SPSO Individual Decisions

C, an advocate, submitted a complaint on behalf of the family of A. A was a resident of a care home and attended hospital with low potassium levels. A later sustained a leg fracture around the time of the first discharge and was re-admitted to hospital. A later died. C complained that the nursing and medical care provided by the board was unreasonable. We took independent advice from a nurse, consultant orthopaedic surgeon and consultant geriatrician. We found that there were failings in the nursing and medical care provided and that the board failed to carry out a reasonable investigation into the concerns raised. We also found that A did not receive appropriate care and treatment after they sustained a leg fracture. Specifically, there was a lack of recorded consultant input, delays in having a second cast fitted and delays with A being discharged afterward. In addition, the concerns raised regarding how the leg fracture occurred weren’t appropriately investigated across multiple agencies and it took a number of contacts by both C and the SPSO before a full response was provided. Therefore, we upheld this complaint.

C complained to the board about the midwifery care and treatment that they received during and following the birth of their baby. In particular, C complained that they had been unsupported during the birth, that their birth plan had not been followed, that the umbilical cord had snapped during delivery and that no meeting had been arranged to discuss the incident despite requesting one. C also complained that there had been a failure to recognise that this had been a traumatic incident for them, and that the board’s response to the complaint had lacked empathy. The board’s response advised that C had been assisted during the birth, however they apologised that C's expectations had not been met at the time. The board also apologised that it had not been understood that C had intended to use the water pool for pain relief only, and that they did not want to give birth in the pool. In relation to the cord snapping, the board explained that this had been recognised as an emergency incident straight away, but on reflection, the emergency buzzer could have been activated sooner. In terms of communication, the board explained that the circumstances of the birth had been discussed with C by the delivery midwife during a post-natal visit to C's home. When a further meeting was requested, the board said a meeting date had initially been offered by text message which C declined. In hindsight, the board recognised it would have been better to arrange this with C by phone. It was further explained that C had been given contact details to arrange discussion with a consultant in keeping with their request, however C had not gone on to take up that offer. We took independent advice from a consultant of obstetrics and gynaecology. We found that a minimum standard of care had not been met on this occasion. We noted that key aspects of the medical notes and birth plan had not been read, as C’s preference not to birth in the pool was clearly documented but had not been known

C complained about the practice on behalf of their spouse (A). A is paraplegic (affected by or relating to paralysis of the legs and lower body) and was receiving district nursing treatment for various wounds, including one on the large toe of their left foot. The condition of A’s left foot deteriorated and they were showing signs of infection. A was seen by a district nurse who took photographs of A's foot and showed them to the duty GP at the practice. The GP made an urgent referral to vascular surgery, which was sent the next day, but did not assess A themselves or communicate the management plan to them. A’s condition worsened and a few days later they required immediate admission to hospital and urgent surgery. A subsequently required amputation of some of their toes. C complained that A’s outcome may have been better had they been assessed by the duty GP and/or admitted to hospital the same day. We took independent GP advice. We were not critical of the fact the duty GP did not carry out a face to face assessment of A. We found that the GP followed the relevant guidelines by making an urgent referral to vascular surgery, which was a reasonable assessment. However, we found that the GP should also have made direct contact with the vascular surgery team for advice as to whether A required to be seen the same day. We found that the GP also should have communicated their management plan to A and to C, as they acknowledged in their complaint response. This would have allowed the opportunity to raise any concerns with the GP directly. On balance, we upheld this complaint.

