant. There was also no evidence that A had received antibiotics nor had been monitored with the frequency stated by the board. We also found that nursing staff failed to escalate a further deterioration in A’s deterioration and that there had been an unreasonable delay of around two hours in transferring A to HDU

C spent time in hospital for their mental health. C complained about how the board had managed their prescriptions and about the lack of treatment for their physical symptoms of migraines and hand/arm injuries. We took independent advice from a consultant psychiatrist adviser. We found that C’s perspective was recorded in contemporaneous notes, that they had requested a change of medication and that their doctor agreed to the trial of an alternative. C’s consent was regularly sought and this was good practice. The evidence suggested that C’s reports of physical symptoms were also properly investigated and that C was offered appropriate pain relief for their migraines. As such, we did not uphold the complaints. Related reading View Decision Report 202108962 as a PDF (24.16 KB) Updated: July 19, 2023

C complained on behalf of their parent (A) that the board did not provide a reasonable standard of nursing care. A was admitted to hospital with COVID-19 and had to be nursed in isolation due to their COVID-19 positive status. We took independent advice from a nursing adviser. We found that the majority of the events described by C and A would not necessarily be documented. That in itself was not evidence of a failing, merely that events documented in the notes would be largely clinical in nature rather than communication. Due to the time that had passed since the events complained about, staff did not recall the specific period of care. We found that there was no evidence of unreasonable nursing care or treatment in the medical notes. As such, we did not uphold the complaint. Related reading View Decision Report 202111811 as a PDF (24.19 KB) Updated: July 19, 2023

C complained about the care and treatment provided to their parent (A) by the practice. Over a period of several months, A and/or family members had multiple contacts with the practice. A started to physically decline more rapidly and was experiencing severe pain which was presumed to be from a prolapse (a displacement of a part or organ of the body from its normal position). Shortly afterwards, there was a more acute clinical deterioration and an Out-of-Hours medical assessment concluded that A was terminally ill and in need of end-of-life care. There were subsequent assessments by the practice and discussion on best management. A's care was continued at home with general practitioner (GP) and district nurse involvement until A's death. We took independent advice from a GP adviser. We found that there were occasions where a face-to-face review or examination of A would have been appropriate, or where a more comprehensive assessment of the history and more detailed management discussion would have been reasonable. Whilst a number of the reviews and adjustments of medication made by the practice were reasonable, we found that there was a lack of medication review on two occasions. We found that the documentation of the consultations was often lacking in detail and that there was little history or clinical findings to support clinical decisions taken. On some occasions, consultations were not documented at all. Overall, we upheld the complaint that the practice failed to provide reasonable care and treatment to A.

C is a former patient of the medical practice. C complained to the practice that they failed to address their enquiries about their healthcare, which they submitted to the practice in writing and by email. The practice decided that they could not meet C’s expectations and concluded that there was a breakdown in the doctor/patient relationship. The pracitice subsequently removed C from their patient list. C complained to the practice but were dissatisfied with the response that they received. C complained that the practice failed to respond to C's complaint and earlier correspondence, and that the practice did not follow reasonable process when removing C from their patient list. In respect of how they responded to C’s correspondence, we agreed that the situation became complex. While C did not always get a response to their correspondence, we concluded that the practice acted reasonably overall. We recognised that the practice were trying to meet the individual needs of their patient, but the situation had become untenable. We did not uphold this aspect of C’s complaint, however we provided feedback to the practice on their handling of the complaint. With regard to the decision to remove C from the patient list, we concluded that the practice failed to follow General Medical Council (GMC) guidelines as they did not warn C that they were considering removing C from the patient list. We upheld this aspect of the complaint and recommended that the practice apologise to C and take steps to ensure they have an appropriate policy in place.

C complained about the care and treatment that their relative (A) received from the board. A had a history of dementia and was admitted to hospital. C complained that during A's admission the family were given inaccurate information about COVID-19 visiting restrictions, and about the care and treatment that A was receiving. A had also fallen whilst in hospital and C questioned how this could have happened. We took independent advice from a nursing adviser. We found that there had been failings in A's care, and in the communication with C and the family. A should have received enhanced monitoring prior to the fall, although it was not possible to determine how the fall had taken place. We considered that the board had accepted this and provided evidence of the actions that they were taking to improve care for patients and communication with families. We found that these actions were a reasonable and proportionate response and the board had provided evidence that they were implementing the changes required. C's complaints were upheld, as there were acknowledged failings in A's care, however, no further recommendations were made. Related reading View Decision Report 202106298 as a PDF (24.36 KB) Updated: June 21, 2023

