SPSO Individual Decisions

Miss C had a history of occasional minor back pain over a number of years, and was diagnosed with sciatica and a prolapsed disc. In November 2011, Miss C developed pain in her lower back and pelvis, which made walking very painful. The pain moved to her right hip, leg and buttock and she began to experience numbness and muscle weakness. In early January 2012, the pain moved again to her lower back and upper left leg. The pain was severe and affected her mobility. Miss C phoned NHS 24, having not been able to contact her own GP. Miss C's GP was asked to visit her at home. He prescribed pain medication and advised her to monitor her condition and to contact NHS 24 again should the pain worsen when the practice was closed. Miss C contacted NHS 24 again late that night. It was suggested that she attend an accident and emergency unit, but due to the pain she experienced when sitting, standing or walking, she did not feel able to do so. NHS 24 then arranged for an out-of-hours (OOH) GP to conduct a consultation by phone. The OOH GP concluded that Miss C's condition was improving and that she likely had a urinary infection. She was told that she should continue to self-monitor overnight. Miss C's condition deteriorated further the following day and, after another call to NHS 24, she was admitted to hospital where she underwent emergency surgery. She was diagnosed with cauda equina syndrome, where a lesion, or prolapsed disc, presses on the nerves at the base of the spinal cord, causing pain, numbness, weakness and/or urinary disturbance or faecal incontinence. Miss C raised a number of concerns about the OOH GP's assessment of her condition and his failure to visit her at home or to arrange an ambulance to take her to hospital that night. She was left with persistent numbness after her surgery and felt that, had the OOH GP recognised the red-flag symptoms (symptoms that are especially likely to indicate a particular serious illness) of cauda equina, and arra

Mr C attended the hospital's accident and emergency department (A&E) during the night, as he was concerned that he might be experiencing a repeat of a chest condition he had had some years previously. After discussion with a nurse, he was shown to a phone and advised to speak to the person at the other end, who turned out to be from the out-of-hours GP service, NHS 24. NHS 24 advised him to return home, and that they would phone him within an hour to assess his condition. Mr C felt that his situation had not been taken seriously and he left. NHS 24 phoned him three times at home, but Mr C felt too distressed to answer their calls. In the morning, he saw his GP, who diagnosed a chest infection. We explained to Mr C that it is NHS policy that someone should only attend A&E if they have an emergency and that, if they need to see a GP outside their practice's opening hours, they should phone NHS 24. NHS 24 then assess, by phone, whether the patient needs to see a GP and, if so, whether they should travel to the out-of-hours GP, or whether the out-of-hours GP should visit them at home. The papers we received from the board showed that, when Mr C arrived at A&E, the nurse considered whether he did need emergency care and spoke to a doctor, who decided that this was a matter for NHS 24, rather than A&E. We did not uphold the complaint because the hospital appropriately established that Mr C needed to contact NHS 24, rather than themselves, then helped him contact them. We also noted that the board said that, because of Mr C's complaint, if someone arrived at A&E but needed to contact NHS 24, staff now made the phone call themselves, giving NHS 24 the relevant details. NHS 24 would then phone the patient back. They believed this would improve their service for patients, and we welcomed the board's use of a complaint as an opportunity for learning and improvement. Related reading View Decision Report 201203271 as a PDF (11.59 KB) Updated: March 13, 2018

Mr C was on holiday when he was taken ill while on a moored boat. He called 999 but was told that as his condition was not life-threatening he should call NHS 24. When he did so, they said they would ask an out-of-hours doctor at a local hospital to call Mr C within an hour. Mr C complained that the out-of-hours doctor would not arrange an ambulance to take him to hospital, and instead gave him the number of local GP surgeries he could contact. Mr C said that he was in great pain and could not walk, but with assistance managed to get back to his holiday home. When he got there, an ambulance was called and Mr C was taken to hospital. Mr C felt the out-of-hours doctor should have arranged an ambulance to take him to hospital in the first instance. Our investigation found that there was a difference of opinion between the out-of-hours doctor and Mr C about his ability to get off the boat, but the information in the records did not help us resolve this. We took independent advice from one of our medical advisers, who said that there was no evidence to suggest an emergency ambulance was required, and that the out-of-hours doctor had provided appropriate advice. This was that, should Mr C's condition worsen, he should contact the emergency service again. It was also appropriate for the out-of-hours doctor to suggest that Mr C should contact a general practitioner who might have been willing to visit him on the boat. Related reading View Decision Report 201203273 as a PDF (11.32 KB) Updated: March 13, 2018