C complained about the care and treatment that they received from the board prior to and during the birth of their child (A). C complained that the midwives were dismissive of their pain levels during labour, failed to properly assess their condition, was wrongly sent home to allow labour to progress, and that staff denied their requests for an epidural. C also complained about the poor communication from the clinical team when they were in theatre for a caesarean section. The board said that they considered the decision to send C home was made in line with current guidelines but apologised if the reasons for the decision were not communicated at the time. The board explained that C’s request for an epidural was not actioned as labour was progressing rapidly and consideration was being given as to whether an emergency caesarean section was required. We took independent advice from a midwifery specialist. We found that the midwifery care provided to C was reasonable. We noted that the board apologised for some shortcomings in the care provided and that this was a reasonable response. Overall, we were satisfied that the decisions taken by the midwives were based on a reasonable assessment of C’s presenting condition. In respect of the medical care provided during the birth, we acknowledged that there may have been a lack of clarity around the consent process, however, overall, we did not find any significant shortcomings in the clinical care and treatment provided to C. We did not uphold C’s complaints. Related reading View Decision Report 202208600 as a PDF (24.52 KB) Updated: December 20, 2023

C’s parent (A) was receiving palliative chemotherapy, following a diagnosis of terminal cancer, which was suspended as the COVID-19 pandemic worsened. A was admitted to hospital following a prolonged period of vomiting that had not responded to treatment. A remained in the hospital for several weeks before passing away. C raised complaints with the board detailing C’s family’s concerns about A’s cancer diagnosis, decisions about A’s chemotherapy, aspects of the care and treatment of A, and communication with C and their family during A’s hospital admission. The board’s responses indicated that they considered A’s care and treatment had been reasonable overall, but accepted that there had been some aspects that could have been improved. They accepted that there were aspects of their communication that could have been improved, particularly that they should have contacted A’s next of kin when A’s condition deteriorated over a particular night. C was dissatisfied with the board’s responses and brought their complaint to us. We took independent advice from a specialist in palliative care. We found that A’s treatment had been reasonable overall and that while there were certain aspects of A’s care that could have been improved, overall the board provided reasonable care to A. In relation to the aspects of the complaint about the board’s failure to contact A’s next of kin when A’s condition deteriorated over a particular night and about the board’s responses to C’s complaints, we upheld these aspects of the complaint. In relation to the board’s handling of C’s complaints, we found that there were delays in responding, failure to address various clearly raised issues in responses, unreasonable action around the arrangement of a promised meeting within a reasonable timescale and the inclusion of statements that were not supported by evidence. We upheld these aspects of the complaint.

C complained on behalf of their parent (A) who had been admitted to hospital with pneumonia. C complained that they found medication on the floor and in A's bedside cabinet. C complained that A's personal care needs had not been met, as they had not been washed and they had sore gums and an ulcer in their mouth. C also complained that A had red, sore skin in the groin area. The board apologised for the fallen medication and advised that they were undertaking a project to reduce medication errors. They advised that A had not wanted to shower and that both personal and oral care had been undertaken regularly. They also said that the skin in the groin area had been checked and had only become red on the day that C visited. We took independent advice from a nurse. We found that there appeared to be a design fault with the lockers, such that medication could fall out of the medication pod. We also found that A should have had a personal care plan and had not been offered sufficient personal care or oral care. We found that red skin had been noted 11 days prior to C's visit but had been recorded as healthy in the interim period. This would suggest that the skin was not properly checked. Therefore, we upheld C's complaint.

C complained about the care and treatment provided to their late partner (A). A had a history of Chronic Obstructive Pulmonary Disease (COPD, a group of lung conditions that cause breathing difficulties). A was suffering from constipation which was treated by the district nursing team at home. When this did not resolve, A was admitted to hospital for review and treatment of their constipation. C said they asked that A be treated and discharged home as quickly as possible. A fell whilst in hospital and fractured their shoulder. A developed a chest infection and subsequently died in hospital. C believed A's condition could have been treated in the community. C felt A's vulnerability had not been recognised by nursing or clinical staff in hospital. C said that A had been designated as an adult with incapacity (AWI) and do not attempt cardiopulmonary resuscitation (DNACPR) without discussion with them as A's power of attorney (POA). C felt A's fall was avoidable had staff listened to the family's requests for 1-to-1 nursing. We took advice from a registered nurse and a consultant respiratory physician. We found that A was not provided with a reasonable standard of nursing care in the community, as more could have been done to treat their constipation at home. Therefore, we upheld this part of C's complaint. In relation to A's care while in hospital, we found both the standard of nursing and medical care to be reasonable. Therefore, we did not uphold these part's of C's complaint. In relation to communication with C as A's next of kin and POA, we found there was a lack of communication regarding A's care and in particular decisions around designating A as AWI and DNACPR. Therefore, we upheld this part of C's complaint. Finally, we found that A's death certificate should have included the fall as a secondary factor in their death. Initially it was believed that C would need to request this amendment, but the responsibility in fact lay with the board, who have been asked t

