SPSO Individual Decisions

Ms C, an advocacy worker, complained on behalf of her client (Ms A) about the care and treatment provided to Ms A's late mother (Mrs B) by the practice following a home visit by a doctor from the out-of-hours (OOH) service. Mrs B was later admitted to hospital where she died. We took independent advice from a GP. We found that there was no indication, based on the report from the OOH doctor, for the practice to arrange an emergency home visit to Mrs B or that the OOH doctor had requested the practice carry out a home visit. There was also no evidence to suggest that Mrs B was deteriorating in the days following the visit of the OOH doctor. We found that the subsequent sudden deterioration in Mrs B's condition could not have been foreseen and the care provided by the practice following the visit from the OOH doctor, and the plan to visit Mrs B as a routine house visit, was reasonable and consistent with good medical practice. Therefore, we did not uphold the complaint. Related reading View Decision Report 201804029 as a PDF (24.23 KB) Updated: June 17, 2020

Ms C complained about both the health visitor and hospital care provided to her child (Child A) in the context of child protection safeguarding. Ms C felt that there had been a lack of action taken by the health visitor when she reported Child A had ongoing diarrhoea and had a hard and bloated stomach. Ms C was also concerned that child protection procedures should not have been instigated and that the process was not properly communicated to her or reasonably followed in terms of the alleged facial markings on Child A. In responding to the complaint, the board considered that the actions and care provided by staff were appropriate in terms of Ms C's complaints. We took independent advice from a registered health visitor and from a consultant paediatrician. In terms of the care provided by the health visitor, we considered that the care provided to Child A was appropriate and that it was correct to instigate child protection proceedings. However, we upheld this complaint on the basis that there was a failure to either reasonably communicate the decision about instigating child protection proceedings to Ms C or to record the decision not to communicate this to her. We found that the care provided by the hospital was reasonable, therefore, we did not uphold this complaint on the basis that child protection procedures were appropriately followed. However, we were critical of the board's original complaint response to Ms C as it provided limited detail of their complaints investigation in relation to the actions of the health visitor.

Following lower back surgery, Mr C complained about pain in his mid-back which had not been there before. Further reviews of Mr C's symptoms were carried out by the orthopaedic (conditions involving the musculoskeletal system) department and the pain clinic but the cause of his pain, and the pain itself, was not resolved. Mr C considers that his original surgery was not carried out properly and that something went wrong to cause his pain. The board confirmed that Mr C's original surgery was carried out to alleviate leg pain. They said guidelines stated that surgeons should not operate for back pain alone and confirmed that further surgery in Mr C's case was unlikely to help. The board explained that Mr C had been reviewed by a different orthopaedic consultant, and a second opinion had been sought from a consultant in another board area, both of whom agreed that further surgery would not help the symptoms of pain in Mr C's back. We took independent advice from an orthopaedic consultant. We found reasonable history and examinations of Mr C were carried out and that appropriate scans and referrals were made. We concluded that the board provided appropriate treatment in view of Mr C's presenting symptoms. We did not uphold Mr C's complaint. Related reading View Decision Report 201809483 as a PDF (24.31 KB) Updated: June 17, 2020

C, who has diabetes, damaged their foot. C was diagnosed with a broken 4th metatarsal (one of the long bones in the foot). A scan was taken and C was seen at a fracture clinic. C was unhappy with the assessment and the lack of further scans at the fracture clinic appointment. We took independent advice from an orthopaedic surgeon (a medical expert who treats patients with problems in their muscles, bones, joints and other related structures). We found that, due to C's diabetes, C had a high risk of developing a delayed or non-union of the fracture and that this was not recognised by the doctor. Scans should have been taken at the clinic appointment to monitor healing and C was unreasonably discharged before the fracture was healed. Therefore, we upheld this aspect of the complaint. C also complained about the management of their diabetes while they were awaiting surgery on their foot. We took independent advice from a nurse. We found that the management of C's diabetes was reasonable. C had a libre device which monitored their blood sugar levels. While the documentation of the management of C's diabetes should have been clearer, it was reasonable for C to continue to monitor their blood sugar levels on the ward and report the results to staff. We did not uphold this aspect of C's complaint. Lastly, C complained that there was an unreasonable delay in their surgery being carried out. We found that the initial surgery was delayed due to equipment being unavailable. The surgery was a planned procedure and therefore the equipment should have been ordered prior to the day of surgery. When C's surgery was rescheduled, C was unreasonably placed on the trauma list when they should have been placed on the urgent planned list, where there would have been less likelihood C's surgery would be cancelled. We upheld this aspect of C's complaint.

