SPSO Individual Decisions

C complained about the community nursing care their parent (A) received for leg ulcers which had become infected. We took independent nursing advice, which highlighted that inappropriate dressings were applied to A's wound for a period, and also appropriate supplies of dressings were not obtained in a timely manner. When the wound did not improve, there was initially a failure to escalate the matter. We noted that there was appropriate escalation later and the wound management was reasonable from this point. On balance, we upheld this complaint. C also complained that A was discharged from University Hospital Hairmyres (UHH) with an infection still present. We noted that A was receiving antibiotics and a follow-up plan was in place, and that the discharge was reasonable even in the presence of infection. We did not uphold this complaint. C also complained that A was not reasonably assessed when they attended UHH emergency department. C was unhappy that A was assessed without removal of their bandage, and that no swabs were taken. We took independent advice from a consultant in emergency medicine. We noted that there was a reasonable focus on A's knee pain/swelling and no unreasonable omission in terms of examining the leg wound. We did not uphold this complaint. Finally, C complained that the board's response to their complaint failed to refer to A's fall in hospital. In responding to our enquiries, the board offered assurances that A had not fallen, but rather experienced a feinting episode due to low blood pressure. We confirmed that this was supported by the medical notes. We considered the board to have reasonably explained why this was not referred to in their complaint response, and we did not uphold this complaint.

C, parents of infant child (A) complained about the care and treatment that A had received from the board. C had raised concerns that A's Hickman line (a central line catheter inserted into one of the large blood vessels to allow permanent access for treatment) may be infected and had sought advice at hospital. A swab of the insertion site had taken place, however A had been discharged without further treatment. C complained that the board had failed to provide a reasonable standard of treatment to A during their admission. C further complained that the following day at a home visit, nurses had proceeded to flush A's line (procedure required to ensure the line remains clear of blood and to prevent clotting) in spite of their concerns it might be infected and without the results of the swab testing. C asserted that as the line had been infected, A had received a septic shower (sudden systemic release of pathogens into the blood stream causing septic shock) resulting in A's sudden collapse. In their response, the board said that as there had been no diagnosis of a line infection, A's line had been flushed in accordance with the board's Care and Maintenance policy (CVAD policy). However, reflecting on the complaint, the board acknowledged that had there been formal communication between services regarding A's swab testing the evening before, this may have influenced their decision-making to proceed with the flush. They said that as a result of the complaint, they would review and update their CVAD policy to incorporate a standard operating procedure (SOP) and checklist so as to improve information sharing between teams and in circumstances of swab testing, or concerns expressed by families, to ensure medical advice would be sought before proceeding. We took independent advice from a paediatric nursing adviser and consultant paediatric adviser (dealing with the medical care of infants, children and young people). We found that although the board had correctly con

C complained about the treatment provided to their late partner (A). A had reported a number of symptoms by telephone to their practice but they had not made arrangements to see them in person and C said that, as a result, they did not receive appropriate care and treatment. A reported symptoms over a period of time. However, A began to have seizures and tests revealed that A had lesions on their brain. C believed that the practice should have acted earlier and that A's condition could have been diagnosed sooner. We took independent advice from an adviser who is an experienced GP. We found that the practice had provided A with appropriate care and treatment based on their reported symptoms. There was no evidence that A required an earlier face-to-face appointment or that red flag symptoms were missed. We did not uphold the complaint. Related reading View Decision Report 202103008 as a PDF (24.13 KB) Updated: February 16, 2022

C made a complaint about their late parent (A)'s discharge from University Hospital Hairmyres. C believed that A was not fit to be discharged and that this resulted in A having a fall, and sustaining an injury which then contributed to A's death. We took independent advice from a physiotherapy adviser and a consultant physician and geriatrician (a speciality focussing on the health care of elderly people). We found that a comprehensive geriatric assessment was not carried out during A's admission. Given that this is a requirement outlined in the Healthcare Improvement Scotland (HIS) Care of older people in hospital standards, we considered it was unreasonable that no assessment appears to have been carried out. This may have provided a more comprehensive view of the issues affecting A. We also found that A's case was not discussed at a Multidisciplinary team (MDT) meeting prior to A's discharge. If this meeting had taken place, the MDT could have considered whether A would have benefited from further rehabilitation (either in hospital or in the community). Given that an MDT meeting did not take place prior to A's discharge, and given the lack of a comprehensive geriatric assessment in line with HIS standards, on balance, we considered the decision to discharge A was unreasonable. We upheld C's complaint.

