SPSO Individual Decisions

Mrs C, an advice and support worker, complained to the board on behalf of her client (Mr A) about treatment which Mr A received at Raigmore Hospital. Mr A was diagnosed with bowel cancer following a positive bowel screen and endoscopy. Mr A underwent surgery to remove the tumour. Initially, keyhole surgery was planned but during the procedure the surgeon was unable to locate the tumour and the operation was changed to full surgery. Mr A developed an infection in his abdomen following the surgery and had to be taken back to theatre. Mr A remained in hospital for a number of weeks and was subsequently discharged home with a stoma and wound bag. Mr A wished to know what went wrong with his care and treatment. We took independent advice from a consultant surgeon. We found that there were no concerns about the standard of treatment which Mr A received. Initially, it was appropriate to consider keyhole surgery based on the scan results but when the surgery commenced it was noticed that the tumour was in a different position. It was then appropriate to proceed to open surgery, which was completed appropriately with no issues. However, Mr A subsequently developed an infection, which is recognised complication of surgery rather than an indication that the surgery was not performed appropriately. We did not uphold the complaint. Related reading View Decision Report 201909588 as a PDF (24.37 KB) Updated: August 19, 2020

Mr C complained that the practice failed to provide his late wife (Mrs A) with reasonable care and treatment. Mrs A had presented to the practice several times with severe back pain over a ten month period. Mrs A was told to self refer for physiotherapy. Mrs A subsequently went to A&E due to the pain she was suffering in her back. Mrs A was diagnosed with renal cancer which had spread to her spinal column and brain. Mrs A died from her illness. We took independent advice from a GP and a nurse. We found that although the practice doctors had been involved in prescribing painkillers and muscle relaxants to Mrs A, her back pain management and treatment plan was effectively being managed by the physiotherapy service who are independent practitioners. It was reasonable for a GP to expect that if a physiotherapist was concerned about deteriorating or urgent clinical signs in a patient that they would arrange appropriate hospital assessment or a scan. Mrs A had at no stage when she saw the practice doctors presented with red flag signs (indicators that a more serious problem may be developing/underlying) to suggest cancer. As such, the care provided by the practice doctors was reasonable. We found that with regard to Mrs A’s consultations with the advanced nurse practitioner, she had presented with potential red flag signs including unexplained weight loss. While Mrs A’s presenting symptoms were very atypical of renal cancer, it had not appeared that cancer had been considered given Mrs A had shown potential red flag symptoms and signs. We found that these red flag symptoms and signs had not been acted upon. Therefore, we upheld the complaint. We acknowledged that the practice in their complaint response to Mrs A and to this office accepted there were failings by the practice. They said they had learnt from Mrs A's case and we acknowledged the action the practice had taken to address this.

After injuring her finger, Mrs C was referred to the orthopaedic department. Her injury was reviewed on a number of occasions before being diagnosed as dislocated. A procedure was carried out to put the joint back into place. The pain in Mrs C’s finger did not improve, despite cast treatment and physiotherapy, so she was referred back to the orthopaedic department. After a further review, it became apparent that Mrs C had developed a complex regional pain syndrome (CRPS) in her right hand. Mrs C complained to the board that there was an unreasonable delay in identifying that her finger was dislocated. She considered that the procedure to correct the dislocation should have happened sooner and, if it had, she would not have developed CRPS. She remained unhappy with the board’s response so brought her complaint to us. We took independent advice from an orthopaedic consultant (a doctor specialising in the treatment of diseases and injuries of the musculoskeletal system). We found that there were a number of opportunities in Mrs C’s case for her dislocated finger to be identified earlier. We concluded that there was an unreasonable delay in reporting of the x-rays taken of her hand. We upheld Mrs C's complaint.