Mrs C, an advocacy worker, complained on behalf of Ms A about the care and treatment she received at the dental practice when her upper right second molar was extracted. After the extraction, Ms A experienced extreme pain. Her face started to swell and she felt physically sick. She contacted NHS 24 and attended the dental hospital for treatment. Ms A said that the dentist had failed to explain the risk associated with the removal of the tooth and made an error when extracting the tooth. She also felt the dentist had not provided an adequate response to her complaint. We upheld two of Ms C's three complaints. Our investigation found that the dentist had failed to explain the risks involved, and we noted that x-rays were not taken, after difficulties with the extraction were recognised. We also found that there was not enough detail in the dental records and that, while the dentist provided accurate information in responding to Ms A, the response was incomplete because of the inadequate level of detail. However, we found no evidence that an error was made when extracting the tooth, and noted that the complications that occurred were a well recognised complication of the extraction of upper molars.

When Mrs C 's mother (Mrs A) became unwell, Mrs A's carer contacted Mrs C, who went to her mother's house, and a doctor from NHS 24 (the out-of-hours service) visited. He examined Mrs A and wanted to admit her to hospital but his notes recorded that she strongly refused. He prescribed an antibiotic (a drug used to treat bacterial infection) after asking Mrs C if she knew if her mother had any drug allergies. He also advised Mrs C to get in touch again if her mother's condition deteriorated. He later discovered that she was allergic to the drug he had prescribed, and contacted Mrs C to arrange an alternative. Mrs A, however, died during the night. Mrs C disagreed that her mother had refused hospital admission and felt that the doctor should have known of Mrs A's previous experience of the drug. Our investigation found that the doctor could not have known of Mrs A's allergy as he did not have access to her emergency care summary. This consists of basic information about a patient (including allergic reactions) and is available in the out-of-hours centre but not in the out-of-hours doctors' vehicles. The doctor was in his vehicle when asked to attend Mrs A. It was clear he took prompt and appropriate action to check her summary when he reached the out-of-hours centre, and to then arrange alternative medication. We took independent medical advice from one of our advisers, who said that the doctor's other actions, such as his examination of Mrs A, were also appropriate. We could not say for sure whether Mrs A had refused to go to hospital, as the accounts were so different. However, we did not uphold the complaint, as we found no grounds to suggest that the doctor's care and treatment (including his decision not to admit Mrs A to hospital) were unreasonable. Related reading View Decision Report 201203004 as a PDF (11.54 KB) Updated: March 13, 2018

Mrs C complained about the treatment that the Scottish Ambulance Service gave to her mother (Mrs A). Mrs A, who suffers from rheumatoid arthritis (an inflammatory disorder that mainly affects the joints), had hurt her leg and was unable to put weight on it. She had been in pain for a number of days and Mrs C phoned 999 for an ambulance. However, the person who took the call assessed it as a non-emergency situation, and decided not to send an emergency ambulance. Our investigation found that this was reasonable in the circumstances, and that it followed the protocol of the medical priority dispatch system. We did note that the call taker had not told Mrs C that there was another route she could use - she could call NHS 24 to see if her mother could be referred to hospital that way. However, as the service had already recognised this omission when investigating Mrs C's complaint, and had taken steps to address it, we made no recommendation about this. Related reading View Decision Report 201201695 as a PDF (11.18 KB) Updated: March 13, 2018