C complained of a delay in diagnosing their late partner (A)'s cancer by medical staff in University Hospital Monklands. A was diagnosed with a rare cancer and died three weeks later. They had been unwell for around five months and had multiple hospital attendances and admissions. C complained that appropriate tests weren't carried out in a timely manner, and that A was misdiagnosed and treated for potential illnesses they did not have. We took independent medical advice from a consultant in respiratory and general medicine. We found that A's case was complex and unusual and that it was reasonable to consider other diagnoses more likely than cancer, and to treat these accordingly while investigations continued. However, we found that reasonable action was not taken to manage the pleural effusions (fluid around the lung) that A initially presented with. Guidelines indicate that a fluid aspiration (removal of a small amount of fluid for testing) should have been arranged to rule out infection in the pleural space (cavity between lungs and chest wall). This was not arranged until almost eight weeks later. When this was done and the result was inconclusive, guidelines recommended that a biopsy be carried out and this wasn't done either. In addition, an ultrasound scan the following day reported ascites (fluid within the abdomen), and again a fluid aspiration was indicated but wasn't carried out. A biopsy via thoracoscopy (keyhole camera into the pleural space) was not carried out until a further 14 weeks later. A's cancer was diagnosed thereafter. We found that there were earlier indications for a thoracoscopy and missed opportunities to diagnose A's cancer from the time of their initial presentation. While we acknowledged that an earlier diagnosis was unlikely to have altered A's prognosis, we noted it would have enabled palliative care to commence and allowed the family time to prepare and make the most of the time they had left together. We upheld this c

C had power of attorney (POA) for their late spouse (A) and complained about the care and treatment provided to A when they were admitted to hospital from a care home. During their admission, A was detained under the Mental Health (Care and Treatment) (Scotland) Act 2003 due to the severity of their dementia. A's health deteriorated and they died in hospital. C complained about various aspects of A's medical care, nursing care and staff's communication with C. We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly) and a registered nurse. In respect of C's concerns about the medical care provided, we found that while the treatment provided in the earlier part of A's admission was reasonable, staff should have sought C's views about the additional investigations undertaken immediately prior to A's death. We upheld the complaint on that basis. We concluded that while the nursing notes could have been more explicit on some aspects of A's care, the nursing care overall was of a reasonable standard. We also concluded that the communication with C about A's detention and deterioration was reasonable. We did not uphold these complaints.

C complained to us about the care and treatment that they and their two children had received from a dentist. They said that they were told by the dentist that they and the children did not have any cavities, but when they attended another dentist, they were told that they had cavities and needed fillings. One of the children also needed crowns and experienced an abscess. We took independent advice from a dentist. We found that the dentist complained about had failed to take bitewing X-rays (detect decay between teeth and changes in the thickness of bone caused by gum disease) for C and their children, which was unreasonable. There were also failings in relation to documentation. Whilst it was reasonable that one of the children was told that they had no cavities, we found that based on the evidence available, C and the other child had cavities that needed treatment when they attended the dentist. We also found that the abscess experienced by one of the children was not avoidable, however, the dentist did not follow the relevant guidance on treating the abscess and gave the child antibiotics with no justification for their prescription. There was also no evidence available to demonstrate that the dentist discussed and explained treatment plans to C on all occasions. Given these failings, we found that the dentist's practice fell below the expected standard and upheld complaints about the care and treatment provided to all three patients. C also complained to us about the way in which their complaint had been handled. We found that the dentist had not responded to C's concerns regarding their own care and treatment, or that of one of the children. Consequently, we found that the dentist had not handled C's complaint in line with the NHS Complaint Handing Procedure and we also upheld this complaint.