C complained about the care and treatment they received from the board in relation to knee replacement surgery. C said that a surgeon failed to adequately advise them of the potential risks of a total knee replacement and therefore failed to obtain their informed consent for the operation. C also complained that the surgeon failed to adequately examine their leg either pre or post operatively. C said that they had experienced a mal-alignment of their leg as a result of the operation leading to significant pain and loss of mobility. The board was unable to identify the cause of the mal-alignment of C's leg, but did not identify any failings in their care and treatment. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that, despite some failings, the consent process in C's case was reasonable. We also found no evidence that the board's surgeon failed to adequately examine C's leg either pre or post operatively. Therefore, we did not uphold these parts of C's complaint. C also complained that the board failed to adequately investigate or respond to their complaint. We found that the board's complaint response was unreasonable and upheld this part of C's complaint.

C complained about the care and treatment their spouse (A) received from the practice. A had contacted the practice on several occasions with worsening symptoms including headaches, and problems with vision and mobility. C complained that the practice unreasonably failed to undertake tests or act on results, such as when a discrepancy was found in the power of A's legs. C considered the practice unreasonably treated A for anxiety and failed to recognise there was a serious underlying reason for A's symptoms. A was ultimately found to have a brain tumour and died within a few days of receiving this diagnosis. In responding to C's complaint, the practice provided a letter each from two of the GPs involved in A's care which explained their decision making in respect of the presenting symptoms at the time. The practice also explained they had undertaken a Significant Adverse Event Review (SAER) of A's case for learning and improvement. We took independent advice on the complaint from a GP. We found that A had initially been treated for labyrinthitis (an inner ear infection) and urinary tract infection which was reasonable and in keeping with the symptoms reported by A at the time. We also found that after A was given a new prescription for glasses, it was appropriate to trial the glasses for improvement of the symptoms of headache and light headedness on standing. In relation to A's upper leg weakness, we found that this can occur for many reasons and, in isolation, would not suggest a more serious underlying cause. Referring to the working diagnosis of anxiety, we considered that this was not unreasonable in the circumstances. However, the complaint presents a significant learning opportunity, highlighting the need for recognition that symptoms can deteriorate within a short time, and consideration that confused or difficult reporting of symptoms by the patient could in itself be an indicator of an underlying cause. We considered that the practice had provided a reason

C complained about the care and treatment provided to their late spouse (A). A was diagnosed with pancreatic cancer. C was unhappy with the delays with A's treatment and said that these prevented A from receiving any treatment before their death. The board said that their intention was to treat the cancer and that A was required to meet with a consultant to assess their fitness for surgery. The board said that the delay in meeting with a consultant was to allow the health board to carry out two multidisciplinary meetings, for some of A's symptoms (such as jaundice) to improve, and for other investigations and procedures to be carried out (such as, imaging scans and the fitting of stents). The board acknowledged that there was a delay in a PET-CT scan (where a drug is injected before the scan to help clinicians identify how certain body functions are working) being carried out due to failures in the drug production. The board said that when this fails, there is no back-up facility in Scotland to provide a replacement batch. We took independent clinical advice from a consultant colorectal and general surgeon. We found that the timeframe for A's treatment could have been improved even with the allowable delays from the PET-CT scan. We considered that the investigations carried out were reasonable and the early scan and procedure to fit a stent were good points in the treatment pathway. However, the length of the pathway could have been improved and A's lengthy pathway to the offer of chemotherapy was unreasonable. The timing of the clinic appointment and PET-CT could also have been improved. Whilst we recognise some of the delays experienced could not be predicted or avoided, on balance, the timescale for A's pathway was unreasonable. Therefore, we upheld C's complaint.

