SPSO Individual Decisions

C presented to the medical practice with nausea and weight loss. Following blood tests, a significant drop in haemoglobin levels was noted and anaemia (deficiency of healthy red blood cells in blood) was diagnosed. C complained that they were not referred on to secondary care for admission or investigation at this point. A few days later, C collapsed and suffered internal bleeding as a result of a large gastric ulcer (a perforation or hole in the lining of the small intestine, lower oesophagus or stomach). The practice advised that C was a new patient to the practice and had recently been in hospital with acute kidney injury. On first presentation they had a urine infection, which was treated with antibiotics. Following the blood test results, examinations were carried out to check for internal bleeding. No signs of bleeding had been found but C had a bladder full of urine and their catheter was bypassing. The doctor referred to district nursing for a catheter change and a repeat blood test. This was to check whether C was experiencing further kidney injury. There were no obvious signs of dyspepsia (a condition where digestion is impaired) as no heart burn was recorded. We took independent medical advice from a GP adviser. We found that it would have been appropriate to make an urgent cancer referral based on the symptoms, but that it was reasonable not to have suspected a gastric ulcer. We also found that there was no record that the causes of the anaemia had been fully explored or that a treatment plan and safety netting advice had been considered or communicated. We upheld the complaint as we considered that although many of the actions had been reasonable, it did not appear that a cancer referral, a treatment plan or safety netting had been properly considered, recorded or communicated. We did not consider that this had changed C’s outcome and acknowledged that the practice had taken steps to learn from the complaint.

C complained that the board failed to provide reasonable care and treatment to their late parent (A), who died following an admission to hospital. This included issues relating to A contracting COVID-19, that the board unreasonably failed to carry out an SAER/independent review, and that the board failed to reasonably respond to the complaint. We took independent advice from a specialist in geriatrics (medical care for the elderly). We found that the board had carried out a review of A’s care and had accepted some failings, including that there had been an unnecessary transfer and a delay in cleaning. They apologised for this and had taken improvement action and organised training, which we welcomed and considered were appropriate. Whilst there were a number of aspects of care provided to A which were appropriate and reasonable, given the unnecessary transfer, the apparent delay in cleaning, and failings with regard to communication, on balance, we upheld this aspect of the complaint. We also identified complaint handling failings. Whist the complaint response was detailed and lengthy, and attempted to address all of C’s concerns, we upheld this aspect of the complaint, given the lack of detail in the complaint response regarding learning and improvement actions.

C complained on behalf of their late parent (A) that the board unreasonably failed to diagnose A’s cancer, from which they later died. We took independent advice from a respiratory consultant adviser. We found that clinical management from the respiratory team carried out appropriate investigations. We found that there was a failure in communication of the CT results to A and their family and that there was also a delay in intervention following the abnormal CT report, that a biopsy could have been carried out earlier, and that there was no need to await review at an MDT. On balance, we found that there was no evidence of an unreasonable delay in diagnosing cancer, therefore we did not uphold this complaint. Related reading View Decision Report 202108771 as a PDF (24.13 KB) Updated: July 19, 2023

C complained on behalf of their deceased grandparent (A) about care and treatment provided by the board during an admission to hospital following a fall and broken hip. C complained that A received poor nursing care, poor rehabilitation support, had not received enough nutrition and fluids, and had developed necrotic (dead) tissue on the back of their heels. C also complained that communication with the family and the incident management response had been unreasonable. We took independent advice from a nursing adviser. We found that pain relief, personal care and rehabilitation support had been appropriate. However, we found that there was no evidence that assistance was provided with eating and drinking, and that fluid and nutrition charts had been poorly completed. We also found that the pressure sores on A's heels were poorly managed, that there were significant gaps in repositioning and that effective preventative measures were not appropriately implemented. We found that information given to the family was insufficient and incorrect. We also found that the incident management response was unreasonable, as the necrotic heels were not deemed to be serious avoidable harm and therefore no serious adverse event review or duty of candour was undertaken. We therefore upheld C complaints.

