SPSO Individual Decisions

Ms C complained about the assessment of her father (Mr A)'s capacity by old age psychiatry staff who visited him at home and while he was an in-patient at University Hospital Crosshouse. She was also concerned that the assessment of the level of care Mr A required was unreasonable. We took independent advice from a consultant in old age psychiatry. We found that Mr A's capacity had been assessed regularly and that the assessments themselves reached reasonable conclusions. Therefore, we did not uphold Ms  C's complaints. While we found that the assessment of Mr A's care requirements was appropriate, it was noted that Ms C and her family appeared to have received somewhat confusing information from social work staff regarding the level of care needed. We provided feedback to the board on this matter. Related reading View Decision Report 201607947 as a PDF (10.99 KB) Updated: December 2, 2018

Mrs C complained about the care and treatment provided to her late father (Mr  A) at University Hospital Ayr. Mr A was elderly and had a visual impairment. Mrs C complained that nursing staff failed to take into account her father's visual impairment when communicating with him and that they failed to recognise he needed extra assistance when reaching for food and drinks. Mrs C also complained about the handling of the discharge process. She felt that the nursing staff did not give accurate information to the social work department about Mr A's mobility, which resulted in difficulties in managing his care at home. Mrs C also raised concerns about the board's handling of her complaint. The board acknowledged their communication with Mrs C could have been better and that they should have consulted with her more regarding her father's discharge planning. The board also acknowledged that nursing staff communication with Mr A was not acceptable. Mrs C remained unhappy and brought her complaints to us. We took independent nursing advice. We found that the nursing care provided to Mr A was below an acceptable standard and that the discharge planning could have been improved by holding a case conference. We upheld these two aspects of Mrs C's complaint. However, we found that the board did take adequate steps to ensure that Mr A received appropriate post-discharge care at home. We did not uphold this aspect of the complaint. Regarding complaints handling, we found that the board did not handle Mrs C's complaint in line with their complaints handling procedure. We upheld this part of the complaint.

Mrs C complained about the care and treatment provided to her husband (Mr A) by the practice. Mr A attended the practice feeling unwell, having had a history of heart problems. In the following weeks Mr A was admitted to hospital where he was diagnosed with a condition in his heart. Mr A suffered an injury in the brain as a result of a bleed, and his short term memory has been impacted by this. Mrs C considered that if the heart condition had been diagnosed earlier, then Mr A's eventual outcome may have been different. We took independent advice from a GP adviser. We found that the symptoms described and noted were not indicative of a particular illness. We also found that the classic symptoms of Mr A's condition were not seen until the day Mr A was admitted to hospital. We found that the GP took reasonable steps to establish the reason for Mr A being unwell and carried out appropriate tests. We also considered that the GP made an appropriate referral to a cardiologist (a  doctor who specialises in finding, treating and preventing diseases of the heart and blood vessels). The referral to the cardiologist was not sent as a matter of urgency. The GP surgery acknowledged this error and took steps to ensure that this did not happen again. We found that, even if the referral had been sent urgently, this would not have had an impact on the outcome. We did not uphold the complaint. Related reading View Decision Report 201702591 as a PDF (11.3 KB) Updated: December 2, 2018

Ms C complained about the treatment she received from her dentist, particularly in relation to the fitting of a crown which fractured multiple times and required repairs, and areas of untreated decay. We took independent advice from a dental adviser. We found that the treatment Ms C received from the dentist was unreasonable and we therefore upheld the complaint. The repair carried out to the crown was unreasonable, as was the failure to investigate the cause of the fracture. There were failings in the dentist's record-keeping, and we found that Ms C was incorrectly charged for the repair. There were also failings around the untreated decay, though the dentist had already acknowledged and reflected on this. We noted that the dentist had already apologised for some failings. They had also already taken steps to improve their practice and ensure these issues did not arise again, including carrying out an audit on clinical record-keeping, and undertaking some further training. We asked for evidence of these actions and we also made some further recommendations.