Ms C, a patient advice and support advocate, complained on behalf of her client (Miss A). She complained about the care and treatment Miss A received by the diabetology (diagnosis and treatment of diabetes) and neurology (diagnosis and treatment of disorders of the nervous system) services in relation to a range of symptoms including stomach pain, nausea, headaches, and dizziness and her diagnosis of Postural Tachycardia Syndrome (PoTS, an abnormal increase in heart rate that occurs after sitting up or standing). We took advice from a consultant diabetologist and a consultant neurologist. We found that much of the care and treatment provided to Miss A was reasonable. However, there was a significant delay in follow-up from the neurologist, which the board had already agreed was unreasonable and apologised for. On this basis, on balance, we upheld this aspect of the complaint. However as the board had already apologised and taken action we did not make any recommendations on this point. In relation to complaint handling, we found that there was a significant delay in the complaint being responded to by the board. Though we noted that the board had apologised for this, they had not given any explanation as to what caused the delay. They also did not evidence that Miss A was kept updated during the delays. We therefore made a recommendation to the board in relation to their complaint handling.

Miss C, an advocacy worker, complained on behalf of Ms B that the board failed to provide her late mother (Mrs A) with reasonable care and treatment at Aberdeen Royal Infirmary and that staff at the hospital failed to communicate adequately with Mrs A's family about her care and treatment. Mrs A had been admitted to the hospital's intensive care unit with respiratory failure where she died. Mrs A had suffered from a number of chronic illnesses. We took independent advice from a consultant in emergency medicine. We found that the care Mrs A received was reasonable and in line with current guidelines and good clinical practice. The evidence available showed that, ultimately, Mrs A's failure to respond to the treatment was because of the seriousness of her condition, and not the treatment itself. We did not uphold this aspect of the complaint. In relation to communication with Mrs A's family, we found that it was clearly recorded in the clinical notes that on Mrs A's admission there had been a discussion with her family. It had been explained that there was a very real risk that Mrs A would not survive the admission and why performing cardiopulmonary resuscitation (CPR, where the heart and/or breathing is restarted if it stops) would not be in her best interest. However, other than this initial conversation, in general, communication with Mrs A's family was very poor. In particular, the decision to extubate Mrs A (to remove a breathing tube) should have been discussed with her family prior to this taking place. Therefore, we upheld this aspect of the complaint.

Mr C complained about the care and treatment that his late father (Mr A) received at Aberdeen Royal Infirmary and at a palliative care facility. We took independent advice from a consultant head and neck surgeon, from a consultant clinical oncologist (cancer specialist) and from a nursing adviser. We found that the surgical and medical care and treatment Mr A received was reasonable. However, we found failings regarding Mr A's nursing care. In particular, we found that Mr A was not prescribed two hourly position changes at Aberdeen Royal Infirmary and the palliative care facitility when he was at risk of developing pressure damage and that Mr A did not receive care in accordance with the board's policy on adults with tracheostomies (an incision in the windpipe made to relieve an obstruction to breathing). We upheld this aspect of Mr C's complaint. Mr C also complained about how the board handled his complaint. We found that Mr C was not kept updated regarding a timescale for when he could expect to receive the board's complaint response and the minutes of a meeting. Therefore, we upheld this aspect of the complaint.