C made a complaint about the care and treatment provided to their late spouse (A) by the board. C was concerned that A had sepsis (an infection of the bloodstream) at the time of their discharge. C considered that A would not have died had they remained in hospital. We took independent advice from a consultant in geriatric medicine (a doctor who specialises in treating older patients) and general medicine. We found that there was a failure to properly assess A's blood and urine test results prior to their discharge. Had this been done, there would have been a greater likelihood that infection could have been diagnosed and treated prior to A's discharge from hospital. Although A may still have died had they remained in hospital, this could have given A a better chance of surviving their illness. We found that there were failures in communication with A's family. A's family should have been provided with 'safety netting' advice about repeating A's temperature or looking for other potential signs of infection once A had returned home. We also found that there were failings in the board's handling of C's complaint. The board's own complaint investigation did not include all relevant staff for comment, the response was brief and did not provide fully accurate information in relation to A's condition. In light of the above, we found that the board failed to provide A with reasonable medical care and treatment. We upheld C's complaint.

C complained to the board about several aspects of the care and treatment provided to their parent (A) during their time in hospital and also about the discharge planning on each occasion. A was diagnosed with terminal cancer and was in hospital for treatment before being discharged home. A was later readmitted to hospital with illness. A was discharged home again and later died. The board's position was that the discharge planning for A on each occasion was appropriate. There was discussions about what supports could be offered, and it was frequently documented that A's wish was to be at home. Discharge plans were discussed on a daily basis. With respect to the care and treatment provided to A during the second admission, the board commented that A was being treated for a chest infection and apologised if C was not aware of A's chest infection. The board said that there was no indication to replace the nasogastric tube (tube used to deliver food or medicine to the stomach for people who have difficulty eating or swallowing). We took independent advice from a consultant geriatrician (doctor who specialises in treating older patients) and from a registered nurse. We found that the care and treatment provided to A during their admission was reasonable. We also found that given A's condition and prognosis, the decision that A was suitable to be discharged was also reasonable. We did not uphold the complaint about care and treatment. With respect to the planning made for A's discharge home, we found that the planning on each occasion was reasonable. On A's first discharge from hospital, appropriate assessments were carried out and discussions documented about supports which could be put in place for A's return home. It was documented that these were declined by A. With respect to the second discharge, whilst there was no formal discharge plan, given A's prognosis and assessment that they were independent and requesting to go home, it was reasonable to discharge A. Whils

C complained about the care and treatment provided to their late spouse (A) by the board while they were an in-patient at hospital. During A's admission they were diagnosed with stage 4 cancer and COVID-19. A died of COVID-19 in hospital. C complained to the board about A's care and treatment. C also complained about communication with A's family. The board apologised for aspects of their communication, but did not identify any failings with A's care and treatment. C remained unhappy and asked us to investigate. C complained about the care and treatment A received for COVID-19 and about the communication A's family received regarding their COVID-19 diagnosis. C complained that the board had failed to adequately investigate the complaint and had failed to adequately investigate how A caught COVID-19. We took independent advice from a general medicine adviser. We found that aspects of the care A received after their COVID-19 diagnosis, along with aspects of the board's communication with A's family regarding A's COVID-19 diagnosis and treatment were unreasonable. We also found that the board's response to C's complaint contained inaccuracies and that there was a lack of detail. We found that the response failed to adequately address, from a medical perspective, the concerns C had raised, in particular, in relation to A's COVID-19 diagnosis. We upheld C's complaints.

C complained that their sibling (A) had not received appropriate care and treatment from their GP practice in relation to symptoms of an infection. C felt the on-call GP failed to arrange for A to be admitted to hospital and that the practice failed to see and examine A, who died the following day of sepsis (an infection of the blood stream). C also complained that they were unable to access the practice, and that the practice failed to follow its emergency protocol. As such, C complained that the practice had failed to provide reasonable care and treatment to A. The practice considered the care and treatment provided to A had been reasonable. We took independent advice from an experienced GP adviser. We found that it was reasonable for the on-call GP not to admit A to hospital as this was a decision for the Scottish Ambulance Service (SAS) to make and paramedics expressed no concerns. It was also reasonable for the practice to not examine A as they had already been assessed by the Out-of-Hours Service, the District Nurse and paramedics. However, we fund that the practice failed to follow the emergency protocol and C and A were unable to access the practice. We also found that the practice's handling of C's complaint was unreasonable due to the quality of investigation carried out. Therefore, on balance, we upheld these complaints.

