SPSO Individual Decisions

C complained about the care and treatment they received from the board. C experienced pain and discomfort when eating and suffered from gastro-oesophageal reflux (stomach acid travelling up towards the throat). C's gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines) ordered a barium swallow test (BST, a special type of X-ray test where barium is swallowed which shows up clearly on an x-ray to help diagnose problems with swallowing and the oesophagus). The radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) who reviewed the images reported them as normal. C complained about the care and treatment provided by the gastroenterologist and the radiologist's interpretation of the BST. We took independent advice from a consultant radiologist and a consultant gastroenterologist. We found that there were small osteophytes (bony lumps that grow on the bones of the spine or around the joints) in the spine on the BST images. However, these were small and insignificant. We found that images had been thoroughly reviewed by the radiologists and that there was no demonstrable compression of or leakage from the oesophagus. We also considered that the suggestion to change C's medications was reasonable and good clinical practice. The BST showed that no further investigations were required. Therefore, we did not uphold this aspect of C's complaint. C also complained about how the board responded to their complaint. We found that the complaint response may not have been as in depth as C would have preferred, and that the conclusions of the medical staff were not what C was hoping for, however that did not mean the response was unreasonable. There was a delay in providing a complaint response to C, however we found that these were caused by the COVID-19 pandemic and from a further submission of inf

C complained about the nursing care and treatment they received during their admission to Ninewells Hospital. This related to the treatment of a pressure ulcer which C complained was left to deteriorate to the extent that on discharge it was worse than on admission. They said that as a consequence, their treatment had to be continued intensively at home. The board apologised that C's wound had been worse on discharge and accepted that the simple dressings used by nursing staff would not have encouraged wound healing. They also accepted that there was a requirement to support all staff members to attend an update training session on wound care and that encouragement needed to be given to all team members to have the confidence to ask their peers or others working within the multidisciplinary team for advice and assistance. We took independent advice from a nursing adviser. We found that there had been a failure to assess, measure and treat C's wound in accordance with the Scottish adapted pressure ulcer grading tool and Healthcare Improvement Scotland (HIS) Pressure Ulcer Standards (2018). We also found that the review carried out by the board had not been thorough enough, a number of failings had not been identified and that the action already taken by the board was not enough to demonstrate that there had been improvement with regard to pressure ulcer assessment and grading. As such, we upheld this complaint.

C complained on behalf of their parent (A) about the actions taken by the board. A took a number of medications and over the years C became concerned about A's capacity to administer their own medication safely. There was an accidental overdose when A took too much Warfarin (a blood thinning medication). C complained about the care and treatment that A received following the overdose and that the board failed to ensure A could safely administer their medication. We took independent advice from a specialist district nurse. We found that, as A was not bleeding, it was suitable for them to be treated in the community. Appropriate monitoring was carried out and no untoward events occurred for A while they were managed in the community. We noted that district nurses had a role to play in keeping A safe. However, it was not normally their role to administer regular medication and not their sole responsibility to ensure that A was supported in their home to carry out everyday tasks safely. We found that the district nurses had acted reasonably and appropriately, and responded promptly when problems had arisen. We also noted that the record-keeping was of a very high standard. We did not uphold C's complaints. Related reading View Decision Report 201908805 as a PDF (24.33 KB) Updated: December 22, 2021

C complained on behalf of their parent (A). A had dementia, lived in their own home and took a number of medications. C raised concerns that A was not able to take their medication safely without supervision. We took independent advice from a GP. We found that the primary responsibility of the practice was to prescribe appropriate medication for A's condition. They also had a role in assessing A's mental state and making appropriate referrals to other specialists. In terms of those responsibilities, we found that there was no evidence of failure on the practice's part. There was a problem with one of A's prescriptions when they changed pharmacy. The practice addressed this problem quickly and an appropriate apology was given. As such, we did not uphold the complaint. Related reading View Decision Report 202003178 as a PDF (24.12 KB) Updated: December 22, 2021

C had been treated for chlamydia and gonorrhoea (two types of sexually transmitted infection) by the board. C continued to feel unwell and attended an appointment at the board. C was concerned that they were not physically examined or tested for pelvic inflammatory disease (an infection of the female upper genital tract, including the womb, fallopian tubes and ovaries) and that they were advised to isolate with a possible COVID-19 infection. We took independent advice from a consultant in sexual and reproductive health with a background in hospital gynaecology (female reproductive system). We found that C reported symptoms which were consistent with pelvic inflammatory disease. In the circumstances, it was unreasonable that a physical assessment was not performed, or as an alternative, empirical antibiotic therapy commenced for possible pelvic inflammatory disease. It was unreasonable that further steps were not taken to assess for and exclude pelvic inflammatory disease as a possible diagnosis in this case, prior to providing the advice regarding self-isolation for possible COVID-19 infection. In light of the above, we upheld C’s complaint.