C complained about their care and treatment following a hysterectomy (a surgical procedure to remove all or a part of the uterus). C complained that they were not provided with adequate pain relief following the surgery, and that they were not fitted with an abdominal drain (a thin plastic tube which is inserted into an abnormal collection of fluid to help remove it from the body). C was discharged a few days later but disputes whether they were fit to be discharged home at this point. C was later readmitted suffering from a blood clot and an infection. C was discharged with oral antibiotics and again disputes whether they were fit to be discharged at this point. A few days later, C began to bleed heavily. An ambulance was called but the wait was likely to be significant and C was taken to hospital by their partner. C was triaged but asked to sit on a chair in a corridor, despite suffering from obvious heavy vaginal bleeding. C was reviewed by a consultant and sent up to the gynaecology ward where they were then taken for emergency surgery. We took independent advice from a consultant obstetrician (specialists in pregnancy and childbirth) and a consultant in emergency medicine. We found that C received a reasonable standard of care following their surgery and was appropriately discharged on both occasions. Therefore, we did not uphold these parts of C's complaint. In relation to C's attendance at A&E, we found that they were not triaged sufficiently quickly and the way C was asked to wait was not appropriate given their condition. C was medically assessed within an appropriate timescale within A&E and appropriately transferred. The board had accepted there were failings in C's care, but they had not set out clearly how they planned to address these issues. Therefore, we upheld this part of C's complaint. C also complained that the board failed to handle their complaint reasonably. We found that the board handled C's complaint appropriately and did not uphold this pa

C, a support and advocacy worker, complained on behalf of their client (A). A had undergone breast surgery to remove nodes and C complained that the board did not adequately assess and manage A's wound when it showed signs of infection. The wound deteriorated and A became critically unwell with sepsis. The board carried out a Significant Adverse Event Review (SAER), in which A expected greater involvement. C also complained that the SAER failed to identify that the incident met the Duty of Candour threshold and did not address the key issue, which was the inadequate care provided. The board stated the staff involved used their clinical judgement to assess the wound, which did not show signs of infection. However, it was difficult to investigate the adequacy of the wound assessment due to the omission of notes they made. The board acknowledged communication between health care professionals was impeded by a reliance on a paper-based system and the clinical record keeping was inadequate. The board further advised the SAER was a formal process, which did not allow for A's inclusion and maintained the incident did not meet the Duty of Candour threshold. They considered the SAER to be adequate, as an investigation had taken place that had identified a number of learning points and recommendations. We took independent clinical advice from a registered nurse specialising in tissue viability. We found the wound assessment to be inadequate, leading to a missed opportunity for appropriate wound management and that those involved in A's care lacked knowledge of current best practice in terms of wound assessment, wound management and antimicrobial stewardship. We also found the SAER to be inadequate as it failed to address the key issues of wound assessment, wound management and antimicrobial stewardship and failed to identify the incident met the Duty of Candour threshold. As such, we upheld C's complaint.

