SPSO Individual Decisions

Mrs C complained about the care and treatment provided to her late sister (Miss A). Miss A attended the practice and was prescribed medication for suspected vertigo (a sensation of whirling and loss of balance). The following day she collapsed at home and was admitted to hospital. It was found that she had hypercalcaemia (excessive calcium levels), acute pancreatitis (inflammation of the pancreas) and severe dehydration. Miss A's condition continued to deteriorate and she died. Mrs C raised concerns about the level of medication Miss A was prescribed and queried whether they played a role in her death. Mrs C complained that the practice failed to monitor Miss A's medication regime appropriately, to ensure that she received appropriate follow-up for specialist care and that they failed to carry out an appropriate assessment of her condition the day before she collapsed. We took independent advice from a GP. We found that the practice correctly followed the prescribing instruction received by Miss A's specialist and that the list of medications prescribed were reasonable given her symptoms. We concluded it was not the practice's responsibility to chase up the hospital with regards to follow-up appointments. We also found that an appropriate and thorough examination was carried out and there was no evidence to suggest that Miss A was suffering from pancreatitis the day before she collapsed. We did not uphold Mrs C's complaints. Related reading View Decision Report 201901036 as a PDF (24.43 KB) Updated: July 22, 2020

Mr C complained on behalf of his daughter (Ms A). Ms A was suspected to have gallstones (small stones that form in the gallbladder) and was referred for laparoscopic (keyhole) surgery. During the surgery Ms A's gallbladder could not be located and following further investigations, it was confirmed that Ms A had gallbladder agenesis (absent from birth). Mr C complained that Ms A's surgery could have been avoided had further investigations been performed when it was observed during the ultrasound that the gallbladder could not be definitively seen. Mr C also complained about the board's handling of his complaint. The board said that they considered the appropriate investigations were carried out and that further scans prior to surgery were not clinically indicated. We took independent advice from a consultant surgeon. We found that the conclusion of Ms A's scan, which stated it was “suggestive of a contracted bladder” was reasonable on the basis that gallbladder agenesis is sufficiently rare. Further scans were not warranted in this case as Ms A did not meet the criteria. We also concluded that, while the board's final response to the complaint was somewhat delayed, the delay was reasonable in the circumstances. We did not uphold Mr C's complaints. Related reading View Decision Report 201902732 as a PDF (24.34 KB) Updated: July 22, 2020

Miss C complained about the antenatal (before a baby's birth) care and treatment she received when she attended Forth Valley Royal Hospital where her child was stillborn at full term. Miss C raised concerns that, despite attending triage on a number of occasions, in relation to concerns about her blood pressure and possible pre-eclampsia (a pregnancy-related condition involving a combination of raised blood pressure and protein in the urine), she was not adequately supported. Miss C said that she felt that her concerns were not taken seriously, that she received poor continuity of care and that these failings meant that there were missed opportunities to save her baby. The board said that Miss C was provided with reasonable care and treatment. The board found that staff provided appropriate care and treatment and there was nothing that could have been done to prevent the stillbirth of Miss C's baby. The board also requested an external review to be carried out in relation to Miss C's care. We took independent advice from two advisers – a midwife and an obstetrician (a doctor who specialises in pregnancy and childbirth). We found that the midwifery care and treatment given to Miss C was appropriate and in line with relevant guidance. We also found that the obstetric care and treatment given to Miss C was reasonable and in accordance with national guidelines. We found no evidence of missed opportunities which could have affected the outcome in this case and concluded that Miss C's antenatal care was of a high standard. As such, we did not uphold this complaint. Related reading View Decision Report 201808613 as a PDF (24.51 KB) Updated: July 22, 2020

