SPSO Individual Decisions

C complained on behalf of their spouse (A) about the care and treatment that they received from the board. A initially presented with a locally advanced cancer which at the time of presentation had already spread to their lymph nodes. A underwent treatment, however, went on to develop progressive disease in their lymph nodes and also evidence of spread to the bone. While further treatment was given, A's general condition deteriorated and after a number of admissions to hospital, A died of a progressive cancer. C raised concerns that the board had failed to provide reasonable, timely and appropriate medical care and treatment to A during their admission to the treatment centre. We took independent advice from an oncologist adviser (cancer specialist). We found that the treatment A had received conformed to current guidelines from the European Urology Association and Medical Oncology Associations, and overall, we found that the management of A’s care was reasonable and that there were no significant failings in relation to the care and treatment given to A. However, we found that, while there was little, if no, evidence that earlier CT scans would have influenced the final outcome, given the circumstances of A's case, the CT scans carried out could have been done sooner. With regard to C's concerns about the way that A's prognosis was communicated to them, while we found that overall the communication had been reasonable, we acknowledged that the method of communicating A's diagnosis to them had not met their needs and we provided feedback to the board about this. While we found that the majority of the care and treatment given to A was reasonable, given that the CT scans could have been done sooner, on balance, we upheld this complaint. C also raised concern about the medical care and treatment given to A during their admission to hosptial. In particular, that there had been clinical failures to pay attention to which medications had previously failed, which led to t

C complained about the care and treatment a close family member (A) had received from the practice. A was admitted to hospital having suffered a heart attack and stroke. On further investigation masses were found on both of A’s ovaries, later confirmed to be ovarian cancer. A died a short time later. C complained to the practice that they had not given proper consideration to A’s presenting symptoms and had missed opportunities to identify A’s cancer and start treatment sooner. C also complained that the practice had not given appropriate consideration to the family’s history of breast cancer or undertaken CA125 testing (blood test to check for raised levels of a protein called CA125, which is linked to ovarian cancer). The practice apologised for being unable to detect A’s cancer at an earlier stage, noting ovarian cancer often only presents at a very advanced stage which had been the case for A. They explained a CA125 test had not been checked as the clinical information available at that time had not suggested malignancy. They also noted that a family history of breast cancer would not directly predispose to a risk of ovarian cancer in the absence of evidence of BRCA gene (specific mutations to this gene increase lifetime risk of cancer) positivity. They did not identify any substantive failings in A’s care and treatment, but agreed to use A’s case for reflective learning. To investigate the handling of this complaint, we sought independent advice from a GP. We found that CA125 testing is not an effective screening tool for ovarian cancer. While A’s initial presentation at the practice had met the National Institute for Health and Care Excellence (NICE) criteria for considering checking CA125 levels, A had undergone further gynaecological review a few months later, which had suggested no evidence of an abdominal pelvic mass. Overall, we considered that the practice had not acted unreasonably in not identifying A’s malignant diagnosis prior to their pres

C complained that the board provided their late parent (A) with inadequate care and treatment when they were an in-patient in hospital. C complained to the board that they had failed to provide A with adequate personal care, nutrition and hydration. C also complained that the board had failed to accommodate A’s disabilities. The board identified failures in A’s care and apologised for these. C remained unhappy and brought their complaint to us. We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that more consideration should have been given to A’s minimal fluid intake, and the impact of this in terms of delirium and escalation to medical staff. In addition, we found that it appeared that more could have been done to support A in relation to their toilet needs. Therefore, we upheld the complaint. Additionally, we found that the board did not provide C with sufficient explanations related to the learning and improvement taken from A’s experience. We also found that the board had delayed in providing C with copies of minutes from a meeting and that no appropriate apology had been made for this. We made recommendations in light of these failings.