C complained about the care and treatment their spouse (A) received from the practice. Following a routine smear test, A was advised to see a gynaecologist (specialist in the female reproductive system) as soon as possible and they attended a private appointment the same day. Investigations confirmed A had stage four endometriosis (a severe case of tissue similar to that found in the uterus growing outside of the uterus). The private gynaecologist advised A that they should ask their GP to refer them to the Endometriosis Speciality Clinic. C complained that there was an unreasonable delay to A's referral for a specialist review. They noted that, when a referral was issued, it was sent to the local gynaecology department, rather than the endometriosis specialists. We took independent advice from a GP. We found that an urgent gynaecology referral was created promptly following the smear test. We noted that the NHS appointment was cancelled by A while they pursued private investigations. Following a telephone consultation between A and the practice, during which they discussed the findings of the investigations and the recommendation that they be referred to the Endometriosis Speciality Clinic, we found there was an unreasonable delay in the practice sending a referral back to gynaecology. We noted the referral was not marked as urgent and A later had to ask for this to be prioritised. We found that A was appropriately referred to local gynaecology services but we were concerned by the communication around their desired referral to the Endometriosis Specialty Clinic. There was a lack of clarity regarding what referral had been made, and why. Therefore, we upheld this part C's complaint. C also complained about the practice's handling of A's complaint. We found that there were delays in the handling of A's complaint and that communication with A regarding the complaints procedure was lacking. We also found that the complaint response did not address some of the key aspe

C attended A&E following problems they had had with their elbow. Their doctor had advised them to go to A&E if it worsened. C complained that they were not properly triaged as they were not triaged in a private area and their pain score was not noted. We took independent advice from a nurse. We found that the triage process had not been appropriate. The board had also accepted this and put in place measures to improve the triage process. Therefore, we upheld C's complaint but did not make any recommendations in light of the actions already taken by the board. Related reading View Decision Report 202104005 as a PDF (24.04 KB) Updated: May 24, 2023

C complained on behalf of their spouse (A) about the care provided by the practice. A developed a wound in their left leg and received several courses of antibiotics and wound treatment but the wound deteriorated. A was referred to a vascular specialist several weeks after they first attended the practice. A was later admitted to hospital and died. We took independent advice from a practice nurse adviser. We found that there were particular concerns about the lack of robust record keeping. The required wound assessment was not carried out or repeated at least every seven days as required. There was no record of the rationale behind the dressings used. There was no record of leg ulcer assessment being carried out and no documentation to support why this was the case until the referral. We found that the use of inadine (a type of surgical dressing) was inappropriate and that the choices for other wound dressings chosen were not detailed. We also found that the ongoing referral was not made in a timely manner. Therefore, we upheld the complaint.

C complained that the practice failed to provide a face to face appointment to their late spouse (A) which contributed to a delay in onward referral, and ultimately delayed diagnosis of amyloidosis (a condition in which amyloid proteins build up on organs like heart, kidney and liver). A had multiple telephone consultations with their GP over the year, presenting with varying symptoms. C complained that the frequency with which A presented should have prompted a face to face appointment. The practice response stated that it was not common practice to offer face to face assessment during the COVID-19 pandemic and that A had not requested a face to face appointment We took independent medical advice from a GP adviser. We found that the practice’s failure to offer a face to face appointment was not reasonable. The frequency with which A presented and the symptoms that they described should have been identified as ‘red flags’ which triggered a face to face appointment and onward referral for specialist investigation, regardless of COVID-19 restrictions in place at the time. Therefore, we upheld this complaint. We noted that the practice had already reflected extensively on their management of A, demonstrated learning and things that they would do differently in future, and offered apology to C. As such, we made no further recommendations. Related reading View Decision Report 202110925 as a PDF (24.48 KB) Updated: April 19, 2023