C complained about the attitude of a doctor during an inpatient admission. C stated that the doctor had treated them in a dismissive, derogatory and unprofessional manner. C further complained that the doctor removed their diagnosis, stopped their medication and made no arrangements for them to receive support following their discharge. C told us that the actions of the doctor had resulted in them not receiving a reasonable standard of care. We found that the inpatient doctor's communication and documentation did not meet the required professional standards and impacted on the board's overall communication of C's care and treatment needs. The clinical records evidenced a dismissive and disrespectful attitude towards C. The doctor's documentation lacked a clear clinical rationale for the decisions that they made about C's diagnosis and medication. Therefore, we upheld this part of C's complaint. In relation to the standard of care C received, we found that board staff had ensured that C's care and treatment needs were met. The decision to discharge C from inpatient care was reasonable and the community-based care that was provided was appropriate to C's identified needs at the time. When it was clinically indicated, the board arranged a further inpatient admission and reviewed C's diagnosis and treatment plan. There was evidence that the doctor did not stop C's medication. Therefore, we did not uphold this part of C's complaint.

C complained about the care and treatment provided by the practice. C was diagnosed with polycystic ovary syndrome (PCOS, a condition that affects the function of the ovaries) a number of years ago and had previously had an ovarian cyst removed. Over the following years, C experienced a number of symptoms, including abdominal pain which the practice attributed to irritable bowel syndrome (IBS, a common condition that affects the digestive system). C complained that the practice did not explore a potential link to their PCOS. C attended A&E with severe pain. It was identified that C had a large ovarian cyst which required surgery. C complained that the practice's failure to diagnose the cyst exacerbated their symptoms and led to prolonged pain and discomfort. C also complained about poor postoperative care by the practice. The practice confirmed they were satisfied that their treatment of C's symptoms was appropriate in the circumstances and explained that the NHS does not offer routine surveillance scans for patients with PCOS or to patients who have a history of cysts. We took independent advice from a GP. We found that prior to C's attendance at A&E, there was no significant evidence of a cyst and in the absence of any other clinical indication it was reasonable to attribute C's symptoms to IBS. With regard to C's concern about the postoperative care provided, we noted that the practice diagnosed an incisional hernia and referred C to the Surgical Admissions Unit where an ultrasound was carried out but failed to show anything. A subsequent CT scan identified three hernias. We concluded that the GP's presumed diagnosis of a hernia was reasonable and therefore C was appropriately referred to the Surgical Admissions Unit. Overall, we were satisfied that the care and treatment provided to C was reasonable and we did not uphold C's complaints. Related reading View Decision Report 202206401 as a PDF (24.71 KB) Updated: October 18, 2023

C complained to the practice about the care and treatment provided to their relative (A). A began to experience abdominal pain and was reviewed by doctors at the practice a number of times before being admitted to hospital as an emergency. Following discharge, A was seen at the practice again with continuing symptoms and unintended weight loss. They were referred to hospital and again discharged. A colonoscopy performed suggested acute diverticulitis (where small pouches from the wall of the gut become inflamed or infected). A attended the practice again with worsening symptoms and was admitted to the hospital after an urgent request was submitted. A died in hospital a few weeks after. C was concerned about the standard of care provided to A by the practice. The practice met with A's family. The practice carried out a Significant Event Analysis (SEA). The practice responded to C's complaint and noted their frustration that A had been discharged from the hospital without progress in the management of their condition. However, they did not find that they should or could have done anything differently in A's care. C submitted a further complaint to the practice after they received a response from the health board regarding the care provided at the hospital. The practice responded confirming that an SEA had been carried out. The doctor who had seen A had discussed the case with colleagues in the practice and with their Educational Supervisor. These discussions had been informal and had not been documented in A's notes. C was dissatisfied with the complaint responses and brought the complaint to our office. We took independent advice from a GP. We found that most of A's care was of a reasonable standard. However, there was a delay in acting on concerns about A's condition following their second discharge from hospital. Given the significance of the failures identified, we considered that A's care fell below a reasonable standard and upheld this part of C's complaint. C a