Mrs C complained on behalf of her husband (Mr A) about the treatment he received when he attended A&E of Forth Valley Royal Hospital due to experiencing pain that had started in his neck and had travelled to his hands. In particular, Mrs C was concerned that there was a delay in diagnosing Mr A with sepsis (blood infection). Mr A had been examined and then discharged to the care of his GP on the same day. We found that there was no evidence that Mr A had sepsis at that time. A diagnosis of sepsis requires a source of infection and evidence of abnormal physiology; however, the urinalysis showed no signs of infection. Therefore, there was no failure to identify sepsis at this stage. The following morning Mr A was taken by ambulance to hospital and was admitted again. Mr A was diagnosed with a urinary tract infection and then developed sepsis. While we did not consider there to be a failure to diagnose sepsis, Mr A is a diabetic and we found that there was a failure to carry out a bedside blood glucose finger prick test during his first attendence at hospital given glucose was found in Mr A's urine following the urinalysis. On this basis, we considered that the board failed to provide Mr A with reasonable care and treatment. Therefore, we upheld this complaint. Mrs C also complained about the response she received to her complaint regarding the content of the discharge letter to Mr A. The response to the complaint correctly stated what was in A&E notes (the GP was to consider referring Mr A to neurology (the branch of medicine concerned with the diagnosis and treatment of disorders of the nervous system)), but the discharge letter to Mr A's GP did not mention this. We upheld the complaint on the basis that the discharge letter should have contained this information and the complaint response should have identified this discrepancy. We upheld this aspect of the complaint.

C underwent a polypectomy (a procedure used to remove polyps from the inside of the colon). C said that they informed staff prior to the procedure that they had a platelet disorder (platelets are the cells responsible for making blood clot. A platelet disorders mean that injured blood vessels bleed more than usual and heal more slowly), however, no precautions were taken prior to the polypectomy being carried out. C later experienced bleeding. C complained that the board unreasonably managed their care in relation to their history of a platelet disorder and failed to reasonably manage their care after they were admitted with bleeding. We took independent medical advice. We found that clinicians undertook a pre-assessment with C. While C had a history of experiencing bleeding as a child, a more recent operation had not resulted in significant bleeding. We found that it was reasonable that no further tests were carried out prior to the procedure being undertaken, as there was full blood count and clotting information available to clinicians which would have highlighted any long standing problem with the number of platelets if there were any. We did not uphold this aspect of the complaint. We found the board's management of C in the acute situation was adequate and carried out in a reasonable timescale. There was no indication a specific platelet or clotting factor transfusion was required. We did not uphold this aspect of C's complaint. Related reading View Decision Report 201901296 as a PDF (24.42 KB) Updated: June 17, 2020

Miss C complained about the care and treatment provided to her child (Child A) by the board. Child A was born by caesarean section. When Child A was older, they experienced a seizure and a scan showed right-sided ventricular enlargement (when the muscle on the right side of the heart becomes thickened and enlarged) and associated white matter loss, indicating brain damage or brain injury. Miss C had concerns about how the brain damage occurred, when it occurred, and the delay in identifying this. She said that her view was that the board had caused the brain injury when Child A was born. She also complained that Child A had not received a brain scan earlier despite developmental difficulties. We took independent advice from a paediatrician (doctor dealing with the medical care of infants, children and young people). We found that there was no indication in the medical records of any events which were likely to have caused brain injury in Child A during birth or during the neonatal period. We also found that Child A's early developmental course did not suggest the need for a scan and there did not appear to have been any delay in diagnosing the brain injury. We did not uphold Miss C's complaint. However, we noted during our investigation that there were failings in the board's handling of Miss C's complaint in relation to updating Miss C, not responding to her questions, failing to refer to SPSO, and failing to acknowledge correspondence in a timely manner. Therefore, we made a recommendation to the board in light of this under section 16G of the SPSO Act 2002, which requires the Ombudsman to monitor and promote best practice in relation to complaints handling.

C complained that the board had unreasonably stopped their medication in prison. We took advice on the complaint from a medical adviser. The medication had been stopped after a check had been carried out and it had been found that some of C's medication was missing. We found that it had been reasonable to stop the medication and that the care provided to C had been reasonable. Medical staff had acknowledged C's mental health conditions and had directed them to engage with the mental health team. We did not uphold the complaint. Related reading View Decision Report 201809380 as a PDF (23.91 KB) Updated: June 17, 2020

Ms C complained to us about the care and treatment provided to her father (Mr A) before his death from suicide. Mr A was admitted to Forth Valley Royal Hospital after expressing suicidal thoughts. He was discharged on the following day. Ms C complained that it was unreasonable to discharge Mr A at that time. We took independent advice from a psychiatric adviser. We found that there was no evidence that Mr A had been adequately assessed and we upheld the complaint that he was discharged unreasonably. Mr A returned to the hospital on the day he was discharged and asked to be readmitted. However, it was decided that he would not be readmitted. Ms C complained that this decision was unreasonable. We found that it was unreasonable that the nursing staff did not consult a doctor and carry out an assessment when Mr A returned to the hospital. We also upheld this complaint. Ms C complained that Mr A's medical records were inadequate. We found that there were failings in relation to describing the assessment of risk, the clinical rationale for the management of Mr A, discharge planning, changes in his mental state and information available from his family. We upheld this complaint. Finally, Ms C complained that the board had delayed in completing a significant adverse event review. The board had accepted that there were delays in this and had apologised for this. We upheld this complaint. We were satisfied, however, that the board had taken reasonable and appropriate action to try to prevent all of these failings recurring. They had also apologised to the family for most of the failings, although we recommended that they issue a further apology for the delay in completing the significant adverse event review.