Mr C complained about the treatment he received from the prison health care service and from the hospital he attended. In particular, he was concerned about the treatment he received for both a hand injury and hip pain, withdrawal of medication and how his complaint was handled. We took independent advice from a consultant orthopaedic surgeon and from a GP adviser. Mr C said that he had not received reasonable and appropriate treatment in relation to an injury to his hand. We found that the treatment Mr C had received when he attended the accident and emergency department about the injury had been reasonable. Mr C was also referred to an orthopaedic consultant in another board for a second opinion. However, we found that there had been an unacceptable delay in supplying Mr C with a physiotherapy exercise ball in relation to the injury. Therefore, we upheld this aspect of his complaint. We noted that the board had already apologised for this. Mr C also complained that the board had failed to provide reasonable and appropriate treatment in relation to his hip pain. Whilst there had been a delay in informing Mr C of the result of a scan, this had been carried out by another board and it was their responsibility to act on this. We found that the treatment Mr C had received from the board for his hip pain had been appropriate. We did not uphold this aspect of his complaint. Mr C complained that the board had withdrawn his medication after he was found to have too many tablets in his possession. We found that the prison health care service's actions in relation to this matter had been reasonable. We did not uphold this aspect of Mr C's complaint. Finally, Mr C complained that the board had failed to deal with his complaints adequately. Mr C had made a large number of complaints, but we found that there had been a significant delay in responding to one of the complaints. Therefore, we upheld this aspect of his complaint.

Mrs C, who works for an independent advocacy service, complained that there was unreasonable delay in providing the required care and treatment to her client  (Miss A) when Miss A was admitted to Crosshouse Hospital after her Percutaneous Endoscopic Jejunostomy tube (PEJ tube - a feeding tube that is put inside an outer tube which goes into the stomach. The inside tube goes into the small intestine) became blocked. Mrs C also complained that the board's handling of her complaint was unreasonable. We took independent advice from a gastroenterologist (a doctor who specialises in the digestive system). We found that the board's staff referred Miss A for an initial review, specialist review, arranged investigations and arranged for a replacement PEJ tube in a reasonable time. In view of this, we did not uphold Mrs C's complaint regarding the time taken to treat Miss A. However, we identified that there was no nutrition team involvement in Miss A's care, and that a nutrition assessment was not carried out. We were critical of this and made a recommendation to the board to address this matter. Regarding complaints handling, we found that there was a lack of clarity as to how the board were investigating the issues raised by Mrs C. In addition, we found that the board did not adhere to the timescale required, nor did they appropriately update Mrs C on their progress. We, therefore, upheld this aspect of the complaint.

Mrs C complained about the care and treatment she received during out-patient consultations at University Hospital Crosshouse. Mrs C initially attended a consultation in the renal medicine department (department of medicine relating to the kidneys) and it was felt that her test results showed that she had sub-clinical hypothyroidism (a condition where thyroid stimulating hormone level is higher than normal). Mrs C was prescribed a small dose of medication to treat this. Mrs C subsequently attended a consultation in a different department. This department did not agree that Mrs C had sub-clinical hypothyroidism and recommended that the medication should be stopped. A review appointment was arranged for three months' time. Mrs C was unhappy with this decision and undertook to self-source a supply of thyroid medication. She attended a further consultation in the renal medicine department approximately a year later. At this time, Mrs C was advised to discontinue taking her self-sourced thyroid medication as it was considered that it was causing suppression of her thyroid stimulating hormone. Mrs C disagreed with the board's findings and explained that she felt better taking the thyroid medication, which she reported had also improved her kidney function. She complained to us that the board were not providing her with the medication she felt she needed. Mrs C also complained that she was unreasonably advised to stop taking her self-sourced thyroid medication. We took indepdendent advice from a consultant physician. We found that the test results over a number of years did not show evidence of sub-clinical hypothyroidism. For this reason, we considered it was reasonable for the board to discontinue the medication and to advise Mrs C of the risks of continued use. In relation to Mrs C's consultation in the renal medicine department a year later, we found that it was reasonable for the board to recommend that Mrs C stop taking the medication. We did not uphol