C complained about the orthopaedic care (conditions involving the musculoskeletal system) and treatment that they received from the board. C had a wrist injury and underwent an initial operation and a second operation three years later. C complained that the reason for the second operation was because the first operation carried out had been ineffective and that mistakes had been made. C also complained that they had been allocated two community health index (CHI) numbers which had unreasonably impacted on the care and treatment that they received from orthopaedics. We took independent advice from a consultant orthopaedic surgeon and a consultant radiologist. We found that the orthopaedic care and treatment C received was reasonable and we did not uphold this complaint. We also found no evidence that the issue of CHI numbers had impacted on C’s care and treatment regarding their two operations. We did not uphold this complaint. Related reading View Decision Report 201900901 as a PDF (24.19 KB) Updated: March 22, 2023

C complained about the end of life care that their partner (A) received at home from district nursing services during the final weeks of their life. C complained that the nurses did not listen to their concerns about A’s deteriorating condition, that A’s condition was not adequately assessed and managed, and that they were not included in discussions about A’s care. C considered that there were missed opportunities to admit A for earlier hospice care. We took independent advice from an advanced nursing practitioner. We found that the care provided to A was generally in line with recognised practice for end of life care, with review and prompt action around pain control and symptom management. However, we found that there were significant gaps in communication and clinical assessment which impacted on the care delivered to A. While the nurses recorded C’s reported changes in A’s condition, this did not appear to have prompted any specific action or investigations. We found that there was a lack of clinical examination, and a failure to check and act upon C’s reports of excessive fluid in A’s legs. The board acknowledged that there was a failure to monitor A’s baseline observations when they began to deteriorate, and we found it concerning that this did not happen. The board also accepted that communication with A and C could have been better managed and they committed to raising this with staff. As A’s main carer, we noted that C’s views should have been central to care planning and to ensuring that the care being provided remained suitable as A’s condition changed. We found that there was an unreasonable failure to act upon C’s concerns and consider whether a need for hospice care was indicated. We therefore upheld the complaint.

C complained to the board about the care and treatment provided to their late parent (A) regarding hip problems they suffered. A was admitted to hospital with worsening mobility having suffered a number of recent falls. Under the care of older people’s services they were reviewed by occupational therapy and received physiotherapy, before being moved to another hospital for rehabilitation. A month after being discharged, A was readmitted and underwent an X-ray CT scan. A was initially diagnosed with a broken femur. A underwent hip replacement surgery and passed away a month later. C complained that despite being informed by the board that A had sustained a fracture of their right femur, possibly present some years prior, they were later told that A had not sustained a fracture. Nevertheless, A’s death certificate had recorded a fracture of the right femur as one of the causes of death. This confusion caused the family significant anxiety. In their complaints response the board concluded that junior medical staff had been responsible for misdiagnosing A and apologised for the miscommunication. They also apologised for the misdiagnosis having been included on A’s death certificate. We took independent advice from a medical adviser with expertise in orthopaedics (treatment of diseases and injuries of the musculoskeletal system), and further advice from a radiologist (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that while A did not have a broken femur, the board had failed to act upon a CT scan taken some years previously that showed A was suffering from significant arthritis which therefore went untreated over the subsequent years. Additionally, the board had emphasised the role of a junior doctor in misdiagnosing the fractured femur despite the involvement of more senior management in signing off on this diagnosis. In view of these specific failings, we uphel