Mrs C complained about the care and treatment her father (Mr A) received at Forth Valley Royal Hospital. Mr A had been admitted with sudden onset severe jaw pain, which was radiating to his chest and arms. He subsequently developed abdominal pain and a number of tests were carried out, including an abdominal ultrasound. On the following day, Mr A had a CT angiogram (a specialised scan using x-rays to look at the heart) of his aorta (the largest and main artery in the body). This confirmed a large aortic dissection (a tear) requiring urgent surgical intervention. Mr A was transferred to another board for this surgery. After the surgery, it was discovered that Mr A had suffered a spinal stroke. This left him paralysed and entirely reliant on carers. We took independent advice from a GP, a radiologist (a specialist in the analysis of images of the body) and from a consultant cardiothoracic surgeon (a medical doctor who specialises in surgical procedures of the heart, lungs, oesophagus, and other organs in the chest.) We found that the ultrasound result should have been flagged up as highly significant and with greater urgency. Where a potential life-threatening abnormality emerges on a diagnostic test, every effort should be made to convey this result immediately to the clinical team involved. The failure to do so, in Mr A’s case, led to a delay in definitive diagnosis and potential treatment of the aortic dissection. We, therefore, upheld this aspect of Mrs C’s complaint. However, we found that earlier identification of the dissection and more timely surgery would not have necessarily changed the outcome for Mr A. Mrs C also complained that the board had failed to comply with the relevant record-keeping guidance, as they had been unable to find some of Mr A’s clinical records. We found that the board had failed to follow their ‘Transportation of health records policy’ and we also upheld this aspect of Mrs C’s complaint. Finally, Mrs C complained about the

Miss C complained about the care and treatment which her late father (Mr A) received at Forth Valley Royal Hospital. Mr A, who had a number of pre-existing health conditions, had been admitted after a fall as his general health had deteriorated. He was in pain and died not long after the admission. The family felt that there had been a lack of investigations by staff into a diagnosis and that they failed to appropriately manage Mr A's pain control or provide him with a reasonable standard of nursing care. We took independent advice from a consultant physician and from a senior nurse. We found that while Mr A received a reasonable level of overall care, the management of his pain could have been better in that the rationale behind the decisions to change/amend medication for pain relief were not clear. The level of communication between the staff and Mr A's family could also have been improved. We upheld this aspect of the complaint. In regards to the nursing care, we found that, although there was evidence of good care at times, there was also a failure by nursing staff to fully record Mr A's pain score and other charts which would have evidenced whether appropriate care had been given. Therefore, we upheld this aspect of the complaint.

Mrs C complained on behalf of her late son (Mr A) about the care and treatment he received from his GP practice. Mr A phoned the practice as he was coughing and felt unwell. Mr A was considered to have symptoms of a cold and he was prescribed a cough suppressant. Around a week later, Mr A died from pneumonia (an infection of the lungs). Mrs C complained that the practice unreasonably diagnosed Mr A over the phone, even though he had asthma and learning difficulties. We took independent advice from a GP. We found that as Mr A was noted to have symptoms of a cold, it was reasonable that he was diagnosed over the phone, even though he was a vulnerable adult. We did not uphold this aspect of the complaint. Mrs C also complained that when she was admitted to hospital shortly afterwards, the practice did not contact her son to check on his condition. We found that the practice had not been informed of Mrs C's hospital admission or advised of any concerns about Mr A. Therefore, we found that the practice had no cause to check on Mr A's condition. We did not uphold this aspect of the complaint. Lastly, Mrs C complained about the practice's handling of her complaint. We found that there were failings in their complaints handling, which the practice had already acknowledged and apologised for. We noted that Mrs C's complaint was not acknowledged within the relevant timescale and her request for a phone call was not followed up. Therefore, we upheld this aspect of the complaint.