C complained that the practice failed to provide them with reasonable care and treatment. C suffered from inflammatory conditions of the skin and joints and was under the care of rheumatology (specialists in the diagnosis and management of chronic inflammatory conditions such as rheumatoid arthritis), dermatology (specialists in the in the diagnosis and treatment of skin disorders) and the practice. C was being prescribed an immunosuppressant and the practice was in a shared care agreement with the NHS board for monitoring bloods in regards to the prescription. C required a liver transplant due to liver cirrhosis induced by the treatment. C complained that the practice had not properly monitored their bloods, had not picked up on warning signs and had not communicated appropriately with the relevant specialists or with C. C noted that they had also been incorrectly prescribed an antibiotic containing penicillin. We took independent advice from a GP. We found that the practice had monitored bloods appropriately, and where there were gaps in monitoring, C's attendance had been requested. We also found that the practice had sought specialist advice and followed NICE guidelines appropriately. We noted that the practice had verbally apologised for the penicillin mistake. Therefore, we did not uphold this part of C's complaint but fed back to the practice that it would be appropriate to apologise in writing. C also complained that they were immediately removed from the practice register after making a comment on social media expressing concerns about their treatment. C noted that they were given no warning and that their poor health, vulnerability and their requirement for continuity of care were not taken into account. We found that the practice had not followed guidelines in respect of removing the patient from the register, without warning. Therefore, we upheld this part of C's complaint.

C, an advocacy worker, submitted a complaint on behalf of their client (A). A received treatment from the board for muscular dystrophy (a group of inherited genetic conditions that gradually cause muscles to weaken) over a period of four years. While visiting abroad, A received an alternative diagnosis of polymyositis (a group of rare diseases that involve chronic muscle inflammation and weakness, and in some cases, pain). A complained that their condition was not appropriately investigated or diagnosed, leading to a delay in receiving appropriate care. We took independent clinical advice from a consultant neurologist (specialist in diagnosis and treatment of disorders of the nervous system). We found that the investigations carried out by the board were reasonable and on receiving further information from an overseas clinician, the board took reasonable steps to consider this information. We considered that the board reasonably investigated A's symptoms. Therefore, we did not uphold C's complaint. Related reading View Decision Report 202008532 as a PDF (24.29 KB) Updated: August 16, 2023

C complained about the care and treatment their grandparent (A) received when they were admitted to hospital. A was acutely unwell with a poor prognosis and was treated in the COVID-19 ward for a number of days. A's condition improved and they were discharged home. C complained that A did not have capacity to consent to treatment and that treatment to address A's confusion made their symptoms worse. C believed that clinicians failed to clearly communicate the treatment plan for A, that it was unreasonable for clinicians to focus on end of life treatment and that staff failed to meet A's basic needs. In response to the complaint, the board explained that A was admitted with possible aspiration pneumonia and COVID-19. They said A was treated for COVID-19 and with antibiotics and that the care and treatment in this regard together with the assessment of A's capacity, was appropriate. Nursing staff gave A regular oral hygiene, but due to high flow oxygen therapy this was difficult. Appropriate assessment and treatment was undertaken with respect to A's skin. We took independent advice from a consultant geriatrician (specialist in care and treatment of the elderly) and a nurse. We found that whilst many aspects of A's care were reasonable and of a standard expected, there was a significant failure with respect to the assessment of A's delirium. We also found that there were significant failures with respect to the level of personal care provided to A. Therefore, we upheld C's complaints relating to medical and nursing care and treatment. In relation to communication with C and their family, we found that the records documented an appropriate level of communication with respect to decisions made about A's care. Therefore, we did not uphold this part of C's complaint. C complained that the board failed to handle their complaint reasonably. We found that there was discrepancies and apparent inaccurate information contained in the board's response. Therefore it was reasonabl

C complained on behalf of their sibling (A) about the care and treatment that they received during a hospital admission. A had a cannula (a thin tube inserted into a vein or body cavity to administer medication, drain off fluid, or insert a surgical instrument) fitted which then became infected and caused them to develop sepsis (an infection of the blood stream). C complained that A had requested the cannula be removed sooner and that this was declined. C also complained that A had advised staff that they felt unwell and that this was not taken seriously, and also that their medication had not been properly managed. We took independent advice from a consultant in acute internal medicine. We found evidence in the medical records that A declined to have the cannula removed. There is no other documentary evidence from the time about A either refusing, or requesting, to have the cannula removed. We found that the care and treatment provided was reasonable. We also found that A's medication had been properly managed and that they did not note any failings in the communication with A and their family. We did not uphold this complaint. Related reading View Decision Report 202106489 as a PDF (24.35 KB) Updated: June 21, 2023