C underwent a left total hip replacement for progressive osteoarthritis (chronic breakdown of cartilage in the joints leading to pain, stiffness and swelling). Following the surgery, it was identified C suffered nerve damage which resulted in a foot drop/sciatic nerve palsy (loss of movement and or lack of sensation) and a limp. C complained that the board failed to provide the appropriate aftercare to address these issues. The board confirmed they provided the appropriate aftercare in the form of an ankle foot orthosis (a brace) and physiotherapy. The board noted C's initial problems had resolved and there were other factors that contributed to C's ongoing issues. 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 foot drop was managed appropriately by the provision of the orthosis and several physiotherapy sessions. We also concluded that the board's opinion that there were other factors which were the cause of C's ongoing problems was reasonable. We did not uphold the complaint. Related reading View Decision Report 201807026 as a PDF (24.3 KB) Updated: July 22, 2020

Mr C complained about the board's actions regarding his access to overnight accommodation at a facility provided by them, whilst Mr C was attending New Craig Psychiatric Hospital for treatment. Mr C said that the board unreasonably failed to provide him with overnight accommodation when he attended the hospital. He said that when he questioned this, he was initially advised that the accommodation was fully booked, but was subsequently informed that he would not be provided with accommodation as there had also been complaints about his behaviour there on a previous occasion. Mr C also complained that the board failed to investigate the complaints made about his conduct at the accommodation appropriately. We found that the board had failed to make a written record of the complaints made about Mr C during a previous stay at the accommodation; did not notify Mr C about the complaints; failed to give Mr C an opportunity to respond to the complaints; and failed to make a written record of their assessment of the situation and their decision to no longer offer Mr C accommodation. As the board decided to act based on the complaints they received about Mr C, we considered that the board should have carried out some form of investigation. Therefore, we upheld these aspects of Mr C's complaint. Mr C also said that the board failed to respond appropriately to his concerns and complaint about their handling of the complaints. We found that when MSPs first contacted the board on Mr C's behalf, the board failed to classify this as a first stage complaint under the NHS Model Complaints Handing Procedure (MCHP) and that the board failed to look into matters for Mr C and respond to him, as agreed in an email to him. We found that it was unreasonable for the member of staff to investigate Mr C's complaint to the board, when they were the subject (in part) of the complaint. We also found that the board failed to address all of the issues raised in Mr C's complaint to them and f

Mr C complained about the treatment which he had received at A&E of Caithness General Hospital. He had initially contacted NHS 24 and arrangements were made for him to be taken to hospital. Caithness Hospital does not have an ear, nose and throat (ENT) department and Mr C said that he expected to be transferred to another hospital to see the specialists there, but instead he was discharged home. Mr C's GP made a subsequent referral to ENT at Raigmore Hospital. Mr C felt it had inappropriately been downgraded and that he was not provided with appropriate treatment for his reported symptoms. We took independent advice from an A&E consultant and from an ENT consultant. We found that Mr C had been appropriately assessed and treated at A&E on his initial attendance, and when he was subsequently referred to the ENT department, his symptoms were appropriately assessed and reasonable investigations were carried out in an effort to reach a diagnosis. We did not uphold the complaint. Related reading View Decision Report 201903644 as a PDF (24.19 KB) Updated: July 22, 2020

Mrs C complained about the treatment which she received at A&E of Raigmore Hospital following a fall where she bumped her head and suffered hearing problems. The staff believed the hearing loss would be temporary and discharged her home. However, Mrs C's hearing loss continued over a number of months and she attended her GP on a number of occasions. A referral was made to the ear, nose and throat department (ENT) where a hearing aid was fitted. Mrs C believed that she should have been referred to ENT specialists at the time of the A&E attendance. We took independent advice from a consultant in emergency medicine. We found that staff at A&E carried out appropriate investigations at the time of Mrs C's attendance and that it was reasonable to suspect the hearing loss would be temporary. There was no clinical indication for an immediate referral to ENT and advice was given to attend her GP should the symptoms not resolve. We did not uphold the complaint. Related reading View Decision Report 201909131 as a PDF (24.19 KB) Updated: July 22, 2020

Ms C complained on behalf of her child (Child A) that the care and treatment Child A received from the board was unreasonable. Ms C complained that there was an unreasonable delay in diagnosing Child A's hip dysplasia (when the hip socket doesn't fully cover the ball portion of the upper thighbone) and dislocated hip. 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 it was unreasonable that Child A's legs and hips were not examined during a consultation. We considered that had Child A's hips and legs been examined and concerns noted, this should have prompted further investigations to be arranged, such as x-rays, and there was a high likelihood of an x-ray at this time indicating hip dysplasia. Therefore, we upheld this aspect of Ms C's complaint. Ms C also complained that the board's handling of her complaint was unreasonable. We found that there were delays in the board's response to Ms C's complaint and the board did not provide proactive updates about the status of Ms C's complaint. We found that the board's handling of the complaint was not in line with the NHS Model Complaints Handling Procedure (MCHP) and, therefore, upheld this aspect of Ms C's complaint. We noted that the board had already taken action to improve their complaints handling. We made no further recommendations but did provide feedback on this point.