C complained on behalf of their late spouse (A) who was admitted to Ninewells Hospital. A Do Not Attempt Cardiopulmonary Resuscitation (DNACPR, a decision taken that means a healthcare professional is not required to resuscitate the patient if their heart or breathing stops) was put in place some time after their admission and they died a week later. C complained that clinicians failed to discuss the DNACPR with family prior to this being put in place and, when they were consulted, the family were clear that they were not in agreement with it. The family also complained that the DNACPR form was only signed by one clinician, rather than the two required for the form. C considered this was further evidence that the DNACPR decision was taken incorrectly. In response, the board said that the decision to put a DNACPR in place was made following discussion at the multi-disciplinary team meeting, the records did not show any disagreement by the family at the time and the form was completed by one of the junior medical staff, on the lead consultant’s instruction. We took independent advice from an appropriately qualified adviser. We found that the board failed to follow appropriate processes and procedures in relation to the implementation of the DNACPR, in as far as they failed to both adequately document conversations with family members, and to complete the required paperwork correctly. We upheld the complaint.

C attended A&E at Perth Royal Infirmary following a knee injury. They were diagnosed with a soft tissue/tendon strain and advised to attend their GP for follow-up. C said that their knee did not settle and attended the hospital again six months later. C was then told that they had a meniscal tear (a partial or full tear in the cartilage of the knee). As their condition did not improve, C underwent an operation. C said that they experienced no relief following the operation and their GP made a further referral to orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system). They were advised that further surgery would be unlikely to help and, therefore, there was no clinical reasons to operate further. C complained about the care and treatment they were given by the board. C said that there was a delay in providing appropriate treatment and diagnosis, that their care was poor and that the board did not deal reasonably with their complaints about this. The board said that C’s initial care and treatment had been appropriate and although they were aware of C’s view that they should have been x-rayed when they first attended the hospital, to have done so would not have shown the subsequent diagnosis they received. The board added that scans and x-rays were not routinely carried out for knee injuries and that C had been given appropriate advice. We took independent advice from consultants in emergency medicine and in orthopaedics. We found that, overall, C’s care and treatment had been reasonable. However, there was a failure to carry out an x-ray when they first attended hospital which was contrary to accepted guidance regarding when an x-ray of a knee should be undertaken following trauma. For this reason, the complaint was upheld. In relation to complaint handling, we found that C was kept fully apprised of the progress of their complaint and given a new target date for a response which was met. We did not uphold this complaint.

C attended at Perth Royal Infirmary after falling and injuring their wrist. C complained that the care and treatment they received was unreasonable and as a result, they had been left with continuing pain and loss of function in their wrist for which they are awaiting surgery. We took independent advice from a senior nurse practitioner, a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). In relation to C's initial attendance at A&E where they were seen by a nurse practitioner (NP), we found that the NP recognised from their clinical assessment that C may have sustained a fracture to their wrist and appropriately had the wrist x-rayed. However, it was recorded in C's clinical notes that the x-ray showed no bony injury, which indicated the NP had wrongly interpreted the x-ray as being normal. However, the discharge letter from A&E to C's GP stated a different diagnosis suggesting that the fracture was identified. We only received an explanation from the board for the conflicting diagnoses, which was that the NP had made a mistake in recording there was no bony injury, at a late stage in our investigation. We noted that the treatment the NP provided to C in referring them for an x-ray and making a referral to the virtual fracture clinic was appropriate. We found that the doctor who later reviewed C's case at a fracture clinic correctly identified that C had sustained a fractured wrist. However, the board accepted that C should have been referred to see an orthopaedic consultant at an earlier stage. We noted that the board had apologised to C for this and taken action to address what occurred. Finally, we found that given C's medical history and their significant medical co-morbidity, it was reasonable to take a conserv