Mr C complained about the care and treatment provided to his child (Child A) during an admission at Royal Aberdeen Children's Hospital. Child A had a life-limiting condition, including heart and lung problems which made them susceptible to infection. Mr C complained that the hospital did not monitor Child A's blood gases frequently enough which led to an unreasonable delay in them being intubated. Mr C also complained that the hospital failed to accept a referral to the respiratory department. The board confirmed that they performed monitoring of Child A's blood gases when it was clinically indicated. They also confirmed they could not find any evidence of a formal written referral to the respiratory department. We took independent advice from a consultant paediatrician (consultant specialising in the medical care of children). We found that appropriate monitoring of Child A's blood gases was performed, particularly for in a high-dependency unit setting. We did not find any evidence that the board failed to act upon a referral to respiratory. We did not uphold Mr C's complaints. Related reading View Decision Report 201807008 as a PDF (24.23 KB) Updated: March 18, 2020

Mr C complained about the care and treatment he received from Aberdeen Royal Infirmary. Mr C had a nerve sheath tumour (a type of tumour of the nervous system) in his neck in an area known as the brachial plexus (a group of nerves that come from the spinal cord in the neck and travel down the arm. These nerves control the muscles of the shoulder, elbow, wrist and hand, as well as provide feeling in the arm). Mr C had surgery to remove the tumour. During the operation three nerves were found to be running through the tumour. All three nerves were stimulated electrically. One nerve made the deltoid muscle twitch and this nerve was preserved. The other two nerves produced no apparent muscle movement and were cut and removed with the tumour. This resulted in Mr C losing the use of large muscles in his arm. We took advice from an otolaryngology (the study of diseases of the ear and throat) and head and neck surgeon and from a consultant neurosurgeon (a surgeon specialising in surgery of the brain and nervous system). We found that: advice should have been sought from the Scottish Brachial Plexus Team prior to Mr C's operation intraoperative neurophysiological nerve monitoring (IONM – where fine needles are placed in the target muscles and spontaneous muscle fibre electrical activity is continuously displayed on a screen as waves) should have been used during Mr C's operation Mr C's nerves should not have been cut during the operation Mr C was not referred to the Scottish Brachial Plexus Team within a reasonable amount of time following his surgery the board failed to consider at an earlier stage whether an Adverse Event Review should have been carried out. We upheld Mr C's complaint that the board did not provide him with reasonable care and treatment. Mr C also complained that the board did not inform him of the risks of the surgery. We found that the board did communicate reasonably with Mr C about the risks of the surgery and therefore we did not uphold this

Ms C complained to us about the care and treatment she received from the board when she was diagnosed with lung cancer. Ms C was told that the tumour in her lung had been visible in a CT scan she had several years earlier, which was taken to plan her radiotherapy treatment (a treatment using high-energy radiation) for breast cancer. Ms C complained that the lung tumour was not identified at that time or if it was, she was not offered any treatment. We took independent medical advice from an oncologist (cancer specialist). We found that CT scans for planning radiotherapy are not taken with enough detail to be used for diagnostic purposes. We also found Ms C's lung tumour was small and it could have easily been missed by a clinician who was not reviewing her CT scan for diagnostic purposes. We found it was reasonable that Ms C's lung lesion was not identified at that time and we did not uphold this aspect of her complaint. Ms C also complained about the communication with her about her condition and treatment, leading up to her diagnosis of lung cancer. In particular, that Ms C was sent an appointment letter for a chest CT scan without being told the reason why she was being referred for a CT scan. We took independent medical advice from an acute medical consultant. We found that Ms C and her GP were not appropriately informed about the outcomes of investigations that had been carried out; and why there was a need to carry out further investigations into her condition. We upheld this aspect of Ms C's complaint. Ms C also complained about the board's complaints handling. We found that the board did not keep Ms C appropriately updated during their investigation. We found that the board had failed to identify and respond to all aspects of Ms C's complaint; it was unclear what the conclusions of their complaints investigation had been; and they did not apologise to Ms C for failings they had identified. We upheld this aspect of Ms C's complaint.