Mr C complained about the care and treatment he received at University Hospital Crosshouse following a referral made by his GP. He was suffering from chest pain and was seen by a consultant cardiologist (a doctor who specialises in finding, treating and preventing diseases of the heart and blood vessels) at the hospital. Mr C complained that the examination he received was poor and that the consultant failed to take into account all the information provided by his GP. At a later appointment, Mr C underwent an echocardiogram (echo - a heart scan that uses sound waves to create images) and was fitted with a Holter monitor (a device that measures and records the heart's activity). Mr C considered that the results were not properly reported and no follow-up appointment was made. He complained to the board who confirmed that there had been errors in the consultant's note taking but that they did not impact upon his care. Mr C was unhappy with this response and brought his complaint to us. We took independent advice from a consultant cardiologist. We found that some records contained inaccuracies and that there had been no reference made to Mr C's chest pain which was the reason for his attendance. We also found that no investigations were made at his initial referral and the adviser noted that they would have expected an electrocardiogram (ECG - a test that records the electrical activity of the heart) to be carried out. We found that the subsequent echo was reported as normal although there were some abnormalities. We considered that the board failed to provide reasonable care and treatment and upheld Mr C's complaint. However, we noted that although some information was not recorded correctly, this would not have affected Mr C's treatment.

Mrs C complained about the care and treatment provided to her late husband (Mr A) at University Hospital Ayr. Mrs C felt that Mr A was kept in the emergency department for too long before being admitted to the hospital, and that he was not appropriately assessed during this time. We took advice from a consultant in emergency medicine and a stroke consultant. We found that, overall, the care provided to Mr A by the emergency department staff was reasonable but that they failed to complete transfer observations and handover documentation. We found that the initial assessment of Mr A by the stroke team was poor. We acknowledged that the diagnosis of a stroke, such as the one Mr A suffered, can be difficult to diagnose, however, we found that there was a failure to scan Mr A in the appropriate manner and reasoning for decisions made were not documented clearly. Therefore, we upheld this aspect of Mrs C's complaint. Mrs C also complained that there was a lack of communication to keep her advised of Mr A's diagnosis and treatment. We found that, overall, the medical records showed a reasonable level of communication with Mrs C and, therefore, we did not uphold this aspect of her complaint. Finally, Mrs C complained that the board's handling of her complaint was unreasonable. We found that, throughout the complaints process, there had been a number of failings including delays and a lack of communication. Therefore, we upheld this aspect of Mrs C's complaint. However, since these events occurred, a new complaints handling policy had been implemented by the board and we therefore made no further recommendations on this point.

Ms C complained to us that the practice had failed to provide appropriate care and treatment to her late mother (Mrs A). She said that her mother had attended the practice on a number of occasions and was given a diagnosis of a chest infection, whereas she was in the final stages of lung cancer. Ms C was concerned that the practice had concentrated on a chest infection being the cause of her mother's symptoms. In addition, a chest x-ray which was taken showed signs of a cavity in her lung which was not followed up or mentioned to Mrs A or her family. We took independent advice from a GP adviser and concluded that there were some failings in the level of care provided. During the initial consultations it was appropriate for the GP to arrive at a potential diagnosis of a chest infection and we found that appropriate investigations including an x-ray and blood tests were performed. However, we considered that once the chest x-ray result had been received which showed a cavity on the lung, then further action should have been taken. This would either have been to repeat the chest x-ray within a defined time frame with a view to onward referral to a chest specialist, or to make a direct referral at that time to a chest specialist. Further action should also have been taken as Mrs A's blood results revealed that she was anaemic. We also concluded that, although the final outcome would not have altered, the diagnosis would have been reached sooner and this would have allowed Mrs A and her family to make decisions regarding future care and support which would be required. We upheld the complaint.

Mrs C attended two consultations with the practice who had recently taken over from her previous practice. She had attended her previous practice five years earlier after she had experienced an increase in epileptic seizures. Mrs C complained that, during these two consultations, the practice unreasonably focussed on the events of five years previously. She raised concerns that the practice placed undue focus on the reporting requirements of the Driver and Vehicle Licencing Agency (DVLA) and she found it difficult to get her health concerns across. Mrs C also complained that, during the first consultation, she was unreasonably prescribed the wrong dosage of epilepsy medication. We found that the first of the two consultations was Mrs C's first with the practice altogether, following them taking over the running of her local practice. Her prior consultation with her previous practice noted concerns about the management of her epilepsy and an intention to notify the DVLA. We took independent medical advice from a GP, who confirmed that DVLA guidance requires patients with epilepsy to notify them. We considered that it was reasonable for the practice to discuss Mrs C's epilepsy and DVLA reporting requirements during her consultations. Therefore, we did not uphold this aspect of Mrs C's complaint. Mrs C also complained that she was prescribed the wrong dosage of her epilepsy medication. We found that there had been a prescribing error and that the practice did not address this when responding to Mrs C's complaint. Therefore, we upheld this aspect of Mrs C's complaint. However, we noted that the practice acknowledged that the error was their fault and that this was fixed before any medication was actually issued.