C, a support and advocacy worker, complained to us on behalf of their client (B) about the care and treatment provided to their child (A). Over a ten-year period, A had several referrals to the board's children and adolescent mental health services (CAMHS) on both a routine and emergency basis. C raised various concerns, in particular about delays in diagnosing A and that A was not admitted for in-patient psychiatric treatment following incidents of self-harm or attempted suicide. We took independent advice from an adviser in child and adolescent psychiatry. We found that aspects of A's care and treatment were unreasonable. In particular, we found that there was an unreasonable delay in assessing A for adult attention deficit hyperactivity disorder (ADHD, a behavioural disorder that includes symptoms such as inattentiveness, hyperactivity and impulsiveness); that A was given an emergency assessment that fell below a reasonable standard; the other professionals involved in A's care did not have a clear understanding of the level of input they could expect from CAMHS; and that there was a lack of evidence CAMHS tried to adapt their approaches to better engage A. We upheld the complaint. In relation to complaint handling, the board provided us with additional electronic records when they responded to our draft decision and not at the outset of our investigation. We have made a recommendation to address this.

C complained about the board's management of a retinal detachment (when the thin layer at the back of the eye becomes loose) and other issues affecting their eye. C attended hospital with a small hole in the centre of the retina and subsequently attended a number of appointments with the board's ophthalmology department (specialists in the study and treatment of disorders and diseases of the eye). Due to the condition of C's eye, a “watch and wait” approach was taken. C later experienced a deterioration in their eye and attended an emergency clinic. A scan was carried out and C was discharged home on the basis that the eye remained stable. C was concerned that the examining consultant did not carry out additional tests or provide any treatment in light of the deterioration in their vision. C travelled abroad on holiday the following month and their eye deteriorated further. They attended a local ophthalmologist who identified a full retinal detachment. C underwent retinal reattachment surgery. C complained that the retinal detachment should have been diagnosed at the emergency appointment and that, had it been diagnosed, they would have undergone surgery, avoiding the expense of private treatment abroad. We took independent advice from a consultant ophthalmologist. We found that changes to the eye were visible on the scan taken at the emergency appointment. We considered that this should have led to a more detailed examination of the eye and that a retinal detachment would likely have been identified at that point. We upheld C's complaint. However, even if a retinal detachment had been identified at that point, it would have been a matter for the professional judgement of the surgeon as to whether surgery was advisable. It would not have been unreasonable for the surgeon to have advised against surgery, given the condition of C's eye and the risks association with surgery.

C complained that they were unreasonably diagnosed with bicuspid aortic valve (a type of abnormality in the aortic valve in the heart where the valve has only two small parts (leaflets), instead of the normal three). C was diagnosed with bicuspid aortic valve by the board and as a consequence, made significant changes to their life and retired early. C was later given a different diagnosis (when they were under the care of a different NHS board) and took the view that the diagnosis given previously was, therefore, incorrect. We took independent clinical advice from a consultant general cardiologist (specialist in diseases and abnormalities of the heart) and a consultant cardiologist with particular experience in the reading of echocardiograms (a scan used to look at the heart and nearby blood vessels). We found that C had been diagnosed previously with bicuspid aortic valve when they were resident in Wales. Relevant information was passed to C's new GP when they moved to Scotland who made a referral to Perth Royal Infirmary for continued follow-up. A further echocardiogram was performed at that time, which was reasonable and appropriate. We confirmed that although interpretation of C's echocardiogram was not necessarily straightforward because of calcification (a build-up of calcium in body tissue) and the fact that C was not echogenic ('echogram-friendly'), the conclusions reached (of bicuspid aortic valve) and reported to C at the time were entirely reasonable in the circumstances. While C's diagnosis had since been amended, this did not mean that the diagnosis given by the board was an unreasonable one. We noted that it was not unusual for diagnoses to be amended. Therefore, we did not uphold C's complaint. Related reading View Decision Report 201904200 as a PDF (24.59 KB) Updated: July 21, 2021

C has been diagnosed with Emotionally Unstable Personality Disorder (EUPD). C was admitted to a specialist mental health facility on two occasions. Whilst there, C was under the care of a consultant psychiatrist. C complained to the board about various matters including the decisions to discharge C to care in the community, given C's EUPD diagnosis, and that the community mental health team (CMHT) were providing support only by telephone, rather than face-to-face contact, due to arrangements in place during the COVID-19 pandemic. In their response, the board explained that international evidence advised that patients with EUPD should be cared for in the community wherever possible and that the board had sought to offer C the most appropriate care when they encouraged C to leave the ward. C was dissatisfied and raised their complaints with this office. We found that C's discharges were reasonable in terms of the planning undertaken, discussions held and arrangements made both in terms of C's diagnosis and the particular circumstances of the time. We also found that these decisions were in line with relevant guidance. We did not uphold this complaint. Related reading View Decision Report 202001295 as a PDF (24.32 KB) Updated: June 23, 2021