C complained about a failure to diagnose their late partner (A)'s spinal cord cancer when they attended Wishaw General Hospital. They attended the Accident & Emergency Department and were referred on to the medical team for an urgent MRI scan for a suspected malignant spinal cord compression (MSSC, MSCC can happen when cancer grows in the bones of the spine or in the tissues around the spinal cord). However, this was subsequently changed to a CT scan, the result of which was normal, and A was discharged. A attended a private neurology (the science of the nerves and the nervoussystem, especially of the diseases affecting them) appointment the following week, where arrangements were made for an urgent hospital admission and a tumour in the spinal cord was diagnosed. A was left confined to a wheelchair following surgery and died around ten months later. C complained that, in not carrying out an MRI scan, the board failed to adhere to national guidance on MSCC management. We took independent medical advice from a consultant radiologist (a specialist in the analysis of images of the body), who advised that it is normal practice to initially investigate any patient with a history of prior malignancy and suspected MSCC with an MRI of the whole spine. We, therefore, considered that it was unreasonable in A's case for the board to have carried out a CT rather than an MRI scan. It was noted that there was limited MRI scanner availability the day A presented, however, guidance allows for an MRI scan to take place within 24 hours. We found that an MRI scan should have been undertaken the following day and this omission was unreasonable. Had the MRI scan taken place, the spinal tumour would have been detected earlier. We were unable to say whether this would have had an impact on A's overall prognosis. Therefore, we upheld this complaint.

C complained about treatment provided by the board to their spouse (A) who was initially admitted to University Hospital Monklands with a fractured leg before being transferred to Wishaw General Hospital for further management. A's condition subsequently deteriorated, in response to which they received a full dose of Tinzaparin (anticoagulant). As A showed no improvement, they underwent an exploratory laparotomy (a surgical incision into the abdominal cavity, for diagnosis or in preparation for major surgery). A few hours later, due to further deterioration, A underwent a further laparotomy. During this procedure, significant bleeding and an injury to A's spleen was identified. A splenectomy (a surgical operation involving removal of the spleen) was then performed. A's condition did not improve and they died shortly after. We firstly obtained advice from a consultant orthopaedic (conditions involving the musculoskeletal system) surgeon. We found no failings in relation to the orthopaedic care provided to A. We then obtained advice from a consultant general surgeon. We found that while it could not be definitively said how the tear to the spleen identified at the second laparotomy had been caused, it was possible that this may have been caused some time between commencing closure of the abdomen at first laparotomy and the second laparotomy. However, we also noted that A should not have received a full dose of Tinzaparin before it was established whether they would need surgery, as this was irreversible and greatly increased the risk of bleeding during surgery. The surgical adviser told us that the dose of Tinzaparin administered prior to surgery intensified the bleeding caused by the injury to A's spleen and contributed to A's death, although they may still have died from the underlying cause of their acute illness that could not be identified during post mortem examination. We upheld the complaint.

C complained on behalf of their relative (A) about the treatment A had received from the board. A had emergency surgery to repair a dissected aorta (a tear in the heart) and was discharged following treatment. A developed an infection in their surgical wound and was readmitted to hospital for further treatment. C complained that in treating A's infection, the board incorrectly administered A with penicillin (an antibiotic) to which they are allergic. Following intravenous Co-Amoxiclav (antibiotic used for bacterial infections), A developed a skin rash. C also complained that A was administered ibuprofen which should not have been prescribed to A due to the heart medication they were taking. We took independent advice from a clinical adviser. We found that there was no evidence in A's medical records of a penicillin allergy prior to the development of their skin rash following intravenous Co-Amoxiclav. We also found that the board's use of a penicillin derivative was reasonable and an appropriate choice of antibiotic for A's wound infection. We noted that the potential adverse effects of taking ibuprofen did not mean that it could never be used in patients taking A's heart medication. In A's case, the use of ibuprofen postoperatively had not been sufficiently documented, therefore we were not able to determine whether its use was appropriate. On balance, we found that the board had provided a reasonable standard of treatment to A and did not uphold this aspect of C's complaint. C further complained that the board had not provided A with clear information regarding their cardiology (area of medicine concerning diseases and defects of the heart and blood vessels) rehabilitation and aftercare, resulting in a delay in A receiving appropriate follow-up appointments. We took independent advice from a cardiologist. We found that the board had not correctly processed A's referrals for cardiology follow-up and cardiac rehabilitation or done so in a timely manner.