C, an MSP, complained on behalf of their constituent (B) about the care and treatment of their adult child (A). A had awoken with a cut and bruised face and no memory of how the injuries had been sustained. A attended a minor injuries unit before being sent by taxi to A&E for further assessment. A was assessed and discharged without further treatment or follow-up. A few months later, A died suddenly. B believed that A had suffered a seizure on both occasions and that A's assessment had been inadequate. B felt staff had failed to consider whether A had suffered a seizure nor had they considered prescribing medication which could have prevented further seizures. B was also unhappy with the way their complaint was handled. We took independent advice from a consultant in emergency medicine. We found that the examination of A was thorough. However, given the uncertainty over the cause of A's injuries and the symptoms they described, further investigation should have been carried out. We did not find that A's death could have been predicted, or that there was any definitive evidence that A had suffered a seizure. However, given that further investigations were justified and were not carried out, we found that the standard of care provided to A was unreasonable and that the cause of A's injuries was not adequately investigated or followed up. Therefore, we upheld these parts of C's complaint. In relation to complaint handling, we found the board's investigation to be reasonable. We did not uphold this aspect of C's complaint.

C complained about the care and treatment that they received from the board. C was diagnosed with an ovarian cyst and admitted to hospital for a laparoscopy (a surgical procedure that allows a surgeon to access the inside of the abdomen and pelvis through a small hole in the skin) to remove the cyst. During the procedure, no cyst was found. However, an unusual mass was identified but not removed. An MRI scan was arranged to further investigate the findings of the laparoscopy. C was discharged from hospital but became unwell. C attended the A&E with severe vomiting and diarrhoea and was admitted to hospital that same day. An MRI scan was carried out and the results indicated that the previously identified mass was a haematoma (a collection of blood) and C was discharged home with antibiotics. C became unwell again and attended a hospital in England where they were diagnosed with Clostridium Difficile Infection (CDI, a bacterial infection of the large intestine, a common healthcare associated infection). A CT scan also identified a cyst. C commented that clinicians were surprised that C had not been screened for CDI when they previously attended hospital, having presented with diarrhoea several days after a laparoscopy. The clinicians also reportedly questioned why C’s haematoma was not removed when it was diagnosed given the likelihood of infection. C complained that the board misdiagnosed their haematoma and failed to screen them for CDI, resulting in unnecessary complications and illness. The board, in their response to C’s complaint, explained that there was no clinical indication that C was experiencing ongoing diarrhoea, and were satisfied that they did not therefore screen for CDI. The board said that having reviewed the care provided to C during their admission, they were satisfied that, whilst C suffered complications, the care provided was appropriate and reasonable We took independent advice from a general surgeon adviser. We found that C presented

C complained about the care and treatment provided by the board when they were admitted to hospital. C said that they had collapsed at home and were told on admission to hospital that they had an abscess on the muscle connecting their back and hip, which was treated with antibiotics. C said that their leg continued to swell and bruise and that the pain continued to get worse, resulting in their legs giving way on a number of occasions whilst in hospital. C complained that the board failed to appropriately diagnose, assess and treat them and failed to arrange appropriate follow up care on discharge. C also complained about the communication from the board throughout their stay in hospital. In particular, C said that the board failed to adequately explain the treatment or care that they were provided with. C also questioned the board’s conclusion that their further admission to another hospital was not due to the issues that they experienced at the original hospital, but due to an INR issue (International Normalised Ratio: a test which measures the time for the blood to clot when taking Warfarin). C said that this is not what they were told by the hospital. We took independent advice from a registered consultant physician. We found that there was a failure to provide appropriate follow up for C on discharge, including on-going pain management. There were also record keeping failures during C’s admission to hospital, such as timings of C’s review and ability to identify involved clinicians. We found that the diagnosis, assessment, treatment and follow-up care with regards to C’s leg was not reasonable, and upheld this aspect of the complaint. We found that the board’s communication with C was unreasonable, specifically that there is a lack of evidence of adequate communication about diagnosis and treatment and also in relation to pain management and follow-up care. We upheld this aspect of the complaint. We also found failings in the board’s handling of the co