C complained about the care and treatment provided by the board to their child (A) during a consultation with an orthoptist (specialist in the diagnosis and treatment of eye movement disorders) and optometrist (healthcare professional who provides primary vision care) in relation to the management of A’s strabismus (a squint) and wide-angled esotropia (inward turning of the eye). C made several complaints, including the board's failure to assess the size of the squint, failure to adequately dilate A’s irides using cycloplegic drops (drugs used to paralyse muscles in the eye), issuing a prescription for glasses based on an inaccurate refraction test result, displaying poor clinical knowledge about A’s condition and poor record-keeping. C also complained about how their complaint had been handled by the board, particularly in relation to a meeting that had taken place to discuss the complaint. In response, the board stated that, while A’s refraction test indicated a greater amount of myopia (short-sightedness) than previous tests, differences could occur for a variety of reasons, such as the amount of dilation of the irides. In patients with dark irides, such as A, dilation could be difficult but this had been recognised by the clinicians and drops to dilate were appropriately re-instilled, with the prescription issued in accordance with the test results. The board accepted, however, that there had been communication issues between the orthoptist and optometrist but measures had been put in place to improve this. The board also agreed to amend A’s notes to reflect more accurately what had been discussed at the consultation and arrange a further review of A much sooner than had been agreed. We took independent advice from a consultant in paediatric ophthalmology. We found that A’s refraction test results were inaccurate and should have caused the optometrist to question whether A’s irides had been adequately dilated rather than issuing an incorrect prescription. We als

C complained about the follow-up care provided to their late partner (A) who died around four months after suffering a heart attack. The board said that A was followed up by the cardiac rehabilitation service in line with established practice. We took independent advice from a consultant cardiologist (a specialist in diseases and abnormalities of the heart). We found that A's follow-up care was reasonable in the circumstances (of no face-to-face consultations due to the COVID-19 pandemic). We also found that it was reasonable for the board not to follow up on blood tests taken at A&E following A's attendance with chest pain. The board said that the test results showed no evidence of a new cardiac injury. We considered it reasonable to have excluded a new cardiac injury as the cause of A's chest pain, and we were not critical of the care provided. Therefore, we did not uphold these aspects of C's complaint. C also complained about the conduct of a telephone consultation with a cardiac rehabilitation nurse. A called to report symptoms of breathlessness and C complained that the nurse diagnosed a chest infection and/or anxiety over the phone, and did not arrange for A to be seen. However, the nurse did not recall making such a diagnosis, and their recollection was that there was no apparent indication for A to be seen. We were unable to reconcile the differing recollections, and we considered that the actions of the nurse appear to have been consistent with reasonable practice. C was unhappy that the call was not documented. The board said that the call was not documented as A had been discharged from the cardiac nurse service, and in such circumstances patients are directed to their GP for any advice required. We noted that referral back to primary care for non-urgent symptoms is consistent with established good practice. We did not uphold this complaint. Finally, C complained that A's post mortem described A as having severe heart disease, and they comp

C complained about the care and treatment that their late parent (A) received at University Hospital Monklands. A was admitted to hospital to have fluid drained from their abdomen but died in the hospital a few days later. C was concerned that the drain was left in too long and caused A to suffer a perforation of the bowel, and that medical staff delayed and/or failed to investigate whether A had suffered internal damage as a result. We took independent advice from a consultant hepatologist and gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the gastrointestinal tract, liver, pancreas and gall bladder). We found that without a post mortem it was impossible to determine the cause of the perforation. We also found that while A's drain had been left in longer than recommended, it was unlikely that the delayed length of time the drain was left in and the subsequent perforation were related, as A did not have any immediate complications nor signs of problems from the drain for a number of days before developing a bowel perforation. We found that the clinical action taken by the team involved in A's care at this time was reasonable. Once there was a suspicion of a perforation occurring, a chest x-ray had been carried out and this had been good practice. The board acknowledged and identified lessons to be learned and we considered the board's actions to address what occurred were reasonable. However, we found that the delay in removing the drain was unreasonable and we upheld C's complaint.