Mr C complained that the board failed to communicate reasonably with him and his wife (Mrs C) about his child's (Child A) care and treatment. Mr C raised concerns about the timeliness and accuracy of medical advice; the failure to engage with Mr and Mrs C in a meaningful way; and a failure to obtain proper consent on a number of occasions. We took independent advice from a paediatrician, and a paediatric surgeon with an interest in gastroenterology (the branch of medicine that deals with disorders of the stomach and intestines). We found that many aspects of communication had been reasonable, however, there was a lack of documentation regarding information given to Mrs C both prior to and following a endoscopy procedure (a medical procedure where a tube-like instrument is put into the body to look inside) carried out on Child A. The documentation was not in line with General Medical Council guidance on consent and protecting children and young people. We therefore upheld this aspect of Mr C's complaint. Mr C also complained about the care and treatment provided to Child A. We found that the care and treatment provided was reasonable and did not uphold this aspect of the complaint. Finally, Mr C complained about the board's handling of his complaints. Whilst we acknowledged that there was a significant volume of correspondence for the board to consider and respond to, we considered it clear that there were multiple occasions on which Mr and Mrs C's complaints were not handled in line with the appropriate complaint handling procedures. We considered that the volume of complaints made by Mr and Mrs C was partially as a result of complaints not being managed and responded to in an effective and timely manner; and that the board's failure to address correspondence correctly contributed to the breakdown in the complaints procedure. We also noted that the board had agreed at one point to issue a formal written apology about Child A being removed from the hospital w

Ms C complained that the board unreasonably administered morphine to her during her admission to Woodend Hospital. Ms C complained that during her operation she was administered morphine by an anaesthetist despite being severely allergic to the drug and this being known to board staff. Ms C said this caused her to become very unwell and her admission to be extended. We took independent advice from a specialist in acute and internal medicine. We found that it was reasonable for the board to have administered morphine to Ms C, and there was no evidence to support it was known that Ms C was allergic to the drug prior to it being administered. We did not uphold this aspect of the complaint. Ms C also complained that the board unreasonably failed to obtain all relevant information before determining her complaint. Ms C said that when she submitted the complaint to the board, she referred to the attending consultant being aware of her allergy, and the doctor's views were not sought by the board before they issued their response. We found that the board took reasonable steps to seek comments from the clinician directly involved in the complaint as well as to consider the contemporaneous record from the events complained about before they issued their response. We did not uphold this aspect of the complaint. Related reading View Decision Report 201803661 as a PDF (23.9 KB) Updated: November 20, 2019

Ms C complained that the board failed to provide her with reasonable information about a fistulotomy (a surgical procedure to treat a fistula - a small tunnel that develops between the end of the bowel and the skin near the anus), the risks involved and the other options available, before carrying out the procedure. Ms C was left incontinent after the surgery. We took independent advice from a consultant surgeon. We found that Ms C had not been seen prior to the fistulotomy to discuss the risks and incontinence was not documented on the consent form. We found that although it had been reasonable to offer the surgery to Ms C, she should have been seen in clinic to discuss the risks and benefits as well as the other options for surgery. We considered that Ms C had not been provided with reasonable information about the fistulotomy before the operation was carried out. We, therefore, upheld this aspect of the complaint. Ms C also complained that the board’s response to her complaint was inaccurate. The board’s response to her complaint had stated that other surgical options had been discussed with her. There was no evidence in the documentation we received from the board that this had been discussed with Ms C. We found that if this had been discussed, it should have been documented. Therefore, we upheld this aspect of the complaint.

Mr C complained that the care and treatment given to his late wife (Mrs A) by her GP practice were unreasonable. Mrs A had a history of rheumatoid arthritis (an inflammatory disorder that mainly affects the flexible joints). Her health began to deteriorate further, but Mr C said that it took time to establish that Mrs A had heart problems for which she needed an operation. After surgery Mrs A was discharged home, but months later she required to be admitted to hospital again. Mrs A had developed a serious infection in her heart and died shortly afterwards. Mr C complained that it took too long to diagnose his wife's infection. We took independent advice from a GP. We found that in the early stages of her illness, Mrs A had been investigated and treated appropriately and it had been very unusual for a patient to have developed such severe heart disease in a short space of time. After her operation and return home, Mrs A became increasingly unwell and was regularly seen by members of the GP practice who treated her for a urinary tract infection. However, we found that the severe heart infection (endocarditis) had not been considered as a possible diagnosis, as it should have been, particularly as it was known that Mrs A had an artificial heart valve and persistent signs of infection. Her pre-existing heart condition could have predisposed Mrs A to developing endocarditis, and it was unreasonable not to consider this. This led to a delay in diagnosis and a delay in admitting Mrs A to hospital. Therefore, we upheld the complaint. During the course of our investigation, we also found the complaint handling to be unreasonable.