C complained about the care and treatment their spouse (A) received over a number of years by the board. C submitted a complaint to the board expressing A’s concern that they did not take reasonable care when carrying out two surgeries. C and A were dissatisfied with the board’s investigation and response to their complaint. A underwent surgery in their abdomen in an attempt to resolve recurring infections and said they suffered significant pain afterwards. We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We were satisfied that this surgery did not cause the pain that A had linked to the procedure. However, we were critical of the board for failing to recognise that scans taken prior to the surgery had shown evidence of staples in A’s abdomen from previous surgeries. We found that the staples were a likely source of A’s infections and that this should have been identified prior to the surgery taking place. Had it been identified, A’s management plan may have been different. Therefore, we upheld this aspect of C’s complaint. A also underwent a procedure on their reproductive organs. C complained that the procedure that was carried out, as described in the record of the operation, was not the one to which A had consented. We found that it had not been possible to complete the planned procedure due to an issue in the affected area, which had not been apparent until the procedure began. Whilst we were critical of the way that the procedure was described in the records, we found that the procedure itself was reasonable and appropriate in the circumstances. Therefore, we did not uphold this aspect of C’s complaint. C and A complained that despite the board’s complaints procedure stating that complaints could be submitted in writing, in person, or over the telephone, the board insisted that A’s complaint was submitted in writing. A explained that they found it difficult to p

C complained on behalf of their spouse (A) regarding the care and treatment A received from the board. A has serious health issues and has had multiple surgeries over a number of years. Following a scan of A’s abdomen, it was identified that they had staples attached to their bladder. A considered that these had been left behind following surgery to remove their J-pouch (a pouch made from part of the small intestine and attached to the anal canal to form a pathway for the passage of stool). C complained that A experienced recurring infections and other complications as a result of the staples being left in their abdomen. A said that these had a detrimental impact on their long-term health. We took independent advice from a general and colorectal surgeon (specialist in conditions in the colon, rectum or anus). While it was not possible to establish exactly which operation the staples came from, we considered that the staples were a likely source of A's infections. We found that the staples were clearly visible on previous scans but that these had not been reported on by radiology and therefore the clinical team did not consider these when they were assessing A’s likely source of infection and future treatment. Therefore, we upheld this aspect of C's complaint. C also complained about the handling of their complaint. Whilst we found that there were some delays to the board’s investigation, we recognised that many years had passed between the events complained about and the complaint being submitted to the board. This meant that some issues were reasonably time-barred and some parts of the investigation were delayed due to difficulties sourcing the records and staff comments. Overall, we were satisfied that communication was generally reasonable with C and A, and that the board’s complaints procedure was followed appropriately. Therefore, we did not uphold this aspect of C’s complaint.

C complained to us about the medical and nursing care their late parent (A) received. A attended hospital for a bronchoscopy (a procedure to look directly at the airways in the lungs using a thin, lighted tube) and a biopsy (a medical test to determine the presence or extent of disease). A became unwell and was admitted. The biopsy result confirmed that A had cancer. It was considered A was not fit for treatment and a palliative approach to care was recommended. A’s condition worsened and they died in hospital. C complained about aspects of A’s care and treatment. C also complained about the communication from medical staff. The board did not uphold C’s complaint but apologised because they felt that communication had been poor. C remained unhappy and escalated the complaint to us. We took independent advice from a specialist in general medicine and in acute nursing. We found that A’s care and treatment was reasonable. We also found that the communication with C and A was reasonable. Therefore, we did not uphold C’s complaints. However, we did provide the board with feedback on telephone updates to patient’s families. Related reading View Decision Report 202003950 as a PDF (24.39 KB) Updated: January 18, 2023

C was referred by their local health board ophthalmology (the branch of medicine that deals with the anatomy, physiology and diseases of the eye) department to the general hospital for specialist eye surgery. C underwent a vitrectomy procedure (the surgical operation of removing the vitreous humour from the eyeball) which they felt was not managed appropriately as their retina was still detached following the procedure and they had to undergo further surgery from an independent health provider. The board felt that they had provided an appropriate standard of care and treatment to C. We took independent clinical advice from an ophthalmology adviser. We found that there were no concerns about the standard of treatment which was provided to C. C had suffered a serious eye injury and although the retina was not fully reattached during surgery, this was a recognised complication of the surgery, and that further surgery would be required at some point. We did not uphold the complaint. Related reading View Decision Report 202100828 as a PDF (24.3 KB) Updated: December 21, 2022

