SPSO Individual Decisions

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'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 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 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 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 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 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.

C complained to the board about the treatment that they received from the board when they attended A&E on the advice of their GP. C had informed the GP that their back pain of three months had worsened over the week. C reported concerns about the on-call doctor’s manner toward them. C also complained about the assessment and clinical decisions made, particularly that they were sent home despite experiencing a significant level of pain. C was later diagnosed with Cauda Equina Syndrome (CES, a collection of neurological symptoms caused by compression of the nerves at the end of the spinal cord) and required emergency surgery. Related reading View Decision Report 202103284 as a PDF (24.11 KB) Updated: February 15, 2023

C complained that the board provided their late parent (A) with inadequate care and treatment when they were an in-patient in hospital. C complained to the board that they had failed to provide A with adequate personal care, nutrition and hydration. C also complained that the board had failed to accommodate A’s disabilities. The board identified failures in A’s care and apologised for these. C remained unhappy and brought their complaint to us. We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that more consideration should have been given to A’s minimal fluid intake, and the impact of this in terms of delirium and escalation to medical staff. In addition, we found that it appeared that more could have been done to support A in relation to their toilet needs. Therefore, we upheld the complaint. Additionally, we found that the board did not provide C with sufficient explanations related to the learning and improvement taken from A’s experience. We also found that the board had delayed in providing C with copies of minutes from a meeting and that no appropriate apology had been made for this. We made recommendations in light of these failings.

C complained about the care and treatment their spouse (A) received over a number of years by the board. C submitted a complaint to the board expressing A’s concern that they did not take reasonable care when carrying out two surgeries. C and A were dissatisfied with the board’s investigation and response to their complaint. A underwent surgery in their abdomen in an attempt to resolve recurring infections and said they suffered significant pain afterwards. We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We were satisfied that this surgery did not cause the pain that A had linked to the procedure. However, we were critical of the board for failing to recognise that scans taken prior to the surgery had shown evidence of staples in A’s abdomen from previous surgeries. We found that the staples were a likely source of A’s infections and that this should have been identified prior to the surgery taking place. Had it been identified, A’s management plan may have been different. Therefore, we upheld this aspect of C’s complaint. A also underwent a procedure on their reproductive organs. C complained that the procedure that was carried out, as described in the record of the operation, was not the one to which A had consented. We found that it had not been possible to complete the planned procedure due to an issue in the affected area, which had not been apparent until the procedure began. Whilst we were critical of the way that the procedure was described in the records, we found that the procedure itself was reasonable and appropriate in the circumstances. Therefore, we did not uphold this aspect of C’s complaint. C and A complained that despite the board’s complaints procedure stating that complaints could be submitted in writing, in person, or over the telephone, the board insisted that A’s complaint was submitted in writing. A explained that they found it difficult to p

C complained on behalf of their spouse (A) regarding the care and treatment A received from the board. A has serious health issues and has had multiple surgeries over a number of years. Following a scan of A’s abdomen, it was identified that they had staples attached to their bladder. A considered that these had been left behind following surgery to remove their J-pouch (a pouch made from part of the small intestine and attached to the anal canal to form a pathway for the passage of stool). C complained that A experienced recurring infections and other complications as a result of the staples being left in their abdomen. A said that these had a detrimental impact on their long-term health. We took independent advice from a general and colorectal surgeon (specialist in conditions in the colon, rectum or anus). While it was not possible to establish exactly which operation the staples came from, we considered that the staples were a likely source of A's infections. We found that the staples were clearly visible on previous scans but that these had not been reported on by radiology and therefore the clinical team did not consider these when they were assessing A’s likely source of infection and future treatment. Therefore, we upheld this aspect of C's complaint. C also complained about the handling of their complaint. Whilst we found that there were some delays to the board’s investigation, we recognised that many years had passed between the events complained about and the complaint being submitted to the board. This meant that some issues were reasonably time-barred and some parts of the investigation were delayed due to difficulties sourcing the records and staff comments. Overall, we were satisfied that communication was generally reasonable with C and A, and that the board’s complaints procedure was followed appropriately. Therefore, we did not uphold this aspect of C’s complaint.

C complained to us about the medical and nursing care their late parent (A) received. A attended hospital for a bronchoscopy (a procedure to look directly at the airways in the lungs using a thin, lighted tube) and a biopsy (a medical test to determine the presence or extent of disease). A became unwell and was admitted. The biopsy result confirmed that A had cancer. It was considered A was not fit for treatment and a palliative approach to care was recommended. A’s condition worsened and they died in hospital. C complained about aspects of A’s care and treatment. C also complained about the communication from medical staff. The board did not uphold C’s complaint but apologised because they felt that communication had been poor. C remained unhappy and escalated the complaint to us. We took independent advice from a specialist in general medicine and in acute nursing. We found that A’s care and treatment was reasonable. We also found that the communication with C and A was reasonable. Therefore, we did not uphold C’s complaints. However, we did provide the board with feedback on telephone updates to patient’s families. Related reading View Decision Report 202003950 as a PDF (24.39 KB) Updated: January 18, 2023

C was referred by their local health board ophthalmology (the branch of medicine that deals with the anatomy, physiology and diseases of the eye) department to the general hospital for specialist eye surgery. C underwent a vitrectomy procedure (the surgical operation of removing the vitreous humour from the eyeball) which they felt was not managed appropriately as their retina was still detached following the procedure and they had to undergo further surgery from an independent health provider. The board felt that they had provided an appropriate standard of care and treatment to C. We took independent clinical advice from an ophthalmology adviser. We found that there were no concerns about the standard of treatment which was provided to C. C had suffered a serious eye injury and although the retina was not fully reattached during surgery, this was a recognised complication of the surgery, and that further surgery would be required at some point. We did not uphold the complaint. Related reading View Decision Report 202100828 as a PDF (24.3 KB) Updated: December 21, 2022