Miss C complained about the care and treatment provided to her mother (Mrs A) at her GP practice. Miss C was concerned that the practice were not addressing Mrs A's health problems or taking into account her fear of medical situations. Miss C had power of attorney for Mrs A and complained that the practice provided Mrs A with unreasonable treatment and that they were not keeping her informed of Mrs A's health care. We took independent advice from a GP. We found that the practice had completed a full assessment of Mrs A and a full advanced care plan was done. Mrs A was seen on a house call, as requested, and appropriate treatment was provided. There had also been communication between the practice and other professionals regarding Mrs A's healthcare. We considered that the practice provided Mrs A with appropriate care and treatment, and therefore, did not uphold this aspect of Miss C's complaint. In relation to Miss C's complaint about the practice failing to keep her informed, we found that at the time of Miss C's complaint, the practice held a letter confirming that Mrs A did have capacity. A subsequent assessment confirmed she lacked capacity, but the practice had not been aware of that at the time of the complaint, nor had they been aware of the power of attorney. We found that the practice acted appropriately in maintaining Mrs A's confidentiality until such time as it was brought to their attention that she no longer had capacity and Miss C had power of attorney. We did not uphold this aspect of Miss C's complaint. Related reading View Decision Report 201703571 as a PDF (11.26 KB) Updated: December 2, 2018

Mrs C complained that the practice had not provided her with reasonable care and treatment when she raised concerns about her skin condition. We took independent advice from a GP adviser. We found that the GPs at the practice had taken Mrs C's concerns seriously and that they had made reasonable and appropriate referrals to several specialists. We found that they had sent samples to a microbiology laboratory to be tested and that they had communicated thoroughly with the specialists regarding Mrs C's symptoms. We also found that the practice staff had communicated appropriately with Mrs C during consultations and when advising her of her diagnosis, and that the prescribed medications were appropriate. We did not uphold Mrs C's complaint. Related reading View Decision Report 201607617 as a PDF (10.92 KB) Updated: December 2, 2018

Mrs C complained about the clinical and nursing care and treatment provided to her late husband (Mr A) when he was admitted to the University Hospital Ayr. We took independent advice from a consultant in emergency medicine, a consultant in acute medicine and a nursing adviser. In relation to the clinical care and treatment provided to Mr A, having considered the available evidence and the advice provided to us we found that, overall, the medical care and treatment Mr A received was reasonable. The advice we received from the consultant in acute medicine was that Mr A's death was not preventable by the time he was admitted to hospital. We did not uphold the complaint. However, whilst the advice we received from the consultant in acute medicine was that cardiac monitoring would not have saved Mr A's life, they considered that the board should have a clear policy regarding which patients require cardiac monitoring. We made a recommendation regarding this. Regarding the nursing care provided to Mr A, we found that there were gaps in the assessment and monitoring of Mr A and that the board wrongly focussed on anxiety being the cause of Mr A's shortness of breath. We also found that the guidance on using the Modified Early Warning Score (the monitoring of vital signs such as respiratory rate which helps alert clinicians to patients with potential for clinical deterioration or with established critical illness) was not followed, in that Mr A's Modified Early Warning Score was not repeated in line with guidance and there were gaps in the recording of his vital signs which was unreasonable. We further found that Mr A's Modified Early Warning Score should have been repeated on transfer to a new care area. We upheld the complaint.