Mr C complained about the treatment which his child (Child A) received at Forth Valley Royal Hospital. Mr C said that Child A had been unwell for many months following a viral diagnosis and that they had continued to experience symptoms which had affected their life, including missing school for multiple periods. Although Child A had been referred to otorhinolaryngology (medical treatment of ear, nose and throat) and paediatrics (medical care of children), Mr C felt that a diagnosis should have been reached after such a long time. We took independent advice from a consultant paediatrician. While there was a lack of advice and support provided to Mr C on how to manage Child A's symptoms in the interim, which would have helped to allay their fears, we found that appropriate investigations and assessments had been carried out in an effort to arrive at a diagnosis, including referrals to specialist services. We did not uphold the complaint. Related reading View Decision Report 201809648 as a PDF (23.81 KB) Updated: September 18, 2019

Mrs C complained about the nursing care provided to her cousin (Mr A) during an admission to Forth Valley Royal Hospital. Mrs C raised concerns about various aspects of the nursing care provided to Mr A in respect of his hygiene and whether he was being provided with appropriate support to eat and drink properly. We took independent advice from nursing adviser. We found that there were daily entries in the nursing notes to indicate Mr A's needs were met. We noted that the care plan documentation had not been completed until some time after admission. However, while it would be good practice to do so earlier, this does not necessarily mean the nursing care provided was not of a reasonable standard. We acknowledged that the account provided in the nursing records was not Mrs C's experience. However, we did not consider there to be independent evidence that could verify her view. Therefore, based on the available evidence, we did not uphold this complaint. Mrs C also complained about communication issues she experienced as Mr A's power of attorney. The board had previously provided an apology for Mrs C's experience but there were still a number of areas Mrs C was unhappy about. On balance, we concluded that staff's communication with Mrs C was reasonable in the context of a busy hospital environment. We acknowledged that communication was not as good as it could have been, but we did not consider it to be unreasonable. We provided some feedback to the board but, on balance, did not uphold the complaint. Related reading View Decision Report 201802977 as a PDF (24.04 KB) Updated: September 18, 2019

Mr C complained about a change in his pain medication and said that he suffered significant pain as a result. We took independent advice from a medical adviser. We found that the decision to change Mr C's pain medication was reasonable and that this was made following an appropriate and adequate assessment of his pain. We did not uphold the complaint. Related reading View Decision Report 201802741 as a PDF (23.46 KB) Updated: August 21, 2019

Mrs C complained about the care and treatment given to her late husband (Mr A) while he was a patient at Forth Valley Royal Hospital. Mr A had a history of cancer and his condition was investigated. His results were in keeping with alcoholic hepatitis. Mr C had abnormal liver function results and changes had occurred in his brain as a consequence of his liver disease. He had lost a lot of weight and went on to develop influenza A (a highly contagious viral infection of the respiratory passages). Mrs C complained that when she visited Mr A in hospital he was often unkempt and dirty. He also experienced an unwitnessed fall but Mrs C said that he was not properly assessed after this. Mrs C felt that Mr A's condition was allowed to deteriorate, and after developing sepsis he died. We took independent nursing and gastroenterology (medicine of the digestive system and its disorders) advice. We found that on admission, nursing staff failed to complete a Malnutrition Universal Screening Tool (MUST) which, had they done so, would have alerted staff to his malnutrition and prompted further steps (for example referral to a dietician). A falls assessment should also have been carried out earlier in his admission and then regularly after that, particularly after his fall. However, while we found no evidence that he had not been nursed in a dignified way, we found that there had been failures in Mr A's medical care, there was poor documentation and monitoring of his liver disease, insufficient investigation of his fall, and a full sepsis screen had not been carried out. We upheld Mrs C's complaint.

Mr C complained about the care and treatment he received for back pain while in prison. He had previously been prescribed dihydrocodeine and found this effective. The board's treatment plan included physiotherapy, a transcutaneous electrical nerve stimulation (TENS) machine (method of pain relief involving the use of a mild electrical current), heat packs and non-steroidal anti-inflammatory drugs, but he complained that these were not effective. He had also been referred to a pain management clinic. We took advice from an independent GP adviser. We considered the board's prescribing for Mr C's pain to be reasonable, along with the other supportive measures referred to above. We noted Mr C's wish to take dihydrocodeine for his pain, but highlighted that this is an opiate and that the prescribing of opiates in the prison setting leads to risk of misuse. The fact that the board's GPs chose not to prescribe dihydrocodeine, does not suggest that the care they have provided was below a reasonable standard. We considered that Mr C's treatment was in line with guidance on good medical practice, and therefore did not uphold this complaint. Related reading View Decision Report 201804988 as a PDF (23.91 KB) Updated: June 19, 2019