C, an advocate, complained on behalf of their client (B). B's spouse (A) died of advanced lung cancer. A started experiencing pain between their shoulder blades and was referred by their GP practice to University Hospital Hairmyres for a chest x-ray. A attended A&E at University Hospital Hairmyres on three different occasions and received further x-rays. A was admitted to University Hospital Wishaw and after undergoing further investigations, they were diagnosed with advanced lung cancer. C complained about the clinical assessment of A's symptoms when they attended A&E. C complained that A had signed a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) form during a hospital admission when they did not have capacity to understand it. B was unhappy that they had not been consulted about the DNACPR. C also complained that communication about A's diagnosis was very poor. They complained that A was not informed that their cancer was life limiting or terminal. According to B, they were unaware of the prognosis or that A only had a short time to live. We took independent advice from an emergency medicine adviser. We found that A's symptoms were appropriately assessed and treated during each of their attendances at A&E. We considered that A was appropriately referred for further investigation and we did not uphold this aspect of the complaint. We also took advice from a consultant physician. In relation to communication regarding the DNACPR, we found that A's capacity was appropriately assessed and that their consent was reasonably obtained. We considered that there was no obligation for staff to discuss the DNACPR with A's family and we noted that A's admission was during the initial weeks of the COVID-19 outbreak when restrictions for visits were in place and hospitals were under considerable pressure. We did not uphold this aspect of the complaint. We noted that there was a disparity between what clinicians thought that A's family understood regarding A's

C made a complaint about the nursing care and treatment that their late parent (A) received at University Hospital Wishaw. C was concerned that A was not nursed in an elevated position and was kept lying flat. C also said that A's nutrition was not taken seriously and that the food record charts were not completed properly to monitor A's intake. We took independent advice from a nursing adviser. We found that it is not usual to document a patient's position in bed (whether they are upright or lying flat). Therefore, we were not critical of the board's record-keeping in this regard. We found that the monitoring of A's nutrition and fluid intake was unreasonable because the Malnutrition Universal Screening Tool (MUST) assessment was not completed within 24 hours of A's admission to hospital, the food record chart and the fluid balance chart were not completed appropriately during A's admission and A's personal centred care plan was not updated to reflect their condition. We upheld C's complaint in this regard.

C complained about the care and treatment that their parent (A) received during an admission to a community hospital. A had a degenerative condition which affected their mobility and was latterly diagnosed with a form of vascular dementia (a common form of dementia, caused by problems in the supply of blood to the brain). A was admitted to hospital following a fall. C told us that A had a number of falls in hospital and suggested that one of these falls led to an injury to A's leg. C raised a number of general concerns regarding the nursing care and implied that A was allowed to become dehydrated, only drinking when assisted by family members or when family members prompted the ward staff. C also raised concerns about the clinical aspects of A's care. C said that A became lethargic and unresponsive during their admission to hospital. Family members expressed their concern to staff that this may have been the result of sepsis (blood infection) or a urinary tract infection. However, they were reassured that A's symptoms were likely caused by antibiotics. A suffered a heart attack. Staff performed cardiopulmonary resuscitation (CPR) and revived A. A was then transferred to a general hospital for care where A died five days later. C explained that A was uncomfortable and agitated during their final days. C said that staff there had expressed concern that no Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) had been signed for A. C complained that the additional five days of suffering that A experienced could have been avoided had a DNACPR been discussed with family members. We found that A's condition and medical history meant that clinical staff should have considered DNACPR each time that they reviewed A. Whilst we were critical of the board for failing to do so in A's case, we acknowledged that they had already taken action to improve their procedures and ensure that the consideration of DNACPR is not left until an emergency situation develops. We fou

C complained about the care and treatment that they received from the board. C had experienced severe nausea but initial investigations found no definitive cause for their symptoms and a presumed diagnosis of irritable bowel syndrome (IBS, a condition of the digestive system that can cause stomach cramps, bloating, diarrhoea and constipation) was made. C said that they were provided with medication but this had little effect. C developed severe abdominal pains later the same year which required immediate surgery and initially appeared to recover well. However, their abdominal pains returned a few months later and they required a hospital admission. Further surgery was carried out, establishing and resolving the root cause of the pain. Whilst C's pain resolved following the second surgery, they raised a number of concerns regarding the care and treatment provided by the board, delays to diagnosing the cause of their symptoms and inaccurate documentation of the procedures that they had had. We took independent advice from a consultant gynaecologist (a doctor who specialises in the female reproductive system). We found that the initial view that C's symptoms were being caused by a bowel condition was reasonable and that IBS was a reasonable working diagnosis while tests were carried out to confirm or rule out other possible causes of their nausea. We were satisfied that the working diagnosis and the focus of investigations changed when C's symptoms escalated. We were also satisfied, following the recurrence of their abdominal pain, that the board followed a reasonable and recognised pathway to establishing the cause of C's pain. Therefore, we did not uphold these aspects of C's complaint. We were critical, however, of a number of errors in C's medical records, including details of another patient's procedures being misfiled in C's notes. We upheld this aspect of C's complaint.