C had been seeking treatment for urinary incontinence but said they experienced significant delays and were asked to attend unnecessary appointments. C also raised concerns about the standard of communication and treatment decisions during this period. C told us that they had been unable to work as a result of the failings. We took independent advice from a consultant urological surgeon (a doctor who specialises in the male and female urinary tract, and the male reproductive organs). We found that when C was referred to gynaecology (specialists in the female reproductive system), no surgical options had been available for the treatment of urinary incontinence in the health board area for a number of years and that this was not explained to C until 21 months after referral, despite C having seen at least two gynaecologists by that time. We also found a lack of organisation in terms of staff identifying and communicating the treatment options available to C and putting a treatment plan in place from an early stage. Therefore, we upheld C's complaint.

C brought a complaint to us about the gynaecology (medicine of the female genital tract and its disorders) care and treatment they received when they attended Ninewells Hospital. In particular, C complained that they suffered complications from the surgery they underwent and felt that a number of things had gone wrong due to incorrect procedures. C explained that they felt that they were not listened to, nor were they cared for properly or treated with dignity and respect. We took independent advice from a consultant gynaecologist. We found that while there was some learning for the board in relation to the saving of ultrasound documentation (pictures or hard drive images) and advising C to check for coil threads, the overall care and treatment given to C was reasonable and the complications which arose in this case were recognised complications. We also found that C had been fully and appropriately consented for these. We did not uphold this aspect of C's complaint. C also complained about the way the board handled their complaint. We found that the board have already acknowledged and apologised for failings identified and said that changes had been made to individuals' practice and to some systems. In the circumstances, while we upheld the complaint, we had no recommendations to make. Related reading View Decision Report 201908608 as a PDF (24.39 KB) Updated: May 19, 2021

C, a support and advocacy worker, complained on behalf of their client (A). A is profoundly deaf and British Sign Language (BSL) is their first language, and so A relies upon BSL interpreters when attending medical appointments. A requested a gender specific interpreter for a GP appointment but when they arrived they found that the interpreter was not the gender they had requested. The interpreter had to leave the room when A required an intimate examination and they were unable to communicate with their GP during this time. C said A felt that they had not been treated with respect and dignity. We found that A did not receive the level of service they could reasonably expect from the board which led to difficulties in accessing general practice services and significant distress. The failings in the service provided included an unreasonable delay in the provision of an interpreter, misleading information about the status of interpreters, lack of a gender specific interpreter, and an inadequate risk assessment. We upheld the complaint.

C was referred to the board's urology service (specialists in the male and female urinary tract, and the male reproductive organs) via an urgent referral due to suspected cancer. C was diagnosed with transitional cell carcinoma (a type of cancer that typically occurs in the urinary system). C underwent laparoscopic (keyhole surgery) nephroureterectomy (a surgical procedure to remove the renal pelvis, kidney and entire ureter, along with the bladder cuff). C then had follow-up appointments and treatment. C complained about delays in diagnosis, in surgery, in follow-up appointments and treatment, along with poor communication from the board. We took independent advice from a consultant clinical oncologist with specialised urology oncology practice. We found that the board failed to meet the Cancer Waiting Time (CWT) standards with regards to the 62-day timescale from referral to treatment, and the 31-day timescale from decision to treat to treatment. Since C's complaint, the board have taken a number of actions to improve waiting times within the urology service and their communication about waiting times. We considered that the actions the board had already taken were comprehensive and we did not make further recommendations to the board to improve the way they do things. However, we recommended that the board apologise for the failure to meet the CWT standards. As a result, we upheld this aspect of C's complaint. C also complained that the board's handling of their complaint was unreasonable. We found that the board did not acknowledge C's complaint within the timescales set out in the Model Complaints Handling Procedure, and did not always update C with revised timescales as to when C could expect a response to their complaint. In addition, the board did not reply to two letters from C, sent in reply to the board's response to C's complaint. As a result, we upheld this aspect of C's complaint.

C, a support and advocacy worker, complained on behalf of their client (A). A, whose first language is British Sign Language (BSL), was admitted to Perth Royal Infirmary with concerns about their heart and lungs. During their admission, A's spouse (B) had to translate for them, which they found extremely difficult as B is severely deaf and BSL is their preferred method of communication. C said that this was contrary to the board's policy on their interpretation and translation service and showed a lack of deaf awareness. We took independent advice from a specialist in equality. We found a number of failings that had an impact on the board's ability to meet A's communication requirements effectively which caused distress to A and B. These failings included misleading information about the level of the interpretation translation service provided to patients and staff; and that the level of the aforementioned service was inadequate and not in line with the board's policy. We upheld the complaint.