Miss C complained that her GP practice was not recognising her mental health problems and that they refused to carry out home visits. Miss C told us that she believes she has agoraphobia (a fear of entering open or crowded places, of leaving one's own home, or of being in places from which escape is difficult), although she has not been given a formal diagnosis. Miss C wanted a diagnosis of agoraphobia and also had various concerns about her physical health. Given her condition, she wanted to be seen at home. In their response to our enquiry, the practice confirmed that Miss C had been referred to mental health services and that they had prescribed appropriate medication. They explained that they would always discourage home visits as they are not the correct setting for most medical problems. They said that in Miss C's case, they had concerns about visiting at home due to a mental health assessment which identified a concern that home visits could have a negative effect on Miss C's wellbeing. We took independent advice from a GP adviser. We found that the treatment provided to Miss C was reasonable and the adviser had no concerns about the care provided by the practice. In relation to the home visit requests, the adviser noted that Miss C had not been diagnosed with an acute mental illness which would stop her from attending the surgery. They said that unless the patient is housebound, patients are best seen in a practice environment. We found that the practice had taken reasonable measures to support Miss C by offering quiet appointment times, phone consultations and offering home visits from a community psychiatric team. We noted that Miss C had declined to engage with services or treatment to help her, and considered that there was no further action the practice could reasonably take. Therefore, we did not uphold either of these complaints. Related reading View Decision Report 201700247 as a PDF (11.52 KB) Updated: December 2, 2018

Mr C complained about a consultation that his brother (Mr A) had with an out-of-hours service doctor. Mr A was referred to the on-call doctor by NHS 24 when he called to report pain in his chest and both arms. Mr A was examined by the on-call doctor who considered that muscular pain was the likely cause. Mr A returned home, however, later that evening he was taken to the emergency department by Mr C and was ultimately diagnosed with a heart attack. Mr C complained to the board about the consultation with the on-call doctor as he considered that Mr A's condition should have been identified sooner. Mr C was also concerned that the board's response to his complaint was unreasonable. We took independent advice from a GP experienced in out-of-hours care. We found that Mr A did not have the typical presentation of a heart attack and consequently, this could not have been foreseen by the on-call doctor. We found that arriving at what later turned out to be an incorrect diagnosis did not mean that the on-call doctor was at fault and we found that there was evidence that they had adequately and appropriately assessed Mr A. We did not uphold this aspect of Mr C's complaint. Regarding Mr C's complaint about the board's response to his concerns, we found that there was a minor inaccuracy in the response and that there was a lack of evidence that Mr C had been kept properly updated when the timescale for responding to his complaint passed. We upheld this aspect of Mr C's complaint.

Mr C complained about the care and treatment provided to his mother (Mrs A) during her admission to University Hospital Crosshouse. He raised particular concerns about an initial cancer misdiagnosis for what was a chest infection / pneumonia. We took independent medical advice from a consultant physician who considered that it was reasonable for medical staff to have considered the possibility of a cancer diagnosis given Mrs A's presentation and background. They advised that this did not impact on the treatment provided as reasonable steps were taken to continue to treat for infection, while planning appropriate investigations. However, the adviser said it appeared that communication with the family may have been unduly weighted towards the likelihood of cancer. In addition, they noted that there was a delay in the clinical team receiving an x-ray report, which might have contributed to the lack of clarity and prolonged the apparent overestimation of the probability of an underlying cancer. On balance, we did not uphold this aspect of the complaint but we made some recommendations. Mr C complained that the focus on a cancer diagnosis led to a delay in commencing appropriate treatment. He noted that Mrs A's blood pressure rose unchecked resulting in her suffering a stroke. While the adviser reiterated that treatment for infection was appropriately continued, they identified that the treatment choice for the initial 24 hours was unreasonable. They noted that Mrs A's CURB 65 score (a score which guides treatment for community acquired pneumonia) should have been calculated and this would have indicated the need for a second antibiotic. After the initial 24 hours, however, the adviser noted that a stronger antibiotic was appropriately administered. The adviser noted that there were factors preventing optimal monitoring and treatment of Mrs A's blood pressure, but they considered the management of this was reasonable in the circumstances. They noted that ther

Mrs C complained about the care and treatment she had received from the board. However, during our investigation we were advised that Mrs C had commenced legal action against the board. We must not investigate any matter which has been, or is being, considered in a court of law. Therefore we did not take these aspects of Mrs C's complaint forwards. Mrs C also raised concern about the board's handling of her complaint. We found that the board failed to provide updates and delayed in advising Mrs C that her complaint was out of time and would not be investigated, in line with the complaints procedure. We upheld this aspect of Mrs C's complaint.