C complained that nursing staff failed to provide them with adequate personal care following an enema (an injection of fluid into the lower bowel by way of the rectum to expel its contents, to introduce drugs or to permit X-ray imaging) at University Hospital Monklands. C also complained about the provision of toilet facilities on a ward. They said that their experience had caused significant trauma. We took independent advice from a nursing adviser. We found that there was insufficient evidence to suggest that that the board provided C with inadequate personal care. We did not uphold this complaint. C also complained that the board had failed to communicate effectively with them after they had a laparoscopy (an examination of the abdominal organs using surgical methods to determine the reason of pain or other complications of the pelvic region or abdomen) at a private hospital under a waiting list initiative. They said that this had caused delay to their treatment. We found that there had been a delay in communicating the results of the laparoscopy to C and this caused delay to C's treatment. The board were wrong to consider that C's GP should have discussed the results of the laparoscopy with them. The board requested the laparoscopy and it was their responsibility to discuss this with C. We upheld this complaint.

C, an advocate, complained on behalf of their client (B) about the care and treatment provided to B's late spouse (A). A had attended their GP practice complaining of pain between the shoulder blades and breathlessness on exertion and was seen by a nurse practitioner. The nurse referred A to hospital for a chest x-ray which they received the next day. A then received further x-rays throughout the month following attendances at A&E. They were referred to another hospital where they were later diagnosed with advanced lung cancer. B complained about the about the nurse's assessment and that the practice failed to follow up on the chest x-ray they referred A for, and failed to follow up on their various attendances at A&E. Had they done so, B considered that A might have been diagnosed sooner. We took independent advice from a nurse and a GP. We found that the assessment by the nurse practitioner was reasonable and the decision to refer A for chest x-ray and spirometry (a simple test used to help diagnose and monitor certain lung conditions) was appropriate. In relation to the x-ray taken after the nurse's referral, the results recommended referral to respiratory medicine but the practice did not receive the report until after A's death. We found that it was the responsibility of radiology (specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) to send the x-ray report to the GP, which in this case had not happened and would not expect a practice to chase up records. We also noted that the practice now log all investigation requests and check that results have been returned, which is good practice and above the standard level of care. In relation to the various attendances at A&E, we found that it is not expected of the practice to follow up on these attendances. There was no mention in the discharge letters sent to the GP of any action required. Therefore, we did not uphold C's co

C complained about the care and treatment that their parent (A) received from the board. Following surgery to remove bladder lesions, A experienced severe pain and urinary problems. It was established that they had a bladder perforation. C complained that, whilst A's consultant initially accepted and apologised for the fact that A's bladder was likely perforated during surgery, the board subsequently backtracked and suggested that there could have been a number of causes. C did not consider that their family had been given a clear explanation as to how A's bladder had been perforated. A subsequent review of A's case established that they had cancer invading their bladder muscle. The cancer could not be treated with chemotherapy or radiotherapy and staff had discussions with A regarding the difficulties associated with attempting surgery in light of their other existing medical conditions. A was readmitted to hospital via A&E the following month, due to bladder spasms and catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) pain. A CT scan was carried out and A was admitted to a ward for ongoing monitoring and treatment. A's pain worsened and further scans showed that the cancer had spread to their lungs. Surgery was no longer an option and A died shortly afterward. C complained that the communication from the urology staff (specialists in the male and female urinary tract, and the male reproductive organs) during A's hospital admissions was poor and that there was an unreasonable delay to A and other family members being told the extent of A's condition. We took independent advice from a consultant urologist. We considered that, when responding to C's complaint, the board sought to provide a detailed description of events and a clearly set out explanation as to the potential causes of A's bladder perforation. That said, we found that information provided by C was not taken into account and, had it been, a clearer explan