C complained about the care and treatment that their child (A) received from the board. A had an autistic spectrum disorder (ASD) diagnosis and a history of treatment through the board's Child and Adolescent Mental Health Service (CAMHS). A was placed on an urgent waiting list for further assessment and treatment. A was assessed and was assigned medication and individual therapeutic work. Following a number of appointments, A was discharged from the individual appointments, was seeking support in the community and was supported with accommodation. C reported concerns about A's behaviour, including an incident where they set a mattress on fire. A subsequently attended another appointment thereafter. C complained that professionals failed to respond adequately to an escalation in A's behaviour which should have prompted an urgent appointment. C also complained that a later appointment did not result in a reassessment of A and the support that they required. In response to the complaint, the board said that there was no evidence of any new psychiatric symptoms that required urgent assessment, and that the later appointment was appropriate with a plan for A agreed at the time. We took independent advice from a mental health services specialist. We found that appropriate assessments were completed following C's reports of concerns about A's behaviour. We found that the decision not to carry out an urgent psychological review was reasonable and that the records showed a thorough and detailed assessment was carried out at the later appointment. We found that the conclusions reached were reasonable. As such, we did not uphold the complaints. Related reading View Decision Report 202104211 as a PDF (24.65 KB) Updated: June 21, 2023

C complained about the care and treatment provided to their partner (A). A had been suffering from an extended period of constipation which the District Nursing Team had attempted to treat at home. A's GP referred them to hospital for further treatment. A died following a fall in hospital. C raised a number of concerns about the GP's assessment of A's condition and the decision to refer them to hospital. C said that the GP should have visited A at home, should have considered alternative treatments at home, and that the GP made assumptions about A's wishes and condition. C believed that there were no grounds for admitting A to hospital and that the GP's actions led directly to A's death. We took independent advice from a general practitioner adviser. We found that the care and treatment provided to A was of a reasonable standard. It was not a requirement for the GP to visit A at home prior to referring them for admission. The admission had been discussed with C, and the decision to refer A for hospital admission was a reasonable clinical judgement for the GP to make in the circumstances. The GP's referral had acknowledged C and A's wishes for resuscitation to be attempted and the advice did not consider that there was an unreasonable focus on this in the admission. We found that the care and treatment provided to A was reasonable and that the practice had acted appropriately when considering and responding to C's concerns. We did not uphold C's complaints. Related reading View Decision Report 202104070 as a PDF (24.5 KB) Updated: June 21, 2023

C raised complaints about the nursing and medical care their parent (A) received whilst in hospital. English was not A's first language and C also raised complaints about the board's communication with A and their family and whether appropriate follow-up care was provided by the board following C's discharge. The board had accepted that A's nursing care fell below a reasonable standard in several areas, including the standard of record-keeping, the failure to discuss A's personal care with their family, and the assumptions that were subsequently made about A's preferences in relation to this. The board provided us with the nursing action plan they had developed following C's complaint. We took independent advice from a clinical nurse lead and a consultant geriatrician (specialist in medicine of the elderly). We found that the board's actions and action plan had been reasonable overall but there were some areas where the action plan could be improved. We upheld this part of C's complaint. Similarly, the board accepted that the standard of communication with A and their family fell below a reasonable standard and had apologised for this. We found that the board's verbal and written communication could have been significantly improved, including their record-keeping. While the majority of issues were addressed by the action plan, there were some specific issues where staff could receive further feedback. We upheld this part of C's complaint. C had been specifically concerned about modifications to A's medication and monitoring and treatment of A's feet. We found that the board's actions in relation to these had been reasonable and that A's medical care had been, overall, reasonable. We did not uphold this part of C's complaint. Finally, the board had acknowledged their management of A's discharge and the communications associated with it, fell below a reasonable standard and had taken action with the aim of preventing any recurrence of this. We found that the actions p