Mr C complained that staff at the dental practice had failed to deal appropriately with his concerns that his gums continued to bleed after having four teeth extracted. He was on warfarin medication (a medication to prevent blood clots) which meant that he was at high risk of bleeding. He reported this to the dentist, who said that it would be alright and he could leave the practice. When Mr C got home, the bleeding continued and he contacted the practice again and was asked to attend. He saw a second dentist who also said that he was not to worry and that the bleeding would stop. However, the bleeding continued that evening and Mr C had to attend hospital, where the bleeding eventually stopped and he was sent home. We took independent advice from an adviser in general dentistry and concluded that the second dentist was aware that Mr C was on warfarin medication and that they had repeated the advice given earlier by the first dentist about what Mr C should do in the event of bleeding from his gums. We considered this to be reasonable and we did not uphold the complaint. Related reading View Decision Report 201702748 as a PDF (11.11 KB) Updated: March 13, 2018

Mr C complained that dental staff at the practice had failed to deal appropriately with his concerns that his gums continued to bleed after having four teeth extracted. He was on warfarin medication (a medication to prevent blood clots) which meant that he was at high risk of bleeding. He reported this to a dentist, who said that it would be alright and he could leave the practice. When Mr C got home, the bleeding continued and he contacted the practice again and was asked to attend. He saw a different dentist, who also said that he was not to worry and the bleeding would stop. However, the bleeding continued that evening and Mr C had to attend hospital where the bleeding eventually stopped and he was sent home. We took independent advice from an adviser in general dentistry and concluded that the first dentist was aware that Mr C was on warfarin medication, that they had checked his clotting status prior to the extractions and that they had stitched and packed the tooth sockets following the extractions. The first dentist had also provided Mr C with a detailed post-operative instruction sheet, which provided advice on action which should be taken regarding any bleeding. We did not uphold the complaint. Related reading View Decision Report 201702492 as a PDF (11.19 KB) Updated: March 13, 2018

Mr C complained on behalf of his wife (Mrs A). Mrs A had undergone a colonoscopy (a procedure to examine the inner lining of the large intestine) at University Hospital Crosshouse and, during the procedure, a complication had occurred which caused a perforated bowel. As a result of the perforated bowel, Mrs A had to undergo emergency surgery and she spent time in an intensive care unit. Mrs A required a temporary colostomy (a surgical procedure where an opening is formed in the abdomen). Mr C complained that the colonoscopy was not carried out to a reasonable standard. We took independent advice from a consultant general and colorectal surgeon. We found that a colonoscopy was the appropriate and recommended procedure in Mrs A's case, taking into account her existing medical conditions. We also found that the doctors involved in the colonoscopy had the relevant experience and were suitably qualified to carry it out. The board said that the perforated bowel was a recognised complication and risk of the colonoscopy. They also said that when the perforation occurred it was quickly recognised and prompt and appropriate action was taken. The board had apologised for the complication that had occurred, and had set out the action they had taken to improve clinical safety. Taking account of the evidence and the independent advice we received, we did not uphold Mr C's complaint. However, we did ask the board to provide us with evidence of the action they said they had taken, and we made a recommendation to the board with a view to encouraging learning from this complaint.