C complained about the care and treatment provided by the board to their parent (A), who was admitted to hospital with a suspected liver problem. Ascites (a build-up of fluid in the abdomen) was diagnosed and paracentesis (a drain of the fluid) was performed, during which it was noted that A had accidentally bumped the drain. The following day A reported being in pain and, after a CT scan, it was determined that A was suffering from an un-operable arterial bleed. Shortly thereafter A died. C complained that A’s consent was not properly obtained, that staff had failed to carry out the drain procedures reasonably, that A’s pain was not managed appropriately, that a CT scan was delayed, that communication from the board had been poor and inconsistent and that the level of review undertaken after the incident was not sufficient. We took advice from an independent medical adviser in gastroenterology (medicine of the digestive system and its disorders). We found that the timescale for the CT scan was reasonable, that pain medication was appropriate, that the case had ultimately been appropriately reviewed and that the drain procedure appeared to have been carried out by appropriately trained staff under adequate supervision. However, we found a number of failings. Firstly, the board had obtained verbal consent but failed to adequately record this. Secondly, the board’s complaints response had unreasonably focused on A having bumped the drain as being the cause of the arterial bleed. This was something that could not have been known with any certainty. Additionally, this explanation was not consistent with the post-mortem examination and internal case review, both of which found that the more likely cause of the bleed was as a recognised complication of the drain insertion. Therefore, we upheld these aspects of the complaint.

C complained that the practice failed to provide their late spouse (A) with appropriate care and treatment. C said that GPs at the practice failed to see their partner at face to face consultations where they could observe their reported symptoms of facial weakness. Phone calls were made on a Friday and Monday but A was still not seen despite contacting the Out Of Hours Service (OOHS) at the weekend. A died a few days later of a stroke. C felt that the practice should have seen A face to face rather than via telephone consultations. The practice believed that the GPs involved had provided A with appropriate care and treatment based on their reported symptoms at the time. We took independent advice from an appropriately qualified adviser. We found that the practice had provided a reasonable level of care based on A’s reported symptoms. Therefore, we did not uphold the complaint but provided the practice with feedback concerning the standard of record keeping. Related reading View Decision Report 202103864 as a PDF (24.19 KB) Updated: November 23, 2022

C’s parent (A) lived in a nursing home and had been shielding during the COVD-19 pandemic. A was later admitted to hospital and was placed in a green pathway (a ward for COVID-negative patients) ward in preparation for emergency surgery. Following surgery and a few days in the High Dependency Unit, A was transferred to another ward which C was advised was a red pathway ward (a ward for COVID-positive patients). A was discharged over a week later. C complained to the board about A’s transfer to a red pathway ward and had not been satisfied with the explanation the board provided. C also complained about the standard of nursing care, the decision to discharge A, and that the board failed to arrange follow-up care for A following their discharge. We took independent advice from a nurse and a consultant geriatrician (specialist in medicine of the elderly). We found that, while the decision to transfer A to a red pathway ward had been reasonable and appropriate in the specific circumstances, the board had not reasonably explained the decision to C. Therefore, we upheld this part of C’s complaint. We also found that the standard of nursing care and decision to discharge A was reasonable. The board also made the relevant referrals to the appropriate community services after A’s discharge. Therefore, we did not uphold these aspects of C’s complaint.

C complained that the board did not repeat a test for Helicobacter pylori (H. Pylori, bacteria usually found in the stomach) given their symptoms, abnormalities in their blood tests and low ferritin (a blood protein containing iron) levels. C was of the view that had their symptoms been properly investigated, they would have been found to have H. pylori and would have been treated earlier. We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines). We found that C did not have Helicobacter associated symptoms which would have triggered re-testing (such as indigestion symptoms). As there was no clinical indication to repeat a test for H. pylori, we did not uphold C’s complaint. Related reading View Decision Report 202101569 as a PDF (24.12 KB) Updated: October 19, 2022