Mrs C complained to us about the care provided to her late husband (Mr A) by the practice prior to him suffering a fatal heart attack. In particular, Mr A had reported chest pains three times over a three month period to his GP. The GP had felt the problems were related to a stomach problem, prescribed Gaviscon (medication for heartburn or indigestion) to Mr A and said they had ruled out a cardiac cause for the chest pain. We took independent advice from a GP. We found that at the initial consultation it was reasonable that the GP had considered that Mr A's long standing stomach problem was responsible for his reported chest pain, and it was appropriate to prescribe medication. There was a question as to whether Mr A was taking the prescribed medication, which may have resolved the stomach problem, and that it was reasonable to pursue that line of enquiry in an effort to resolve the situation. We found that the GP had carried out an appropriate examination and did not uphold the complaint. We also noted that there was no evidence to suggest that had an earlier diagnosis been made, it would have prevented Mr A's sudden death. Related reading View Decision Report 201809722 as a PDF (23.9 KB) Updated: September 18, 2019

Mr C complained that the care and treatment given to his late wife (Mrs A) by the board was unreasonable. Mrs A had a history of rheumatoid arthritis (an inflammatory disorder that mainly affects flexible joints) and was later investigated for possible heart disease. The investigations proved negative. However, a year later she was admitted to hospital again and found to have severe problems with the functioning of her heart valves. Heart surgery was considered, but Mrs A developed sepsis and multiple organ failure which increased the risks associated with surgery. However, it was considered that Mrs A would not survive without an operation, which went ahead. After Mrs A was discharged home, she picked up a serious infection and suffered a stoke. She died a few months later. We took independent advice from a cardiologist (a doctor who specialises in the heart and blood vessels). We found that it was extremely unusual for a patient's heart condition to deteriorate so rapidly and that this could not have been foreseen; there had been no delay in treating Mrs A's symptoms or in diagnosing her heart problems. Mrs A's health was such that surgery was always going to be risky for her, but there had been no delay undertaking it. Afterwards, the serious infection from which Mrs A suffered had a significant associated mortality rate and her health continued to deteriorate despite her treatment. Therefore, we did not uphold the complaint. Related reading View Decision Report 201804332 as a PDF (24.1 KB) Updated: September 18, 2019

Mrs C complained about the care and treatment her daughter (Miss A) received from the board's out-of-hours GP service on two separate occasions, and from Aberdeen Royal Infirmary during two separate admissions. Mrs C believed that the out-of-hours service had not properly assessed Miss A and should have admitted her to hospital. Miss A underwent an appendectomy (appendix removal surgery) during the first hospital admission and then required to have a further operation for a pelvic abscess which is a recognised complication of appendicitis. Miss A was also found to have Crohn's disease (an inflammatory bowel condition) which further complicated matters. Mrs C believed that it took a long time for staff to decide what to do when Miss A was readmitted to Aberdeen Royal Infirmary, that an unusual antibiotic was administered, and that the medical staff tried too many times to insert cannulas. We took independent advice from a GP and a consultant in general and colorectal (bowel) surgery. We found that the care in relation to the out-of-hours service was of a reasonable standard, because there were clear records made by both GPs of a detailed history being taken, appropriate examination performed, observations taken and tests carried out, with advice given on what to do if Miss A's condition worsened. We also took into account that appendicitis is not always a straightforward diagnosis to make and that other conditions, such as kidney infection, can mimic this. We did not uphold this aspect of the complaint. In relation to the first hospital admission, we found that whilst the timing of antibiotic treatment and surgery were slightly outside national guidelines, we did not consider these delays to be unreasonable. Nevertheless, although it was reasonable to discharge Miss A on antibiotic treatment and arrange for blood tests some days later, we were critical that this safety-netting measure was not appropriate. We considered that arrangements should have been made