Mrs C complained about the care and treatment her child (Child A) received from a practice managed by the health board. Child A had initially attended the practice for treatment of tonsillitis. However, they continued to be unwell and Mrs C took them back to the practice a number of times over the subsequent months. Mrs C complained that, despite raising concerns about Child A's symptoms with the GPs, her suspicion that Child A may have glandular fever was not properly investigated. Based on Child A's presentation, the practice concluded that they were suffering from post-viral symptoms. However, Mrs C stated that this was never communicated to her. Mrs C complained that the practice did not provide reasonable care and treatment to Child A in respect of their presenting symptoms. We took independent advice from a GP. We found that the clinical decision-making and management in respect of Child A's presenting symptoms was reasonable. From the review of the consultation notes, it was likely that post-viral symptoms were discussed with Mrs C. However, we concluded that it was not possible to categorically confirm this from the medical records kept by the practice. While we did not consider this to mean that the practice failed to provide reasonable care and treatment to Child A, we did provide feedback about the fact that Mrs C was not left with a clear understanding of the diagnosis that had been made. However, on the basis of reasonable care and treatment being provided to Child A, we did not uphold this complaint. Related reading View Decision Report 201904820 as a PDF (24.42 KB) Updated: July 22, 2020

C complained about their detention under an emergency detention order under the Mental Health (Care and Treatment) (Scotland) Act 2003. C stated that the detention was unnecessary and that the board failed to inform them about it. C also complained that there was a failure to offer support and signposting to advocacy services. We took independent advice from a consultant psychiatrist (a medical practitioner who specialises in the diagnosis and treatment of mental illness). We found that the detention was appropriate from both a clinical and legal perspective under the Mental Health (Care and Treatment) (Scotland) Act 2003. We found that it was considered to be in C's best interests to detain them because of legitimate concerns about their mental health. The documentation was signed by a medical practitioner with full General Medical Council (GMC) registration and with the consent of a mental health officer, in accordance with the requirements of the act. We did not uphold this aspect of C's complaint. We also found that C was informed of their detention within a reasonable period of time. We noted that prioritisation was given to addressing C's mental and physical health. The clinical team sought the views of C's relatives to inform their ongoing clinical management of C. Under the circumstances, this was an appropriate and reasonable action which then resulted in C's detention being revoked early. We did not uphold this aspect of the complaints. Related reading View Decision Report 201900770 as a PDF (24.41 KB) Updated: July 22, 2020

Mr and Mrs C complained on behalf of their daughter (Ms A) that the care and treatment Ms A received from practice was unreasonable. Mr and Mrs C said that the practice sought to reduce Ms A's prescriptions for morphine and diazepam when she joined as a new patient. Mr and Mrs C further complained that the doctor who saw Ms A did not give adequate reasons for why the medications were being reduced. We took independent advice from a GP. We found that it was reasonable for the practice to seek to reduce Ms A's medications. We also found that the doctor provided a clear explanation to Ms A, and Ms A's clinical records showed that she had received the same explanation on multiple occasions from other medical professionals involved in her care who had sought to reduce her medication doses. Therefore, we did not uphold this complaint. Mr and Mrs C further complained that Ms A was unreasonably removed from the practice list. We found that it was reasonable for Ms A to be removed from the practice list as the doctor/patient relationship had broken down with all the partners in the practice, and while the relevant legislation states that a warning should be given within 12 months, that a warning does not need to be given if the GP does not feel that it is reasonable or practical to do so, which was the case here. Therefore, we did not uphold this complaint. Mr and Mrs C also complained that the practice's handling of her complaint was unreasonable. We found that the practice's complaint responses did not adequately address the issues raised and the practice failed to signpost to this office. Therefore, we upheld this aspect of the complaint.