C complained about the maternity care they received from the board when they gave birth to their twins. C was suspected to have COVID-19 and this was confirmed the day after delivery. C complained that they were placed in a room that wasn’t equipped for labour and that they were pushed towards a vaginal delivery, rather than a planned caesarean section. The board explained that the labour room was set up with equipment stored outside the room for infection control purposes. C also complained that they weren’t provided with appropriate postnatal care. We took independent advice from a midwife. We found that the records supported reasonable decision making surrounding the delivery method and that appropriate discussions had taken place with C in this regard. We also considered that the records evidenced a reasonable standard of postnatal care and that the decision to store equipment outside the room was reasonable. Therefore, we did not uphold this part of C's complaint. C was unable to see their babies in the neonatal intensive care unit (NICU) until after their COVID-19 isolation period ended. C complained that it wasn’t explained to them why they weren’t allowed skin to skin contact before the babies were taken away to the NICU. C also complained that there was no clear process in place for them to see their babies and that staff were initially unable to tell them when this would happen. The board acknowledged that C did not receive an explanation as to why skin to skin contact was not allowed. We noted that the board had asked staff to reflect on C’s negative experience of communication and we were satisfied they had demonstrated learning from this. We found that the restrictions in place for visiting the NICU were reasonable, that there were clear processes and guidelines in place to support this, and that the records showed this was appropriately communicated to C. Therefore, we did not uphold this part of C's complaint. We provided complaint handling feedback t

C, a support and advocacy worker, complained on behalf of their client (A) that the board failed to ensure clinicians provided a surgical assessment and procedure to A within a reasonable time frame. A had been referred to the board’s neurosurgical department (specialists in surgery on the nervous system, especially the brain and spinal cord) following an injury to their back but decided to undergo a surgical procedure privately following delays from the board. A continued to experience pain and felt that the board's delay had led to an adverse outcome from the surgery. We took independent advice from a consultant neurosurgeon. We found that the board unreasonably delayed the clinical assessment and treatment of A. We also found that there was an unreasonable delay to A being given a clinic appointment and that communication around the treatment time guarantee process could have been better. However, we could not say with any certainty that the delay led directly to an adverse outcome for A. We upheld C's complaint.

C complained on behalf of their spouse (A) about the care and treatment that they received from the board. A initially presented with a locally advanced cancer which at the time of presentation had already spread to their lymph nodes. A underwent treatment, however, went on to develop progressive disease in their lymph nodes and also evidence of spread to the bone. While further treatment was given, A's general condition deteriorated and after a number of admissions to hospital, A died of a progressive cancer. C raised concerns that the board had failed to provide reasonable, timely and appropriate medical care and treatment to A during their admission to the treatment centre. We took independent advice from an oncologist adviser (cancer specialist). We found that the treatment A had received conformed to current guidelines from the European Urology Association and Medical Oncology Associations, and overall, we found that the management of A’s care was reasonable and that there were no significant failings in relation to the care and treatment given to A. However, we found that, while there was little, if no, evidence that earlier CT scans would have influenced the final outcome, given the circumstances of A's case, the CT scans carried out could have been done sooner. With regard to C's concerns about the way that A's prognosis was communicated to them, while we found that overall the communication had been reasonable, we acknowledged that the method of communicating A's diagnosis to them had not met their needs and we provided feedback to the board about this. While we found that the majority of the care and treatment given to A was reasonable, given that the CT scans could have been done sooner, on balance, we upheld this complaint. C also raised concern about the medical care and treatment given to A during their admission to hosptial. In particular, that there had been clinical failures to pay attention to which medications had previously failed, which led to t

C complained that the board failed to provide appropriate care for their parent (A). C said that the lack of care resulted in A falling from their bed, while the bedrails were in place. As a result, A fractured their hip. C said that staff had been made aware that A was confused a very disorientated at the time. We asked the board to provide an explanation as to how A was able to fall from the bed if bedrails were in place. The information provided by the board showed that A had been found trying to get out of bed on two previous occasions. This led us to question what interventions were put in place to try and prevent a fall from happening and why this appears not to have been successful. We took independent advice from a nursing adviser. We found that the lack of a proper assessment of A’s mental capacity and their previous attempts to climb out of bed contributed to the fall incident and that this was a significant oversight. Additionally, we found that the board failed to maintain accurate and appropriate records, particularly in relation to the 4AT (Rapid Clinical Test for Delirium Detection), on the two occasions that A was found trying to get out of bed, and the fall itself. We therefore upheld the complaint.