C complained about various aspects of the treatment provided by the board to their late parent (A) who was initially admitted to Glasgow Royal Infirmary with a fractured hip following a fall. A was subsequently discharged after surgery and received care at home from district nurses. However, A developed an infection at the site of their surgical wound and was readmitted to hospital, where they underwent several further surgeries to control the infection. A went on to develop further infections and subsequently died. C complained that there had been a delay in carrying out surgical repair of the hip, that A had been discharged without appropriate physiotherapy follow-up, that an out-of-hours GP had failed to readmit A to hospital sooner and that nursing staff were unaware of a surgical procedure A had undergone. C also complained that there had been a delay in referring A to psychiatry, that A developed further infections, that A’s skin had not been correctly looked after, that there had been poor communication about the decision to withdraw care and that there had been errors on A’s death certificate. We took independent advice from specialists in orthopaedic surgery, general practice community nursing and hospital nursing. We found that reasonable care had been given in relation to the choice of surgical procedures A underwent. We also found that reasonable care had been given to the management of A's infections whilst in hospital, the level of community nursing care, the management of A’s skin, PICC line (a thin flexible tube inserted through a vein to give medicine directly into the bloodstream), referral to psychiatry and end of life care. However, we found that there had been unreasonable care provided in relation to a delay in carrying out A’s initial surgery. We also found failures by an out-of-hours GP to record sufficient detail about A’s condition and ensure A was provided with prompt antibiotic treatment, requiring A to complete two consent forms for the

C complained regarding the treatment that they had received from the board in relation to a pharyngeal pouch (a pocket in the lining of the pipe that carries food from the mouth to the stomach). They complained about issues regarding the surgery they had in relation to this and about the information they were given. We took independent advice from an ear, nose and throat (ENT) surgeon. We found that C was given reasonable information in advance of their surgery and that it was reasonable to examine a pharyngeal pouch through surgery. It was appropriate that C's pharyngeal pouch was emptied of partially digested food as otherwise it would not have been possible to examine it. It was also reasonable that C was offered a cricopharyngeal myotomy (where a surgical cut is made in the muscle that allows swallowing to weaken it) to treat their pharyngeal pouch, as it is one of the treatment options set out in the relevant clinical guidance. Although an external myotomy was recommended, C was given the option to explore alternative approaches, but the clinicians felt the pouch was too small for stapling. In addition, it was reasonable that C's outpatient appointment with the ENT surgeon was cancelled, given they were unhappy to proceed with the proposed treatment option. Therefore, we did not uphold the complaint. Related reading View Decision Report 202002811 as a PDF (24.37 KB) Updated: October 19, 2022

C complained about treatment they received in relation to an alleged failure to promptly identify and treat developing symptoms of cauda equina syndrome (CES, compression of the nerve roots in the lower back affecting various neurological functions). C was initially admitted to hospital within another health board area before being discharged the following day on the basis that there was no evidence of CES at that time. However, C re-presented to the emergency department at the same hospital four days later with new symptoms thought to be CES. On the basis of advice provided by NHS Greater Glasgow and Clyde’s neurosurgical department at the Queen Elizabeth University Hospital (QEUH) to clinicians at the health board, C was fasted and underwent an MRI scan the following morning, which showed a large disc protrusion compressing the cauda equina nerve roots. C was thereafter taken by emergency ambulance to the QEUH where they underwent surgery the same day. In order to investigate the neurosurgical advice provided by NHS Greater Glasgow and Clyde to the other health board, we took independent advice from a consultant neurosurgeon. We found that the advice provided had been reasonable given that it was well accepted practice that surgery to decompress the cauda equina nerve roots should be performed within 24-48 hours of a patient presenting to hospital, which had occurred in this case. Therefore, we did not uphold C's complaint. Related reading View Decision Report 202110356 as a PDF (24.46 KB) Updated: October 19, 2022