Mrs C complained about the treatment she received at the practice to have a leg wound dressed. Mrs C said that she attended on a number of occasions and told nursing staff that the wound was sore and infected but that they ignored her concerns. Subsequently, one of the nurses arranged for a swab to be taken and this identified that the wound had become infected. Mrs C felt that the nursing staff should have acted on her concerns earlier and that it would have saved her the additional pain and distress. We took independent advice from a nurse. We found that the nurses involved provided appropriate wound care and that there were no recorded signs of infection. A swab was taken because of slight inflammation of the wound which subsequently identified an infection which was treated with antibiotics. We did not uphold the complaint. Related reading View Decision Report 201905688 as a PDF (24.12 KB) Updated: June 17, 2020

Mr C complained on behalf of his wife (Mrs A) about a physiotherapy (the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) assessment she underwent. The assessment found that Mrs A could safely use a three-wheeled walking aid outdoors under close supervision. Subsequently, Mrs A suffered a fall while using the three-wheeled walking aid on a downhill slope. Mr C raised concerns that the assessment did not include a slope; it did not assess Mrs A's ability to use the brakes; and that close supervision would not have prevented the accident. We took independent advice from a physiotherapist. We found that Mrs A's assessment was unreasonable. We found that the record of the assessment lacked appropriate detail. We found it did not address Mrs A's ability to safely negotiate slopes or to use the brakes and that the advice given to Mrs A and Mr C during the assessment was unreasonable. We upheld Mr C's complaint.

Miss C, an advocate, complained on behalf of her client (Ms A) that the board had decided, from an urology (the branch of medicine and physiology concerned with the function and disorders of the urinary track) perspective, there was no reason to refer Ms A for an immunology (the branch of medicine and biology concerned with immunity) opinion. We took independent advice from a consultant urologist. We found that the care and treatment given to Ms A was reasonable, and that appropriate advice had been given in relation to her condition. We also found that Ms A had not completed the investigations necessary to diagnose her condition and that, in these circumstances and from an urology perspective, there was no reason to refer Ms A for an immunology opinion. Therefore, we did not uphold Miss C's complaint. Related reading View Decision Report 201806587 as a PDF (24.11 KB) Updated: June 17, 2020

C complained about the treatment provided to their child (A). A was admitted to hospital with a worsening lung infection, linked to their genetic disorder, and was found to be in acute kidney failure. As part of a number of tests, it was found that A's ferritin levels were very high, and when this was identified by the clinicians involved in A's care, A was diagnosed with an uncommon and serious problem with their immune system. A died from the condition. C complaind that the ferritin test results were not acted on in a reasonable timescale to provide appropriate treatment. We took independent advice from a consultant nephrologist (doctor specialising in internal medicine that focuses on the treatment of diseases that affect the kidneys). We found that, overall, the treatment provided to A was reasonable. It was reasonable that the ferritin test was not actively sought out by A's clinicians as it was not considered to be crucial in treating A's acute illness. We found that there was nothing to indicate the very rare condition before the ferritin result, and that this was not an expected part of the management of an acute illness. We did not uphold C's complaint. Related reading View Decision Report 201809849 as a PDF (24.28 KB) Updated: June 17, 2020

Mr C complained about the treatment provided to his late father (Mr A). Mr A had complained about poor memory and poor balance over a number of weeks. The board carried out a number of investigations, however, due to the wait for follow-up appointments, Mr A decided to seek private treatment and he was subsequently diagnosed with Creutzfeldt-Jakob Disease (CJD - a rare degenerative brain disorder). Mr C complained that the board failed to carry out the appropriate investigations, and that the board inappropriately discharged Mr A when his condition was getting progressively worse. The board confirmed they were satisfied that the appropriate investigations were undertaken. They acknowledged that they could not offer Mr A an earlier appointment and explained that this was due to the service being understaffed. We took independent advice from a consultant neurologist (a doctor who specialises in the brain and nervous system). We found that the appropriate investigations were carried out. Due to the nature of Mr A's condition, a number of conditions had to be ruled out first and there is no single test that can be performed in order to reach a diagnosis. The board subsequently informed us that the staffing issues have since been resolved. We also considered that it was appropriate to discharge Mr A as the risks of complications was much lower at home than in hospital. We did not uphold Mr C's complaints, however, feedback was provided regarding the board's communication with the patient and his family and the manner in which Mr A was prioritised. Related reading View Decision Report 201807994 as a PDF (24.5 KB) Updated: March 18, 2020