Ms C complained that the decision to stop her medication when she arrived at prison was unreasonable. When Ms C arrived in prison, a doctor reviewed her prescribed medications. The doctor discussed the matter with Ms C's community practice and following that, took the decision to stop the medications no longer required. Ms C said that the stopping of her medications left her in severe pain and affected her mental health. We took independent advice from a GP adviser. We found that appropriate pain relief medication had been prescribed to Ms C and that the decision to stop the other medications was reasonable because there was no requirement indicated for them to be continued. We did not uphold the complaint. Related reading View Decision Report 201806246 as a PDF (23.64 KB) Updated: May 22, 2019

Mr C has a complex medical history and made a number of complaints to the board. Mr C complained that the board failed to adequately address repeated errors in the provisions of prescription drugs, failed to inform the prison service of the requirements of his care plan and allowed his medical records to be altered retrospectively. Mr C also complained about the board's handling of his complaint. We took independent advice from an adviser specialising in general medicine. We found that, on occasion, there had been delays in the provision of prescription drugs. However, these delays did not have a significant impact and it was not unreasonable for the dispensation of medicine to be subject to prison procedures, which limited the hours when medication could be issued. We did not uphold this aspect of Mr C's complaint. In relation to Mr C's care plan, we found that it had been reviewed and he had been able to participate in those meetings along with prison service staff. We considered that the board communicated reasonably and appropriately with the prison service. We did not uphold this aspect of Mr C's complaint. In relation to Mr C's medical records, we found that the board said it was impossible to amend records retrospectively. The adviser noted that this statement was inaccurate and we provided feedback to the board in light of this. However, we found no evidence that Mr C's medical records had been altered retrospectively and did not uphold this aspect of Mr C's complaint. Finally, we found that Mr C had received an explanation from the board for the way his complaint was handled and an apology for any confusion caused. We considered this approach to be reasonable and did not uphold this aspect of Mr  C's complaint. Related reading View Decision Report 201706515 as a PDF (24.07 KB) Updated: April 17, 2019

Mrs C complained about the practice's handling of a phone call made by her late son (Mr A) who had hurt his back. Mr A spoke with a triage nurse, who offered him an appointment with an Extended Scope Practitioner (ESP - a physiotherapist who can undertake extra duties such as ordering investiations or making referrals), which Mr A declined. The triage nurse advised Mr A to take regular paracetmol and ibuprofen, and to seek further assistance if his condition worsened. His request for stronger pain killers and other medication was declined. Mrs C considered that Mr A should have been seen by a GP and complained that Mr A didn't get the help he needed. We took independent advice from a GP and a nurse. We found that the offer of an appointment with the ESP was reasonable for the assessment of back pain, and that it would have allowed for onward referral to a GP if deemed necessary. We also found that the triage nurse carried out a reasonable assessment and recorded no information that indicated the need for a GP assessment. Therefore, we did not uphold Mrs C's complaint. Related reading View Decision Report 201800738 as a PDF (23.88 KB) Updated: February 20, 2019

Ms C complained that her prescribed medications had been mismanaged by the practice. She said that her medications were rarely available to collect from her local pharmacy after she had ordered them through the practice. Ms C said that she had been without key medication due to these access problems. We took independent advice from a GP. We found that the practice prescribed Ms C's blood pressure medication regularly, however, we could not say whether this was provided within a reasonable time of Ms C's requests because there was insufficient evidence available. We also found that the practice was not unreasonable in failing to prescribe an updated contraception medication because they were not notified of the change prior to the medication being issued. Therefore, we did not uphold this aspect of Ms C's complaint. Ms C also complained that the practice refused to take complaints by phone and did not respond to complaints made in writing. Ms C submitted two complaints. We found that the tone used by the practice in their response was confrontational, did not recognise the inconvenience Ms C had experienced, and did not reflect on whether there was learning to be taken from the complaint. We also found that Ms C was given no information about the complaints process and was not told whether she could escalate her complaint, either to stage two of the complaints process or to our office. In responding to the second complaint, there was no acknowledgement that Ms C had not received the previous response, despite it being clearly mentioned to them. We considered that the practice's responses to Ms C's complaints were unreasonable. Therefore, we upheld this aspect of Ms C's complaint.