C complained about the care and treatment they received at Ninewells Hospital. C was diagnosed with a small renal (kidney) cyst a number of years ago. This was treated at the time, but C complained that it was not subsequently monitored. They later developed a mass in their abdomen that weighed nearly three kilogrammes when it was removed several years later. C considered that the board delayed in operating when C was referred to the urology team (specialists in the male and female urinary tract, and the male reproductive organs) and that there were further delays in providing treatment when they were later diagnosed with cancer. We took independent advice from a consultant urological surgeon and a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that C's renal cyst was incorrectly categorised as simple, when in fact it had the features of a complex cyst with a risk of malignancy. This should have required a referral to urology for active surveillance or surgical resection at that time. Therefore, we upheld this complaint. In relation to the delay in operating following a referral to urology, we found that a discussion at a renal multi-disciplinary team meeting and then clinic review and a consent discussion were appropriate when C was subsequently diagnosed with a large left renal mass. We did not uphold C's complaint that the board's urology team had delayed in operating at that time. Finally, we found that C had a very rare form of renal cancer and that the matter was complex because the final diagnosis was not clear. We did not identify any unreasonable delay in C's diagnosis and treatment of cancer. Therefore, we did not uphold this complaint.

C complained on behalf of their parent (A) about the care and treatment they received during an admission to Ninewells Hospital. A was given a working diagnosis of a urinary tract infection (UTI) with delirium but was later diagnosed with encephalitis (inflammation of the brain). C said that because A regularly suffered UTIs, assumptions were made that A was experiencing the same again. C said that, as a result, appropriate investigations were not carried out and there was an unreasonable delay in diagnosis which affected A's outcome. The board said that a UTI had been given as a reasonable working diagnosis and that blood and urine tests confirmed this. They considered that A had been treated reasonably in the circumstances. We took independent medical advice. We found that at the time of their admission, A had non-specific symptoms which were reasonable to diagnose as a UTI. When A deteriorated and their symptoms changed, A was cared for reasonably with an appropriate degree of urgency, and a prompt diagnosis of encephalitis was made. While A suffered a poor outcome, we could not conclude that this was as a result of an unreasonable delay in diagnosis. We did not uphold C's complaint. Related reading View Decision Report 201905821 as a PDF (24.31 KB) Updated: February 17, 2021

C suffered from a gastrointestinal (stomach) disorder and was receiving treatment from the board. C complained that the treatment in response to their condition was unreasonable. We took independent advice from a consultant hepatologist and gastroenterologist (specialist in disorders of the gastrointestinal tract, liver, pancreas and gall bladder). We found the clinicians involved in C’s care considered both the physical and psychological elements relating to C’s condition, undertook reasonable investigations into their condition and provided reasonable treatment in terms of C’s symptoms. We noted that it was reasonable in conditions such as C's, where there was no cure, to focus on the management and improvement of symptoms and prevent harm. As such, we did not uphold this complaint. C complained that the board failed to reasonably respond to their complaint. We found that the board failed to reply to all the points raised by C. C raised a number of concerns regarding the treatment they had received. In response, the board advised that the review undertaken indicated that clinical management was appropriate; however, no details were provided to explain how they had reached that view. While we considered it was reasonable that the board focused on a way forward, to ensure appropriate treatment was carried out in the future and this was a resolution-based approach, this did not remove the requirement to respond to the points C had raised about previous treatment. There was also an unreasonable delay in responding to C’s complaint. As such, we upheld the complaint.

C has felt that they have obsessive compulsive disorder (OCD) for some years. C has seen various clinicians at the board about this but does not feel that they received appropriate care or treatment. C complained to the board about their care and treatment over the previous years. C said that a psychologist did not provide reasonable care or treatment, that a community mental health nurse did not provide reasonable care and that a psychiatrist unreasonably diagnosed C with anxiety. In their responses, the board told C that the psychologist had reviewed their care and treatment. The board outlined the care and treatment C had been offered and had taken up and concluded that C’s care and treatment had been handled reasonably. C was dissatisfied with the board’s response and raised their complaints with our office. We found that the overall standard of treatment provided to C between the period in question by all of the board staff complained of was of reasonable quality and in line with relevant guidance. We did not uphold the complaints. Related reading View Decision Report 201902152 as a PDF (24.19 KB) Updated: February 17, 2021