Ms C complained about the care and treatment provided to her by the practice for a number of symptoms over period of several months. We took independent advice from a GP. We found that the assessments, investigations, referrals and treatment provided to Ms C were reasonable. We did not uphold the complaint. Related reading View Decision Report 201807532 as a PDF (23.82 KB) Updated: March 18, 2020

Ms C complained about the care and treatment provided to her by the board for a number of symptoms over a period of several months. We took independent advice from a GP, from a consultant in acute medicine, from a gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines) and from a neurologist (a doctor who specialises in the brain and nervous system). We found that whilst much of the care and treatment provided to Ms C was reasonable, the possibility of Ms C's symptoms being caused by other disorders should have been discussed with her. Therefore, on balance, we upheld the complaint.

Mr C was admitted to A&E following a road traffic accident. He was concerned that inadequate investigations were carried out to determine the extent of his injuries. Following an MRI scan, it was found that Mr C had a neck injury which required surgery. Mr C also felt his complaints of pain were minimised and often ignored by staff. We took independent advice from an emergency medicine consultant. We found that proper assessments and investigations were carried out in light of the injuries Mr C presented with. We had no concerns about the way staff managed Mr C's reports of pain and that he was given appropriate pain relief. We found that there was no indication that an MRI of Mr C's neck should have been carried out sooner. MRI scans are required to identify injuries to the soft tissues in the neck or the spinal cord and are normally only carried out when patients have symptoms consistent with spinal cord injury or when, in the presence of a normal CT scan, there is a significant suspicion of a ligamentous injury. In Mr C's case, it was noted that when he displayed a foot drop and weakness in his hand, the decision was taken to obtain an MRI scan. We found that the board provided reasonable care and treatment for Mr C's neck injury and, therefore, we did not uphold the complaint. Related reading View Decision Report 201807229 as a PDF (24.37 KB) Updated: March 18, 2020

Mr C complained about the care and treatment his relation (Ms A) received at Raigmore Hospital. Ms A suffered from MPO ANCA associated vasculitis (a rare autoimmune disease) and was admitted to hospital with symptoms of diarrhoea and vomiting, headaches and abdominal pain. Ms A experienced episodes of haemoptysis (coughing up blood) while in hospital and died later that day. We took independent advice from an adviser in acute medicine. We found that, when Ms A was admitted to hospital, a consultant review indicated that a pulmonary haemorrhage (an acute bleeding from the lung, from the upper respiratory tract and the trachea, and the alveoli) was a potential concern along with two other possibilities. We considered it was reasonable at the outset that the board did not proceed to give Ms A a chest x-ray as gastroenteritis (inflammation of the stomach and intestines) was suspected and there was only one episode of haemoptysis. However, we found that there was an unreasonable delay in performing a chest x-ray on Ms A following a second episode of haemoptysis. There was, therefore, a delay in identifying a pulmonary haemorrhage. We noted a member of the nursing staff appeared to identify the possibility of a pulmonary haemorrhage, and whilst this was communicated to the doctor, it was not acted upon. We upheld Mr C's complaint.

Mr C visited his dentist due to pain in one of his teeth and agreed to a proposed course of treatment with the dentist. Mr C believed this would be provided under the NHS. Mr C found the communication around the cost of the treatment confusing saying that the dentist had not properly explained the costs or what was required before the procedure, and Mr C was concerned that he was over-charged. Mr C also complained about the standard of treatment he received and that the dentist failed to handle his complaint reasonably. We took independent advice from a dental adviser. We found that the dentist failed to communicate the treatment plan and options in a reasonable way and that Mr C was not in a position to give informed consent; the breakdown of treatment options (NHS and private/independent) were not in line with relevant regulations; unacceptable materials were used; the findings of x-rays were unreasonably reported on; there was an unreasonable standard of care especially periodontal (gum) care; there was an unreasonable standard of record-keeping; and there were discrepancies in what was charged. We also found that the dentist failed to deal with the complaint in line with the complaints handling procedure. We upheld all aspects of Mr C's complaint.