Mr C complained that his medical practice failed to provide appropriate care and treatment when he had an eye infection and unreasonably refused to allow him to see a GP. Mr C developed an eye infection, and called his practice on a Friday to request an appointment. He was told that there were no appointments available and that he should call again on Monday. By Monday his eyes had not improved, and he contacted NHS 24 (a national phone helpline service for advice on health matters). They advised him to see his GP. His workplace occupational health team also advised him not to work, and to see his GP. When Mr C contacted the practice again, he was told that when he first called he should have been referred to the LENS service (a service set up by the regional NHS board, providing direct access to treatment for minor eye conditions). The receptionist he spoke to on this occasion apologised that he was not told this when he first called, and advised him to contact a local optician, a participant in the LENS scheme. Mr C was treated with various eye drops but his condition was slow to resolve. He contacted the practice several times over the next two weeks asking to see a GP. Although he twice saw a nurse from the practice, he was never able to see a GP. As he was unable to see a GP, Mr C continued with the treatment provided by the LENS service and was discharged the next month with the infection resolved. Our investigation, which included taking independent advice from a medical adviser, concluded that it was reasonable that Mr C should have been referred to and treated by the LENS service. We, therefore, did not uphold the complaint about his initial treatment. The adviser said that the care and treatment provided by the service was reasonable and appropriate, and would not have been different from the treatment provided by a GP. However, we did find that when his condition was slow to resolve, it was unreasonable that Mr C was not given the opportunity

Miss C had been attending her GP for a number of months with a suspected prolapsed disc (ruptured disc in the spine). Before her scheduled orthopaedic (medicine of the orthoskeletal system including the spine) appointment, her condition deteriorated suddenly. She experienced severe pain and numbness in her legs. Due to a lack of response from her medical practice, Miss C contacted NHS 24 for advice. NHS 24 contacted the medical practice and arranged a home visit. Miss C was then advised to attend her hospital appointment, but she continued to be in severe pain. She called NHS 24 again and arrangements were made for an out-of-hours GP to contact her. The GP contacted Miss C and discussed her symptoms, which had worsened and included numbness, pain when urinating and burning sensations in her legs. The GP did not visit her or suggest a hospital attendance. Miss C was advised to self-assess her condition overnight. The following afternoon, Miss C was admitted to hospital where she was diagnosed with cauda equina (a disorder that affects the nerves). Miss C complained that NHS 24 did not provide full details of her symptoms to the out-of-hours GP, resulting in a delay to diagnosis which has left her with nerve damage that may be permanent. Upon reflection, after submitting her complaint to us, Miss C decided that she was satisfied that NHS 24 had in fact provided full information to the GP. She accepted NHS 24 's apology for other incorrect information provided by their staff, as well as their reassurance that steps would be taken to prevent similar issues in the future. She withdrew her complaint, and so we did not reach a finding on it. Related reading View Decision Report 201203000 as a PDF (11.47 KB) Updated: March 13, 2018

Mr C said that an NHS 24 nurse practitioner failed to respond appropriately to a call made to NHS 24 when his mother fell ill. The nurse practitioner explained during the call that she would arrange for an out-of-hours GP to attend within two hours. Following the GP's visit, Mr C's mother was admitted to hospital where she later died. Mr C complained that the nurse practitioner failed to take into account his mother's recent admission to hospital, following the fracture of her hip, and failed to give the case sufficient priority. Our nursing adviser considered the evidence, including a recording of the call, and reached the conclusion that the nurse practitioner's actions were reasonable. She noted that the nurse practitioner had in fact upgraded the response time from 'two hours' to an 'urgent' response after the telephone call but that, unfortunately, the family were not informed of this. As the nurse practitioner's actions were, however, reasonable in terms of the priority given to the call, we did not uphold the complaint. Related reading View Decision Report 201200253 as a PDF (11.18 KB) Updated: March 13, 2018

Mrs C's husband (Mr C) was ill and she called NHS 24. However, she complained that the board failed to respond to her call and that the out-of-hours (OOH) doctor who came did not treat her husband appropriately. She also doubted that the doctor properly recalled the visit. We considered all the relevant information and obtained advice from our medical adviser. We found the information about the telephone calls inconclusive. Mrs C said that the board had not called, however, the board's records said that attempts to call Mrs C were made, but were unsuccessful. We did not see any records of these specific calls, and in the absence of evidence, could not uphold this complaint. We agreed that the OOH doctor had not properly treated Mr C in accordance with his symptoms and had kept poor records of the visit. This meant that the information that the board gave Mrs C when she complained was confusing. We made recommendations to address the failures identified.