Ms C complained about the care and treatment her father (Mr A) received at University Hospital Crosshouse. Mr A had cancer and was suffering from jaundice, requiring him to have bile drained from his body. Mr A had an Endoscopic Retrograde Cholangiopancreatography (ERCP) procedure (a procedure that examines the pancreatic and bile ducts) to try and drain the bile. After this he developed sepsis (a blood infection) and died in the hospital several days later. We took independent medical advice from a consultant in gastroenterology and an intensive care consultant. We found that an ERCP procedure was the recommended and appropriate treatment to attempt to drain the bile and relieve Mr A's jaundice. Whilst we found that it was reasonable for staff to have carried out this treatment, we found that the procedure was unsuccessful as a result of the invasion of the cancer. The resulting undrained bile had led to Mr A developing sepsis, which is a recognised complication of this procedure. We also found that, although there were some delays in carrying out investigations, including the ERCP procedure, these delays were not unreasonable and did not affect Mr A's outcome. We noted that the surgical team could have recognised the deterioration in Mr A's condition more quickly, however, we found that this did not affect his outcome and found his overall medical management was acceptable. Taking account of the evidence and the independent advice we received from both advisers, we considered that, on the whole, the care and treatment Mr A received was reasonable and we did not uphold this complaint. Ms C also complained that hospital staff had failed to communicate adequately with her and her family about the seriousness of Mr A's clinical condition and prognosis. We found that there should have been better communication with Mr A's family regarding the risks of an ERCP procedure and also regarding the severity of his illness and prognosis, in particular, when Mr A's co

Mr C complained about the care and treatment provided to his late wife (Mrs A). Mrs A had amyloidosis (a condition caused by abnormal deposits of a protein called amyloid around tissues and organs in the body) and Mr C felt that the diagnostic process for this was slow. Mr C had concerns that biopsies undertaken by the board were found to be negative for amyloidosis, but were later found to be positive when tested at the UK's National Amyloidosis Centre. We took independent advice from a consultant physician, a cardiologist, and a pathologist. We did not find that there were any unreasonable delays in determining that Mrs A had amyloidosis. The advice we received was that it was reasonable that the National Amyloidosis Centre was able to make a diagnosis when the board did not, as the National Amyloidosis Centre is more experienced in the techniques for testing. We did not uphold this complaint. Mr C also complained about failures in communication and failures in providing adequate support to Mrs A and her family during Mrs A's illness. We took independent advice from a consultant physician and found that the board's communication with the family throughout Mrs A's illness, and the support provided to Mrs A, was unreasonable and insufficient. We considered that a protocol for earlier involvement of specialist nurses, and consideration of how to access information from the National Amyloidosis Centre, would have minimised this issue. We made recommendations regarding this. Finally, Mr C complained about the board's handling of his complaint. We found that the board had failed to meet deadlines and had failed to provide clear explanations to Mr C. We upheld this complaint. However, we found that the board had implemented a new complaints handling procedure since Mr C's complaints and so we did not make any recommendations around this issue.

Mr C attended his GP practice because he was concerned that he may have Lyme disease (an infection transmitted by ticks). He said that the practice failed to follow reasonable process in diagnosing him with Lyme disease. He was prescribed antibiotics on two occasions, some months apart. Mr C said that a GP had failed to note in his medical records that he had a reaction eight days into the second course of antibiotics, which Mr C said was crucial evidence that he had the disease. As a result of the practice's failure to recognise Mr C had Lyme disease, he said that he was concerned for his future health. Mr C also complained that the practice had failed to provide reasonable explanations in their response to his complaint. We took independent advice from a GP adviser. We found that the treatment decisions and investigations carried out by the practice were reasonable in light of the symptoms Mr C presented with. We found that it was reasonable that the practice referred Mr C to several specialists, who did not confirm that Mr C had Lyme disease. We were satisfied that the standard of medical care and treatment was reasonable and we did not uphold the complaint. In relation to complaints handling, we found that the practice properly explained the rationale behind the decision-making on treatment and managing Mr C's symptoms, and that the responses were fair and appropriate. We did not uphold the complaint. Related reading View Decision Report 201607900 as a PDF (11.27 KB) Updated: March 13, 2018

Mr C complained that the prison health centre's decision to reduce and remove his prescribed medication was unreasonable and had caused him to be left in pain. The board said that two nurses had witnessed Mr C attempting to withhold his medication and for that reason a decision had been taken by clinical staff to reduce and remove his medication. They said this was in keeping with an agreement Mr C had previously signed which stated that a failure on Mr C's part to take his medication properly may result in it being reduced or stopped. Our decision, after taking independent advice from a GP adviser, was that the board had acted reasonably and that the alternative medication Mr C had been prescribed was also reasonable. However, we were critical of the board's handling of Mr C's complaints. They had failed to follow their complaints handing process, and had failed to address all of Mr C's main points of complaint. We made several recommendations to address the failings we identified.