C complained about the treatment which they received from the practice. C said that they were ill and had been discharged from hospital following a diagnosis of pancreatitis (inflammation of the pancreas). C saw a GP twice in one month, who diagnosed gastric issues and prescribed Peptac (medication for heartburn/indigestion). C said that they continued to worsen and saw the GP again, who again felt the problem was gastric issues and increased the dosage of Omeprazole (medication for heartburn/indigestion). C said that their condition again worsened and two days later C was admitted to hospital as an emergency where it was found that they had a pancreatic infection, and C remained as an in-patient for some weeks. C felt that their concerns had been dismissed and that, had appropriate treatment been given, their condition would not have been so severe or life-threatening. We took independent advice from a GP. We found that the practice had provided appropriate care and treatment in view of C's reported symptoms and medical history. There was no clinical requirement that C should have been admitted to hospital at an earlier date. We did not uphold the complaint. Related reading View Decision Report 202002252 as a PDF (24.28 KB) Updated: January 20, 2021

C complained on behalf of their family member (A) about a delay in diagnosis of A’s type 2 Diabetes Mellitus (an adult onset diabetes, occurs when the body cannot produce sufficient insulin to absorb blood sugar - T2DM). A was initially diagnosed with type 1 Diabetes Mellitus (T1DM) by their GP and began taking insulin. Over the following years, A was reviewed in the board’s diabetes clinic at varying intervals. After a number of years, and after further tests were performed, A’s diagnosis was changed to T2DM, and their treatment was altered. In response to our enquiries, the board said they considered that A’s care was appropriate and that there was no delay in diagnosis. We took independent advice from a consultant diabetologist (doctor specialising in the diagnosis and treatment of diabetes). We found that there was an unreasonable delay in diagnosing A with T2DM. We found that it would have been reasonable to consider a potential diagnosis of T2DM at the time of the initial T1DM diagnosis, or soon after. We also found that the treatment used for T2DM could have been provided to A much earlier and we noted that there were a number of opportunities over the following years to reconsider the basis for the diabetes and thus additional treatment options. We upheld C’s complaint and made recommendations.

C complained about the treatment their late spouse (A) received from Tayside NHS board. Following a fall, A required emergency hip replacement surgery. A developed a severe infection in their wound following the surgery and later died as a result of this infections. C complained that the board inappropriately ignored issues with A’s stomach when prescribing antibiotics. C also considered that A was required to attend hospital appointments unnecessarily when their condition became untreatable. C stated that at a meeting to discuss their complaint after A’s death the board told them that A had not been expected to live. C said they were shocked and had not been told this before. The board stated A’s treatment had been reasonable. Staff had responded appropriately to A’s serious infection. Although every step had been taken to avoid infection, these did occur. A’s condition had been regularly reviewed and advice taken from microbiology specialists to try and optimise A’s treatment. We took independent medical advice from a orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found A’s treatment was reasonable. They were regularly reviewed and their antibiotics were changed in order to try and improve their outcome. In addition, we noted that A’s condition was such that it was not unreasonable for them to have their wound dressed as an out-patient. Therefore, we did not uphold C’s complaints. Related reading View Decision Report 201903553 as a PDF (24.46 KB) Updated: December 16, 2020

C complained about the care and treatment provided to their late adult child (A) during an out-of-hours (OOH) GP visit. A had been experiencing symptoms including exhaustion, vomiting, and lack of appetite. A was examined and given anti-sickness medication, and advised that they should contact their own GP the next day for urgent follow-up review. A died the following day of acute myeloid leukaemia (an aggressive and fast progressing cancer of the white blood cells). We took independent advice from a GP. We found that, because A was clinically stable (i.e. blood pressure, pulse and oxygen levels were normal), it was reasonable for the OOH service to advise for A to see their normal GP the following day for further investigations, particularly given that the OOH GP service cannot undertake investigations such as blood tests. We did not uphold this aspect of C’s complaint. However, we noted that the board had undertaken significant review of the events, and although the conclusion was that the OOH GP service did not act unreasonably in their appointment with A, we considered that the board had taken significant steps to ensure that all learning possible has been taken from this case. C also complained that the board’s handling of their complaint was unreasonable, as they considered that the family should have been more involved before any investigation took place. We considered the board’s actions in relation to complaints handling to have been reasonable and we did not uphold this aspect of C’s complaint. Related reading View Decision Report 201910708 as a PDF (24.48 KB) Updated: December 16, 2020