Mr C told us that when his wife (Mrs C) became very unwell, he rang NHS 24. He explained her symptoms and told the operator that Mrs C had just completed in vitro fertilisation (IVF) treatment. He said that an hour passed and there was no return call from NHS 24, so he rang again and was told someone would call soon. Another hour passed and Mr C phoned again. He said he was again told someone would call soon. Another 30 minutes passed and having still had no contact from NHS 24 Mr C phoned again, but again they did not offer help. Mr C said he then took his wife to a hospital accident and emergency unit. He said that they received a call-back from NHS 24, but this was three hours after his original telephone call. Mr and Mrs C were upset that it took so long for NHS 24 to return his calls for assistance. Before we could look into Mr C's complaint, we needed more information from him. As we did not receive the requested complaints information, we were unable to reach a decision on his complaint. Related reading View Decision Report 201103498 as a PDF (16.67 KB) Updated: March 13, 2018

Mrs C had surgery in hospital to remove a soft tissue lump from her right thigh. She said that a few days later the wound had become red and infected. She contacted NHS 24 who referred her to an out-of-hours (OOH) GP service where a nurse prescribed antibiotics. Mrs C returned home, but her condition worsened and later that day NHS 24 arranged for an ambulance to transfer her to hospital where she was diagnosed with a skin infection and an infection of the thigh wound. Mrs C had a further surgical excision and drainage, and the wound was left open to heal from the inside. She received antibiotics intravenously (directly into a vein) and was discharged on oral antibiotics. Mrs C complained that the hospital failed to prescribe her with antibiotics after the initial surgery, which she believed might have prevented the infection she later contracted. She also said that the OOH service failed to take her seriously and recognise the seriousness of her condition. Mrs C said that as a result of the failure to provide antibiotics and the failures in the care and treatment she received from the OOH service, she has struggled to recover from her operation and continues to have difficulty in walking. After taking advice from our medical adviser, we found that the hospital's decision not to prescribe Mrs C antibiotics after her initial surgery was reasonable. However, we also found that the OOH nurse failed to recognise the significance of Mrs C's symptoms and admit her to hospital, although our medical adviser said that this would not have affected the outcome.

Miss C complained about the care and treatment provided to her late uncle (Mr A) by his medical practice. Her mother (who is Mr A's sister) had initially made the complaint, but Miss C eventually took it forward on her mother's behalf. Mr A had cancer and was undergoing chemotherapy in hospital. Several days after he was discharged from hospital, he telephoned the practice asking for a prescription for antibiotics and a telephone consultation with his doctor. His doctor returned the call and issued a prescription for antibiotics. A few days later, Mr A's sister became increasingly concerned about his condition and telephoned the practice requesting a home visit from a doctor. The practice advised her to contact emergency services. She was dissatisfied with the advice and phoned NHS 24, who arranged with the practice to send a doctor to visit him at home. The doctor arranged for an emergency ambulance to admit Mr A to hospital. Mr A died several weeks later. Miss C complained that Mr A should have been seen by a doctor after her mother called the practice, and that the practice's response to the request for a home visit was unreasonable. We upheld Miss C's complaints. We found that, given the seriousness of Mr A's illness, he should have had a face-to-face assessment rather than a telephone consultation. We could not establish what was said between Mr A's sister and the practice during the telephone call. However, we found that the problems of communication were compounded by a lack of specific instructions about the advice from the practice to contact emergency services. As a result, there was a delay in admitting Mr A to hospital and, while this may not have affected the outcome, it was clearly distressing to him and his family. We made recommendations in respect of both the doctor concerned and the practice.