Mr C complained about the treatment his mother (Mrs A) received at Aberdeen Royal Infirmary. Mrs A was admitted to hospital to investigate heart concerns and was diagnosed with three vessel disease (a type of heart disease). An operation was carried out, but Mrs A died during the operation. Mr C was concerned about the board's response to Mrs A's reports of discomfort to nursing staff and the subsequent treatment she received. Mr C complained that the delay to take Mrs A's complaint seriously and call a doctor, contributed to her death. We took independent medical advice from a consultant cardiologist (a doctor who specialises in the heart and blood vessels). We found that Mrs A was regularly assessed by both nursing and medical staff, and with the exception of the lack of ECGs on a particular date, appropriate actions were taken when she reported pain. The triple vessel bypass operation was initially successful, however, due to an uncommon complication which could not have been predicted, she died. We did not uphold this aspect of the complaint. Mr C also complained that there were discrepancies between what he was told verbally by staff on the day after the operation and the written response to his complaint. We found that the board's response was an accurate account of events as documented in the medical records. However, while the board provided a reasonable explanation of the treatment provided to Mrs A, they did not reasonably reflect that there were two instances where ECGs were not carried out, which was out with normal process. On balance, we upheld this aspect of the complaint.

Mr C complained about the treatment his mother (Mrs A) received at the practice. Mrs A suffered from chest pain and breathlessness and had concerns she had angina (a heart condition). Mr C complained that appropriate treatment and investigations were not carried out in a reasonable time-frame. We took independent medical advice from a GP. We found that the practice unreasonably failed to carry out appropriate physical assessments during appointments. While the practice did not consider angina was a likely cause for Mrs A's health concerns, at the point where it was agreed to refer her, the practice used the incorrect referral pathway. They arranged for an electrocardiograph (ECG - test that records the electrical activity of the heart) followed by a routine referral to cardiology (the branch of medicine that deals with diseases and abnormalities of the heart), instead of the appropriate action of an urgent exercise tolerance test (or if the patient was not physically capable of doing this test then an urgent cardiology referral). We upheld this complaint.

Mr C complained about the care and treatment that his child (Child A) received for jaundice (a yellowish or greenish pigmentation of the skin and whites of the eyes due to high bilirubin levels. Bilirubin is the reddish yellow pigment made during the normal breakdown of red blood cells) in the days following their birth. In particular, Mr C was concerned that Child A did not receive a blood transfusion and received UV phototherapy instead. We took independent advice from a midwife and a consultant neonatologist (a doctor who specialises in the medical care of newborn infants, especially ill or premature newborns). We found that the care and treatment provided to Child A was reasonable and in accordance with relevant guidelines. We also found that, as Child A's bilirubin level responded well to the phototherapy treatment, it was reasonable that they did not receive a blood transfusion. We did not uphold this aspect of Mr C's complaint. Mr C also complained about the way in which the board handled his complaint. We found that the board failed to provide a revised timescale for when Mr C could expect to receive a response to his complaint. We upheld this aspect of Mr C's complaint.

Mr C complained on behalf of his mother (Mrs A) about the care and treatment Mrs A received at the practice. Mrs A attended the practice complaining of flu-like symptoms and was prescribed a particular antibiotic. That evening she became nauseous and started vomiting. Mrs A's condition deteriorated and she was admitted to hospital three days later with dehydration and acute kidney injury. Mr C was concerned that the practice had prescribed a certain type of antibiotic to Mrs A despite her medical history and about the effect this had on her. We took independent advice from a GP adviser. We found that Mrs A should not have been prescribed the particular antibiotic and that it was almost certain that this aggravated Mrs A's dehydration and acute kidney injury. Mrs A should also have been advised to stop taking other medication until the diarrhoea and vomiting had resolved. We upheld the complaint.