C complained about the care and treatment provided to their late parent (A). A felt unwell whilst residing in a care home. They were coughing up blood associated with green phlegm and had chest and abdominal pain. Staff at the care home contacted NHS 24 and were advised that a home visit would be conducted. However, the GP subsequently carried out a telephone consultation due to concerns around the transmission of COVID-19. They diagnosed A with a chest infection. A second GP visited 48 hours later and suspected A had pulmonary embolism (a blocked blood vessel in the lungs) and deep vein thrombosis (a blood clot in a vein). A was admitted to hospital where this was confirmed. A died a few months later and C said that pulmonary embolism was described as a contributing factor on their death certificate. C was concerned that the GP did not conduct a home visit and subsequently failed to correctly diagnose A's condition and instead focused on the transmission of COVID-19 and associated risks. C believes that if a home visit had been conducted, A would have been correctly diagnosed 48 hours earlier and could have received treatment. The board responded and identified some issues in the medical history and documentation taken. C remained dissatisfied with the board's response and brought their complaint to us. We took independent advice from a GP. We found that it was reasonable that no home visit was offered in the context of COVID-19. However, the medical history and particularly the documentation taken by the GP was unreasonable. In particular, there was no documentation to support the consideration of respiratory rate/breathlessness, leg pain/swelling and pulmonary embolism. In view of these failings, we upheld C's complaint that the board failed to provide A with reasonable care and treatment. The board had already apologised for the failings and had highlighted them to relevant staff as a learning point. However, we  provided some further feedback to the board. Rela

C complained about how the practice had managed their lithium prescription (a medication used to treat mood disorders). We took independent advice from a GP. We found that the practice acted reasonably in requesting that C arrange blood tests every three months to monitor their medication levels. We were also satisfied that the practice had provided reasonable advice about how to ensure C did not run out of medication. We did not uphold C's complaint. Related reading View Decision Report 202201027 as a PDF (23.99 KB) Updated: May 24, 2023

C complained about the care and treatment provided to their child (A). A developed facial weakness, which was initially diagnosed and treated as Bell's Palsy (temporary weakness or lack of movement affecting one side of the face). A's condition did not improve and MRI scans revealed a mass. It was considered this was likely a vestibular schwannoma (a rare, non-cancerous tumour) and follow-up in three months was arranged. A later attended hospital with bleeding from the ear. C suspected this was related to the tumour but doctors treated A for an ear infection. A developed further ear symptoms and attended hospital again. Further scans showed significant tumour growth, requiring surgical debulking (removing as much of the tumour as possible). A's diagnosis was revised as para-meningeal rhabdomyosarcoma (a rare and aggressive form of cancer). A was treated with chemotherapy but they continued to deteriorate and died within a few months of this diagnosis. C complained that the board's decision not to remove A's tumour when it was first detected was unreasonable. We took independent advice from four advisers: a paediatric neurologist (specialist in the diagnosis and treatment of disorders of the nervous system), a paediatric emergency medicine consultant, a paediatric neurosurgeon (specialist in surgery on the nervous system, especially the brain and spinal cord) and a paediatric oncologist (specialist in the diagnosis and treatment of cancer). We found that there was inadequate documentation of the risks or benefits to A of performing a biopsy or resection of the tumour when it was initially detected. However, we considered that surgically it would not have been possible to carry out a full resection and that the risks of trying to obtain a biopsy in the specific circumstances were too high. We concluded that the decision not to remove the tumour when it was first detected was reasonable. Therefore, we did not uphold this part of C's complaint. C also complained that th