Mr C complained that the dentist unreasonably failed to diagnose the cause of his facial pain. Mr C said that he attended his dentist but was told there was nothing wrong with his teeth. He continued to see his GP about his facial pain and several medical investigations were carried out. Fourteen months after Mr  C had attended his dentist, he saw a specialist who found out that he had a long- standing infection. We took independent advice from a dental adviser. We found that the treatment decisions and management of Mr C was reasonable in the circumstances, as was the failure to diagnose an infection. We did not uphold Mr C's complaint. Related reading View Decision Report 201707103 as a PDF (23.64 KB) Updated: January 23, 2019

Mr C complained on behalf of his wife (Mrs A). Mrs A was referred to the board by her dentist for a wisdom tooth extraction. After the procedure Mrs A experienced significant pain and other adverse symptoms. She was re-referred to the board by her dentist for further review, however, they did not identify any post-operative issues such as nerve damage, other than that the surgical site was healing slowly. Mr C complained that the dentist failed to provide thorough information about the risks associated with the wisdom tooth extraction, and that the procedure was not performed correctly. We took independent dental advice. We found that the information and advice provided to Mrs A was clear and in line with national guidance. We also found there was no evidence to suggest the procedure was not performed correctly. We did not uphold Mr C's complaints. Related reading View Decision Report 201801606 as a PDF (23.73 KB) Updated: December 19, 2018

Miss C, an advice worker, complained on behalf of her client (Mr B) regarding the care and treatment of his late wife (Mrs A). Mrs A had been admitted to Forth Valley Royal Hospital for treatment for influenza and was discharged back to her care home with medication. Mrs A had to be readmitted after five days where she was treated for pneumonia (a lung infection). Mrs A did not respond to further treatment and died in the hospital. Mr B felt that Mrs A should not have been discharged from the hospital initially and that staff had reached a wrong diagnosis. We took independent advice from a consultant in medicine and found that Mrs A had received appropriate treatment during the hospital admissions. In the first admission, her symptoms were appropriately diagnosed as being influenza related and she received appropriate investigations and treatment and was discharged when her symptoms improved. Mrs A was then readmitted with different symptoms suggestive of further or a new chest infection. We did not uphold Miss C's complaint. Related reading View Decision Report 201802853 as a PDF (23.83 KB) Updated: December 19, 2018

Mrs C complained that the board failed to ensure a reasonable standard of communication with herself and her late husband (Mr A). Mr A had been diagnosed with cancer, and Mrs C complained that the communication about his diagnosis, prognosis and treatment options was poor and that, as such, Mrs C and Mr A were unable to make an informed decision about the treatment options offered. We took independent advice from an oncology (cancer) nurse and from an adviser who specialises in the care of the elderly. We found that board staff discussed treatment options and potential risks in a reasonable way, and that the records suggested that Mr A understood the nature of his condition and treatment options. We also found that staff followed the relevant General Medical Council Guidance in this respect, and that they acted reasonably in respecting Mr A's stated preferences for information and his decision-making ability. We did not uphold the complaint. Related reading View Decision Report 201608890 as a PDF (11.06 KB) Updated: December 2, 2018

Mr C complained on behalf of his late wife (Mrs A) about the care and treatment she received at Forth Valley Royal Hospital. Mrs A had been experiencing tingling in her fingers, which continued to worsen. Mr C complained there was an unreasonable delay in carrying out a scan to investigate Mrs A's condition. He also considered that there was an unreasonable delay in giving Mrs A the results of the scan. After Mrs A was referred for surgery, her mobility declined. Mr C felt that, with earlier surgery, she may have been walking normally. We took independent medical advice from a consultant orthopaedic surgeon (a doctor who specialises in conditions involving the musculoskeletal system). We found that Mrs A was appropriately referred for an urgent scan and that it was carried out within a reasonable timescale. However, we considered that there was a delay in reporting the results and in giving Mrs A the results, which was unreasonable as there were significant clinical findings that required urgent surgical intervention. The adviser considered that earlier surgery was likely to have improved Mrs A's outcome and mobility. However, they explained that a good outcome was not guaranteed, as her condition was degenerate and it was unlikely she could have been walking normally. In light of these delays identified, we upheld Mr C's complaint.