Mr C complained about the treatment his late wife (Mrs A) received at A&E of Aberdeen Royal Infirmary. Mrs A had collapsed at home, and had suffered a fatal heart attack. Despite attempts at cardiopulmonary resuscitation (CPR), Mrs A died. The board maintained that appropriate tests and investigations were carried out when Mrs A suddenly deteriorated and that the cardiac arrest could not have been predicted. We took independent advice from an emergency department consultant. We found that the staff involved had carried out appropriate assessments and investigations into a possible cause for Mrs A's collapse at home and that she was being monitored appropriately. While the results of investigations were being waited on, Mrs A suddenly deteriorated and staff were unable to save her life. We did not uphold the complaint. Related reading View Decision Report 201810411 as a PDF (23.73 KB) Updated: August 21, 2019

Ms C complained about the care and treatment her late sister (Ms A) received in Dr Gray's Hospital before her death. Ms A attended the emergency department in the hospital after striking her head. She had suffered a laceration (cut in the skin), which was glued shut, and she was then discharged. On the following day, she was admitted to the hospital with a high heart rate and shortness of breath. It was subsequently noted that Ms A was suffering from acute chronic kidney injury and chronic atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). She became unresponsive and was taken for a CT scan to check if her head injury was contributing to her loss of consciousness. Ms A died in the radiology department. We took independent advice from an emergency medicine adviser and a consultant in acute medicine. We found that the standard of documentation for Ms A's presentation to the emergency department was poor. It was also unreasonable that she was not scanned in the emergency department before she was discharged, given her reduced level of consciousness and confusion; her headache; and the fact that she was on anticoagulant medication (medication to prevent blood clots). Further tests should have been carried out and her discharge from the emergency department was contrary to guidance. In addition, the advice given to her when she was discharged from the emergency department would have been challenging for Ms A to understand and retain. It was also surprising that, when she was admitted to hospital, Ms A was given increasing doses of beta-blockers given that she had an allergy to. Therefore, we upheld this aspect of the complaint. The board said that they have taken action to address these failings and we have asked them to provide evidence of this. Ms C also complained that the board had failed to provide an accurate account of Ms A's death. We found that the board's response on this matter had been accurate

Mrs C complained about the care and treatment provided to her daughter (Miss A) when she was admitted to Aberdeen Royal Infirmary for abdominal pain, vomiting, and a high temperature. Mrs C felt that there was a delay in diagnosing Miss A with pelvic inflammatory disease (infection of the organs of the reproductive system). We took independent advice from a general surgeon, a radiologist, and a gynaecologist (a doctor who specialises in the treatment of women's diseases, especially those of the reproductive organs). We found that the care and treatment provided to Miss A was reasonable and that it would not have been possible to diagnose her with pelvic inflammatory disease any earlier. We did not uphold this complaint. Related reading View Decision Report 201708489 as a PDF (23.67 KB) Updated: July 24, 2019

Mrs C complained about a number of issues with the care and treatment she received from the board. Mrs C had a complex medical history and had accessed a number of different services provided by the board. Firstly, Mrs C raised concern that the board had not provided her with timely and appropriate maxillofacial (relating to the jaws and face) care and treatment. Mrs C was referred to the maxillofacial service for extraction of a tooth. After an initial consultation, Mrs C was listed to have the tooth extracted. At the subsequent consultation, a different doctor found that the tooth was vital and could be restored with further treatment. Mrs C was discharged from the service. Mrs C's general dental practitioner made a further referral to the service and after further consultations Mrs C's tooth was extracted. She felt that the board's actions had prolonged her pain. We took independent advice from a speciality doctor in oral and maxillofacial surgery. We considered that the care provided to Mrs C was reasonable. We did not uphold this complaint. However, we found evidence of issues with record-keeping in the service and we made a recommendation in relation to this. Mrs C also raised concern that the board had not provided her with timely and appropriate orthopaedic (the branch of medicine involving the musculoskeletal system) care and treatment. Mrs C had a number of consultations in the orthopaedic service and was unhappy with the way clinicians investigated her orthopaedic condition and managed her care. In response to Mrs C's complaint, the board acknowledged that she had experienced delays and they described that they were reviewing the referral process to reduce delays. We took independent advice from a consultant orthopaedic surgeon. We found no medical failings in Mrs C's orthopaedic care, however, we noted that there was evidence of a significant delay in Mrs C being offered an appointment following a referral from her GP. We upheld this aspe