C, an MSP, complained on behalf of their constituent (A). A had suffered severe pain in the years following a porcine mesh implant (a surgical device, consisting of mesh made of animal tissue, such as intestine or skin, that has been processed and disinfected to be suitable for use implanted into a patient to strengthen a surgical repair) to rebuild their abdominal wall. For a number of years, a pursued treatment for the pain with the board and the possibility of the removal of the porcine mesh. The board's gynaecology department (specialists in the female reproductive system) ultimately advised that they were unaware of any relationship between porcine mesh implants and chronic pain. A was referred to plastic surgery but this was declined on the basis that the plastic surgery department had no additional treatments to offer A. C asked the board for an independent review of A's case and an assessment for surgery to remove the porcine mesh. The board told C that the gynaecology and plastic surgery departments would review A's case in collaboration. A was ultimately only offered an appointment with gynaecology. Following further consideration, but without a joint appointment for A with the two departments, the board concluded that A was being offered appropriate treatment options and that removal of the porcine mesh would not relieve A's pain. The board advised A to seek a joint gynaecology and plastic surgery referral via their GP. We took independent advice from a consultant plastic surgeon. While we found that the assessment of A's pain by the board had been reasonable, we concluded that this had not been reasonably explained to A in a single, clear and comprehensive communication that addressed all of the concerns and queries A raised regarding the nature of the mesh used, why this was distinct from the mesh referred to in media reports, why this was unlikely to be contributing significantly to A's pain and why there was no surgical procedure available to

C underwent a hysterectomy (surgery to remove the womb) and although the procedure was considered successful, C began to bleed from scar tissue soon after the operation. An ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) showed blood clots in C's pelvis and C was kept in hospital in case further surgery was required. C was given blood thickeners and a blood transfusion. C developed a chest infection and suffered from further complications. C raised complaints about their care and treatment following their initial surgery with Greater Glasgow and Clyde NHS Board. C raised a number of specific concerns about their post-operative complications and their management. C was also concerned about the surgery, or that the post-operative complications had caused the nodule on their lung, which was subsequently identified as lung cancer. We took independent advice from a gynaecology (medicine of the female genital tract and its disorders) adviser. We found that C's care and treatment was reasonable and that C had experienced significant post-operative complications, but that these were appropriately managed. We noted that there was no evidence that C received inadequate consultant input post-surgery, or that C's complications were as a result of the surgery being performed poorly or inappropriately. We found that the board were correct to say that there was no relation between C's surgery and the subsequent health issues that they faced. We also found no fault with the level of physiotherapy support offered to C. We concluded that C's medical records showed that they were regularly reviewed by a physiotherapist and that the exercises that were provided to C were also reasonable and appropriate. As such, we did not uphold C's complaint. Related reading View Decision Report 202006396 as a PDF (24.67 KB) Updated: August 24, 2022

C, who suffered with hip problems, was diagnosed with a labrum tear (a condition which occurs due to damage of the soft cartilage that rims the socket portion of the hip joint) and underwent surgery. C's symptoms failed to resolve following surgery and they were informed during a follow-up consultation that a metal artefact was visible on x-rays of their hip. C complained to the board about the advice to proceed with surgery and the treatment that they received. C also complained about their concerns regarding their assessment and suitability for surgery to address their symptoms, and that the surgery had been carried out unreasonably. We took independent advice from an orthopaedic (conditions involving the musculoskeletal system) adviser. With respect to C's complaint about diagnosis and treatment which resulted in the hip surgery being undertaken, we found that C underwent appropriate assessment. We found that the surgery, including relevant complications, was discussed and C had consented to the procedure. On this basis we did not uphold this aspect of the complaint. With respect to the complaint that the board failed to provide appropriate care and treatment during, and following, the hip surgery, we found that whilst the surgery was performed to a reasonable standard, and subsequent problems investigated reasonably by clinicians, the board failed to comply with the duty of candour when they failed to inform C after the operation about the failure of a metal anchor used in the hip repair. We also identified that the board, in their complaints investigation and response to C, failed to adequately address the issue of the metal artefact in their hip following the operation. We therefore upheld this aspect of the complaint.