Mrs C manages a direct payment (a cash payment paid under self-directed support in order to purchase care at home) on behalf of her disabled son (Mr A). The board contacted Mrs C to progress a review of the direct payment and to review the decision that Mrs C should be permitted to be employed as a Personal Assistant (PA) for Mr A. The direct payment included funding for two carers to provide two-to-one support to Mr A. Following the review, the board decided the funding should be reduced to only pay for one PA until a second PA was recruited to provide the two-to-one support. The board also decided that Mrs C should no longer be employed as a PA,and they advised that a second PA needed to be recruited. Mrs C complained that the board acted unreasonably in respect of the review of the direct payment. Mrs C felt that the board unfairly blamed her for the failure to complete the review and that their decision to reduce the funding was unreasonable. Mrs C also complained that the board's decision regarding her employment as a PA was not in accordance with self-directed support legislation. We took independent advice from a social worker. We found that the board acted reasonably in respect of both complaints. We identified that the local authority's decision to reduce the funding until a second PA was recruited was reasonable as the funding should only be used to meet the agreed outcomes detailed in the support plan. We also identified that the board acted reasonably by providing Mrs C adequate notice to recruit an alternative PA. Therefore, we did not uphold the complaints. Related reading View Decision Report 201807054 as a PDF (24.03 KB) Updated: November 20, 2019

Mrs C complained about a decision that was taken by the board to refuse out-of-area funding for a paediatric consultant for her child's (Child A) care. Mrs C said that the process leading up to the decision, how the decision was communicated to her and how the board handled her complaint was unreasonable. We took independent advice from a consultant paediatrician (a doctor who specialises in child medicine) and found that the board followed the correct process in reaching a decision regarding the referral and, therefore, did not uphold this part of the complaint. However, we identified that the board had failed to provide Mrs C with a clear explanation of the process that they followed and the rationale for their decision; to give correct information to Mrs C regarding a third doctor's involvement; to correct their error when communicating with Mrs C; and to provide relevant information to SPSO in this regard in response to our enquiries. We upheld these aspects of the complaint.

Mrs C complained about the care provided to her late sister (Mrs A) when she attended Raigmore Hospital with gastric symptoms. Investigations were carried out into Mrs A's symptoms over two admissions. During the latter admission, Mrs A was diagnosed with a perforated bowel, thought to be related to cancer. Her condition deteriorated very quickly and she died from her illness. We took independent advice from a consultant gastroenterologist (a doctor who specialises in the digestive system) and from a registered nurse. We did not identify any failings in the medical management of Mrs A's condition or in the nursing care provided. We did not uphold this aspect of the complaint. However, we noted that the documentation of her care could have been more detailed and fed this back to the board. Mrs C was also unhappy that board staff did not contact her regarding Mrs A's discharge from the hospital following her first admission. In response to Mrs C's complaint, the board confirmed that another family member had been told about the discharge and so there was no requirement for duplication of information. We did not uphold this aspect of the complaint. Related reading View Decision Report 201802964 as a PDF (23.92 KB) Updated: October 23, 2019

Mr and Mrs C complained about the care and treatment their child (Child A) had received in Raigmore Hospital. Child A had asthma and was referred to the hospital by their GP because of breathing problems. They were admitted to the children's ward and was discharged on the following day. They were readmitted three days later and were then discharged later that day. Child A was readmitted again on the same day after a rapid deterioration in their symptoms. Their condition continued to deteriorate and the emergency team in the hospital took them to theatre. They were then transferred to the intensive therapy unit before being transferred back to the children's ward three days later. Mr and Mrs C complained that staff had unreasonably considered that Child A had anxiety. We acknowledged that it can be difficult on occasions for both clinicians and patients to distinguish feelings of breathlessness due to asthma from those due to anxiety or a combination of both. We found that much of the care and treatment provided to Child A had been reasonable. It was reasonable to carry out spot-checks of their oxygen saturations, and their medication was also in keeping with standard asthma guidelines. However, on balance, the delay by medical staff in responding when nursing staff continued to raise concerns about Child A's condition had been unreasonable. The discharge letter was also inadequate, as it did not describe the clinical course accurately and did not give GPs and those subsequently involved in Child A's care a full picture of the issues. We upheld this complaint. However, we did not make any recommendations, as the board had already apologised to Mr and Mrs C. They had also stressed to staff the importance of listening to patients and the importance of appropriate assessment of any child with breathing difficulties. The board also told us that in future, discharge letters would be verified by a consultant. Related reading View Decision Report 201708328 as