Ms C complained that NHS 24 refused to send an emergency ambulance to take her to hospital but instead referred her to the local out-of-hours service. She said that this was despite her step-daughter and her requesting an emergency ambulance. Having obtained the recordings of the telephone calls during our investigation, however, it was clear that Ms C and her step-daughter did not request an ambulance nor did they raise objections to being advised to visit the local health centre. We did not uphold this complaint. Related reading View Decision Report 201104097 as a PDF (16.25 KB) Updated: March 13, 2018

Mr C was on holiday when he sought treatment for a dental infection. He complained about the care and treatment provided by the board when he attended the emergency department at a hospital. Mr C explained to a member of staff that he was in a lot of pain, his face had become swollen, and that he was seeking antibiotics and painkillers. They told Mr C to contact NHS 24 as there was no dentist available to treat him. Mr C spoke to a healthcare professional at NHS 24 who took some information and told him to return to the emergency department where he would be helped. However, on his return to the emergency department, Mr C said that he was told to leave and that NHS 24 would call him. However, they did not. Mr C received treatment from his own dentist when he returned home several days later. Mr C complained that the board's failure to treat him was unacceptable given the dangers of an untreated infection, and that the board should have treated him with antibiotics and painkillers in the absence of a dentist. Mr C also complained that the board's response to his complaint was inadequate. We took advice from our medical adviser, and found that communication failures led Mr C to leave the hospital, but that a consultation should have been arranged when he returned to the emergency department after his telephone call with NHS 24. The provision of simple pain relief and prescription of antibiotics, if required, would have been reasonable medical care. We told the board this, and upheld this complaint. However, as Mr C had already received an apology from the board and they had taken measures to try to prevent this happening again, we did not make any recommendations. We found that the board had considered and dealt with Mr C's complaint in line with NHS complaints procedures. Related reading View Decision Report 201101039 as a PDF (17.44 KB) Updated: March 13, 2018

Mr C had been experiencing abdominal pain since around 05:00 on a day in June 2010. He became unwell and his pain increased in severity around 22:00. He telephoned the Scottish Ambulance Service (SAS). They did not consider his case to be an emergency and transferred his call to NHS 24. Mr C’s conversation with NHS 24 lasted around 40 minutes, during which time he repeatedly asked for an ambulance to be dispatched to his home. The NHS 24 call handler sought details of his symptoms and ultimately decided to arrange for a duty doctor to call him back within one hour. Mr C was not satisfied with this outcome and arranged for a neighbour to assist him to phone the SAS again. Following this call, a paramedic was dispatched and, following an examination, an ambulance was called. Mr C was found to have a burst appendix. Mr C complained that NHS 24 should have dispatched an ambulance given the nature of his symptoms. He felt that the number and nature of the questions put to him by the call handler was repetitive, unreasonable and inappropriate. He also complained that it was inappropriate and unreasonable for NHS 24 to suggest that a doctor phone him ‘within an hour’ for further assessment when he was clearly in considerable pain and distress. We were satisfied with the nature of the questions asked by NHS 24 and found that, whilst there was some duplication, this was kept to a minimum. The evidence that we were presented with showed that there were some communication issues between Mr C and the call-handler and we considered that these contributed to the length of the call more than the NHS 24 call procedure. Our professional medical adviser shared an opinion expressed by NHS 24 that Mr C’s symptoms indicated a need for a physical examination. Mr C had advised the call-handler that he was unable to make his own way to hospital, so we considered it unreasonable for the physical examination to be delayed further by arranging for a doctor to telephone him. We considered that

Mrs C complained on behalf of her husband (Mr C) about the care and treatment he received from his medical practice in relation to abdominal pain. Mr C had been suffering from constipation for several months. A GP visited Mr C at home as he was unable to attend the practice because of the pain. Mrs C called the practice several times shortly after the home visit, telling two GPs that Mr C's condition was not improving despite intervention from the district nurse and treatment for constipation. The practice did not, however, arrange a further home visit during the telephone calls. Mrs C telephoned NHS 24 and an out-of-hours GP examined Mr C and arranged an emergency admission to hospital. Mr C had an operation on the day of his admission given the seriousness of his condition. He had peritonitis and a large inflammatory mass related to the large bowel. His recovery was traumatic and he continues to experience significant health problems and chronic pain. Mrs C said that if the practice had properly followed up their initial home visit, Mr C would have been admitted to hospital earlier and might not have been so severely ill. She felt that his continuing significant health problems and chronic pain could also have been avoided. We found that the information available to the GPs from the telephone calls and the district nurse should have prompted them to reassess Mr C in person and examine him. Having said that, our medical adviser said that it was not certain that the deterioration in Mr C's condition would have been picked up by clinical examination or whether it would have made any difference to the outcome. A home visit could, however, have improved the chances of a better outcome for Mr C. The practice have already recognised that there were failings and have taken some action to address these.