C complained about the care and treatment that they received from Greater Glasgow and Clyde NHS Board. C was referred to the Early Pregnancy Unit (EPAS) by a private clinic on two occasions. C complained that EPAS took too long to declare the pregnancy non-continuing, that C was required to attend an unnecessary number of scans and that their care was not escalated to a doctor. C also complained that the advice and care that they received by phone, and the fact that they were contacted and invited to a reassurance scan, was unreasonable. C further complained that EPAS asked them for distressing information rather than gathering this from the private clinic and that EPAS did not gather consent from C for surgical management as they ought to have done. C also complained that the care and treatment that they received as an inpatient was unreasonable. The board noted that they apologised for the delay in the time C waited to be seen, that during their admission C fainted and was lowered to the floor by a nurse who then called a doctor, that all options were not discussed and that on reflection there was a missed opportunity to obtain a second opinion. The board also noted, however, that this would not have changed C's management plan. We took independent advice from a consultant obstetrician (the medical specialism for pregnancy, child birth etc) and gynaecologist (medicine of the female genital tract and its disorders). We found that a second opinion should have been sought, which may have allowed miscarriage to be diagnosed earlier. We also found that C should not have had to relay findings or be subjected to repeated examination when diagnosis had already been made by the private clinic and that the necessary documentation ought to have been obtained from the private clinic. We further found that during C's fainting episode, appropriate observations and actions were taken and the faint was well managed. In light of the above, we found that whilst it was reas

C attended Queen Elizabeth University Hospital (QEUH) on a number of occasions prior to being diagnosed with cauda equina syndrome (CES, a narrowing of the spinal column where all of the nerves in the lower back suddenly become severely compressed). C required two emergency surgical procedures and has been significantly impacted by the condition. C complained that there were missed opportunities to diagnose CES, and about the clinical assessments carried out at QEUH. C's complaint concerned assessments in A&E and in gynaecology (specialists in the female reproductive system). We took independent advice from a consultant in emergency medicine and a consultant gynaecologist. We found that C was assessed appropriately during each admission to A&E. We found that C was displaying no red flag symptoms and that appropriate follow-ups were arranged. We also found that C was not exhibiting symptoms which would indicate CES, nor was C displaying symptoms which would have triggered immediate imaging. We were satisfied that C was assessed appropriately and that it was reasonable to arrange follow-up gynaecology assessment later that day. We did not uphold these aspects of the complaint. We also found that C was appropriately assessed when they attended the emergency gynaecology appointment. There was no clinical evidence to suggest C needed emergent care. The doctor noted no symptoms of CES and consulted with the consultant on call before discharging C with appropriate advice. We found this was reasonable. We did not uphold this aspect of C's complaint. Related reading View Decision Report 202007151 as a PDF (24.53 KB) Updated: July 20, 2022

C complained about their waiting time for hip replacement surgery. C was initially added onto the waiting list for surgery but was later removed after C advised the board of their personal circumstances. A couple of months later, C was added back onto the waiting list for surgery but, after a long wait, C had the hip replacement carried out privately later in the year. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that C was correctly removed from the waiting list because their personal circumstances meant that they would be unable to undergo hip replacement surgery. However, this decision was not explained to C at the time. We also found that C was unreasonably added back on to the waiting list, when they remained unfit for surgery. We also concluded that there was no out-patient clinic letter to match the date that C was added back onto the waiting list. For these reasons, we upheld C's complaint.

C complained about the care and treatment provided to their parent (A) when they were a patient at Glasgow Royal Infirmary. C raised concerns that they had to alert staff to the fact that A had become unresponsive. C complained that A was stepped down from critical care to a medicine for the elderly ward when A was still unwell and suffering from delirium. C also complained about changes made to A's death certificate, which had been amended by a consultant, following the initial certificate prepared by a junior doctor. The death certificate was updated to fully reflect A's underlying condition, including the possibility of an underlying cancer diagnosis. However, it was subsequently amended again to remove the reference to cancer in light of C's upset over this. We obtained independent medical advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that A's condition was monitored appropriately and reasonable action was taken in a timely manner when it was noted they had deteriorated. We were satisfied that the board had already acknowledged and apologised for not keeping C updated while they dealt with A's care. Therefore, we did not uphold this complaint. In relation to the second complaint, we considered action was appropriate as A was no longer in need of critical care, and confirmed delirium would not have been a reason to delay the transfer. We, therefore, did not uphold this complaint. With regard to the complaint about changes to A's death certificate, we were satisfied that the board had provided an appropriate explanation and apology, and had demonstrated learning. We had no concerns about the accuracy of the death certificate. However, we noted that it would have been good practice to offer a post-mortem examination in light of the clinical uncertainty, and C's concerns, surrounding a possible underlying cancer. While we fed this back to the board, on balance, we did not uphold this complaint. Related reading