C complained about the care and treatment provided by the board to their parent (A), who was admitted to hospital with a suspected liver problem. Ascites (a build-up of fluid in the abdomen) was diagnosed and paracentesis (a drain of the fluid) was performed, during which it was noted that A had accidentally bumped the drain. The following day A reported being in pain and, after a CT scan, it was determined that A was suffering from an un-operable arterial bleed. Shortly thereafter A died. C complained that A’s consent was not properly obtained, that staff had failed to carry out the drain procedures reasonably, that A’s pain was not managed appropriately, that a CT scan was delayed, that communication from the board had been poor and inconsistent and that the level of review undertaken after the incident was not sufficient. We took advice from an independent medical adviser in gastroenterology (medicine of the digestive system and its disorders). We found that the timescale for the CT scan was reasonable, that pain medication was appropriate, that the case had ultimately been appropriately reviewed and that the drain procedure appeared to have been carried out by appropriately trained staff under adequate supervision. However, we found a number of failings. Firstly, the board had obtained verbal consent but failed to adequately record this. Secondly, the board’s complaints response had unreasonably focused on A having bumped the drain as being the cause of the arterial bleed. This was something that could not have been known with any certainty. Additionally, this explanation was not consistent with the post-mortem examination and internal case review, both of which found that the more likely cause of the bleed was as a recognised complication of the drain insertion. Therefore, we upheld these aspects of the complaint.

C’s parent (A) lived in a nursing home and had been shielding during the COVD-19 pandemic. A was later admitted to hospital and was placed in a green pathway (a ward for COVID-negative patients) ward in preparation for emergency surgery. Following surgery and a few days in the High Dependency Unit, A was transferred to another ward which C was advised was a red pathway ward (a ward for COVID-positive patients). A was discharged over a week later. C complained to the board about A’s transfer to a red pathway ward and had not been satisfied with the explanation the board provided. C also complained about the standard of nursing care, the decision to discharge A, and that the board failed to arrange follow-up care for A following their discharge. We took independent advice from a nurse and a consultant geriatrician (specialist in medicine of the elderly). We found that, while the decision to transfer A to a red pathway ward had been reasonable and appropriate in the specific circumstances, the board had not reasonably explained the decision to C. Therefore, we upheld this part of C’s complaint. We also found that the standard of nursing care and decision to discharge A was reasonable. The board also made the relevant referrals to the appropriate community services after A’s discharge. Therefore, we did not uphold these aspects of C’s complaint.

C complained that the board did not repeat a test for Helicobacter pylori (H. Pylori, bacteria usually found in the stomach) given their symptoms, abnormalities in their blood tests and low ferritin (a blood protein containing iron) levels. C was of the view that had their symptoms been properly investigated, they would have been found to have H. pylori and would have been treated earlier. 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 C did not have Helicobacter associated symptoms which would have triggered re-testing (such as indigestion symptoms). As there was no clinical indication to repeat a test for H. pylori, we did not uphold C’s complaint. Related reading View Decision Report 202101569 as a PDF (24.12 KB) Updated: October 19, 2022

C complained regarding the treatment that they had received from the board in relation to a pharyngeal pouch (a pocket in the lining of the pipe that carries food from the mouth to the stomach). They complained about issues regarding the surgery they had in relation to this and about the information they were given. We took independent advice from an ear, nose and throat (ENT) surgeon. We found that C was given reasonable information in advance of their surgery and that it was reasonable to examine a pharyngeal pouch through surgery. It was appropriate that C's pharyngeal pouch was emptied of partially digested food as otherwise it would not have been possible to examine it. It was also reasonable that C was offered a cricopharyngeal myotomy (where a surgical cut is made in the muscle that allows swallowing to weaken it) to treat their pharyngeal pouch, as it is one of the treatment options set out in the relevant clinical guidance. Although an external myotomy was recommended, C was given the option to explore alternative approaches, but the clinicians felt the pouch was too small for stapling. In addition, it was reasonable that C's outpatient appointment with the ENT surgeon was cancelled, given they were unhappy to proceed with the proposed treatment option. Therefore, we did not uphold the complaint. Related reading View Decision Report 202002811 as a PDF (24.37 KB) Updated: October 19, 2022

C complained about various aspects of the treatment provided by the board to their late parent (A) who was initially admitted to Glasgow Royal Infirmary with a fractured hip following a fall. A was subsequently discharged after surgery and received care at home from district nurses. However, A developed an infection at the site of their surgical wound and was readmitted to hospital, where they underwent several further surgeries to control the infection. A went on to develop further infections and subsequently died. C complained that there had been a delay in carrying out surgical repair of the hip, that A had been discharged without appropriate physiotherapy follow-up, that an out-of-hours GP had failed to readmit A to hospital sooner and that nursing staff were unaware of a surgical procedure A had undergone. C also complained that there had been a delay in referring A to psychiatry, that A developed further infections, that A’s skin had not been correctly looked after, that there had been poor communication about the decision to withdraw care and that there had been errors on A’s death certificate. We took independent advice from specialists in orthopaedic surgery, general practice community nursing and hospital nursing. We found that reasonable care had been given in relation to the choice of surgical procedures A underwent. We also found that reasonable care had been given to the management of A's infections whilst in hospital, the level of community nursing care, the management of A’s skin, PICC line (a thin flexible tube inserted through a vein to give medicine directly into the bloodstream), referral to psychiatry and end of life care. However, we found that there had been unreasonable care provided in relation to a delay in carrying out A’s initial surgery. We also found failures by an out-of-hours GP to record sufficient detail about A’s condition and ensure A was provided with prompt antibiotic treatment, requiring A to complete two consent forms for the