Following advice from NHS 24, Ms C attended a hospital out-of-hours (OOH) service complaining of a two-day history of nausea, pain, itching and an area of what she thought to be shingles on her torso. She also had a small 'protrusion' in the area of discolouration. Ms C asked the OOH doctor if this could be a tick. The doctor removed the object and told Ms C that she thought it was merely a scab. After noting all Ms C's symptoms and her past history of shingles attacks, the doctor made a provisional diagnosis of shingles. Ms C was prescribed anti-viral drugs and advised to 'seek further medical assistance' if her symptoms continued. Ms C's symptoms did continue, and worsened, and she attended her GP five times during the following weeks before being diagnosed with Lyme Disease and given antibiotics. Her recovery is slow and on-going. Ms C complained that the OOH doctor should have examined the object removed from her skin either with a magnifying glass or under a microscope to establish whether or not it was a tick. She also complained that the doctor failed to diagnose Lyme Disease. Our professional adviser said that Lyme Disease is very difficult to diagnose and that the examination and provisional diagnosis made by the OOH doctor was reasonable. They said that it was also reasonable to tell Ms C to seek further advice if her symptoms continued and noted that she had done so, but that she had gone to her own GP, and not the OOH service. It was, therefore, not reasonable to lay the delayed diagnosis at the door of the OOH service. The adviser also said that further examination of the object removed from Ms C's skin would not have helped achieve an earlier diagnosis of Lyme Disease. This is because although ticks can carry and transmit this, a bite from a tick would not automatically mean that the disease had been contracted. Related reading View Decision Report 201101996 as a PDF (14.56 KB) Updated: March 13, 2018

Mrs C complained about the service that she received when attending her local out-of-hours medical service. She felt that the information that she was given delayed her treatment. She had been unwell for a number of days and called NHS 24 for an appointment at the out-of-hours centre. Before the appointment was arranged, she took a turn for the worse and made her way to the centre. She was met by an unidentified individual (understood to be the doctor's driver). She was told that she could wait for the doctor but that this could take several hours. Alrternatively she could return home and call NHS 24. Mrs C returned home. When NHS 24 called with her appointment, she cancelled it as she was too unwell to return to the out-of-hours centre. Mrs C saw her GP the following morning and was immediately referred to hospital. We found that the service provided was poor as a result of the Board's policy for out-of-hours walk-in patients, which required a medical assessment to be made by non-medical staff. Information provided to patients in the absence of a doctor was also found to be poor.

Mrs C had felt unwell for several days. One night she telephoned NHS 24 about her symptoms. They agreed to arrange an appointment for her with the GP out-of-hours service and told her to wait for a call telling her an appointment time. Mrs C, however, felt faint and short of breath before NHS 24 called back with this and went to the out-of-hours service with no appointment. She was told she could not be seen immediately, but could wait. Because she did not feel well enough to wait, she decided to go home. Mrs C was admitted to hospital the next day and was found to have internal bleeding. She later made a number of complaints about how NHS 24 handled her call. These included that they failed to note all her symptoms or to contact her with an appointment in good time. She was concerned that this had delayed her admission to hospital. We obtained the recording of the call, which lasted 17 minutes. During the call, Mrs C spoke to a call handler, then a nurse practitioner. The recording showed that they asked clear and appropriate questions about Mrs C’s symptoms, that Mrs C confirmed them and that she agreed the proposed action. We noted that a particular symptom, which Mrs C felt NHS 24 had ignored, was not in fact mentioned during the call. We, therefore, did not uphold her complaint that they failed to take a full history, or properly note her symptoms. They also appropriately arranged an appointment for her with the out-of-hours service. Although Mrs C felt they had asked her to attend there when she was too unwell to go, the recording showed that she did not say this to them at the time and had agreed to attend an appointment that night. She also said that she was not offered transport or a home visit, or an alternative appointment the next morning, but having investigated this we found that NHS 24 were not required to do any of these as a result of the telephone call. The outcome on this summary page is different to the outcome that appears on the PDF below and t