C complained about the treatment they received at the Queen Elizabeth University Hospital. C said that they had been admitted with problems concerning a foot ulcer and that on both occasions they were discharged home after one night in hospital. C felt that they should have been admitted for a longer period to ensure that their condition improved and that they were able to take any medication which was required. The board felt that C was fit for discharge on both occasions and that there was no clinical requirement that C should remain in hospital and it was appropriate to discharge C home with support from the district nurses. We took independent advice from an adviser and found that staff at the hospital had carried out appropriate investigations and that it was appropriate to discharge C home with support from the district nurses to change the foot dressings. We did not uphold the complaint. Related reading View Decision Report 202009167 as a PDF (24.13 KB) Updated: July 20, 2022

C complained to the practice about a failure of their GP to offer them a face to face consultation when they reported being concerned about a breast lump. C was given a telephone consultation only. C was not seen for a further three months and when they attended the breast clinic, C was diagnosed with breast cancer. We took independent advice from a GP. We found that the GP had acted reasonably in that the plan was to review C two weeks following the telephone consultation should the symptoms not have resolved. C did not contact the practice for a number of months and when they did, appropriate referrals were made to specialists for further consideration. We did not uphold the complaint. Related reading View Decision Report 202100230 as a PDF (24.05 KB) Updated: June 22, 2022

C complained about the board after suffering wound care complications following a caesarean section (an operation to deliver a baby. It involves cutting the front of the abdomen and womb) during the birth of their child. They considered that a number of factors meant that the board had failed to provide reasonable treatment in relation to the birth of their child. We took independent advice from a consultant obstetrician (specialist of pregnancy, childbirth etc) and gynaecologist (specialist of the female genital tract and its disorders). We found that the board had failed to provide reasonable treatment. In particular, we found that the board failed to follow up on a phone call to ensure C's safety when a full triage could not be completed; that they had failed to ensure a timely review by a senior doctor when complications occurred; that they failed to keep reasonable records of C's care; that they failed to identify that a Significant Adverse Event Review (SAER) should have been carried out, meaning that the staff in question were unable to clearly recollect events by the time the complaints investigation was completed and additionally, that the board made insufficient attempts to establish a cause for the complication, which may possibly have been operator error or the result of faulty sutures, either of which would have required further action to ensure wider patient safety and avoid a repeat. For these reasons, we upheld C's complaint.

C complained about the care and treatment that they received following their hip replacement surgery. Immediately following the surgery, C began experiencing severe and continual pain. The cause of C's pain was eventually confirmed to be loose cement from the surgery causing irritation. C complained that, although the surgeon who had carried out their hip replacement was aware of the loose cement, this was not conveyed to C. Instead, C had consultations with a total of five consultants before the source of their pain was identified two and a half years after their surgery and remedial treatment successfully provided. C raised a number of concerns regarding the attitude shown towards their symptoms by the board's consultants and the delays to diagnosing and resolving their pain. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that C's surgery was carried out reasonably and that there was no immediate indication of the complications that they would subsequently experience. We noted that it is not uncommon for patients to experience pain for up to 12 months following a hip replacement. We were generally satisfied that the board's staff took C's pain seriously and carried out reasonable investigations to establish its cause. We also noted that leaked cement is not uncommon and would not initially be viewed as a likely source of a patient's pain. We considered that the complications C experienced were extremely rare and required specialist intervention. We found that it was not until an x-ray taken a year after surgery that it became apparent that a large amount of cement had leaked from the surgical site and a later MRI scan identified that C had a degree of psoas tendinopathy (an inflammation of the tendon or area surrounding the tendon). Whilst we were satisfied that the clinical team followed a reasonable path to establishing and treating the cau