C complained that the practice had failed to provide the correct prescription for their child (A). A had been diagnosed with type 1 diabetes and had been self-administering their medication with no issue. C said that this had changed and A found injections very painful. This had caused both A and the family significant distress. C said that the practice had prescribed the wrong type of needle and that this was not the type of needle specified by the hospital. We took independent medical advice. We found that the practice had reasonably relied on their prescribing software. This was in line with both hospital and pharmacy requirements. The software had substituted a different product, and it was reasonable for this to have been prescribed. Additionally, the practice had responded timeously to C when they reported the problems A was having. Therefore, we did not uphold this aspect of C's complaint. C also complained that the practice had failed to provide an adequate supply of needles. The practice had accepted that A was not provided with the correct number of needles. They did not accept that they had not responded to C's requests for assistance timeously. We found that it was clear that C had not been prescribed the correct amount of needles and that it would be appropriate for the practice to reflect on this error, to improve future practice. Therefore, we upheld this aspect of C's complaint. We noted that the practice had already committed to reviewing A and C's case through a Significant Event Analysis (SEA) and we asked them to provide us with a copy of their findings, as well as feeding them back to the board. We did not make any further recommendations. Related reading View Decision Report 202001843 as a PDF (24.55 KB) Updated: December 22, 2021

C complained about the board's decision to discharge their late parent (A) from University Hospital Monklands. A had metastatic cancer (cancer that has spread from the part of the body where it started) and had been admitted to hospital with blood in their urine. A was treated with antibiotics and antifungals, however, their infection markers remained elevated. As A showed no other signs of infection, their elevated infection markers were attributed to their cancer and they were discharged home. A was readmitted to hospital the following day with a deep vein thrombosis (DVT, blood clot in a vein). Their condition deteriorated and they died eight days later. C complained that A had been discharged from the hospital before they were fit to return home. C also raised concerns about the hospital staff's communication regarding A's condition and discharge. C considered that failings by the board meant that A endured unnecessary suffering which distressed family members. We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We were satisfied that the hospital staff communicated clearly and regularly with C throughout A's admission to the extent that C was kept informed as to how A was fairing on the ward. We were also satisfied that nursing and clinical staff appropriately monitored and recorded changes in A's mobility and attempted to provide physiotherapy when A was willing and able to participate. We found that, in the days before A's discharge, C had raised concerns with the nursing staff regarding A's foot being swollen. We noted that this should have raised the suspicion of a DVT specifically and that investigations should have been carried out prior to A being discharged. Whilst the nursing staff advised C that their concerns would be passed on to the medical team, we found no evidence of this happening and concluded that an opportunity was missed to investigate and diagnose A's DVT prior to their discharge.

C complained on behalf of their late parent (A) who died following surgery to remove cancerous tissue. C said that the care and treatment that A received in hospital was not reasonable, and that A’s cancer should have been detected earlier. C believed there were failings in the management of A’s care which caused A pain, distress and discomfort and this was worsened by the standard of nursing care. We took independent advice from two appropriately qualified advisers. We found that the diagnosis concerning the spread of cancer was reasonable and did not uphold this aspect of C's complaint. In relation to nursing care, we found that there was a lack of accurate and appropriate pressure assessments, and a lack of timely interventions led to the development of severe pressure damage. There was inappropriate wound management causing deterioration to wounds and poor observation of urinary output. We also found that the standard of record-keeping was unreasonable, that national pressure ulcer prevention standards and relevant policy were not followed and there was delay in referring to specialists. Therefore, we upheld this aspect of C's complaint.

C complained about the standard of medical care and treatment provided to their parent (A). A received a likely diagnosis of metastatic lung and liver cancer. They were placed on palliative care, however, after approximately a year, A remained in good health. C sought a further review, A received subsequent scans, and it was ultimately established that they did not have cancer (approximately two years after the original diagnosis). C raised concerns about the basis for the initial diagnosis that A had cancer. They also complained about the subsequent management of A. C said there was no appropriate follow-up or subsequent communication after the diagnosis. Ultimately, C requested a review, but said it took significant time for the board to establish there was no cancer. We took independent advice from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the diagnosis that A likely had cancer was reasonable. It was based on a reasonable radiological opinion given the findings on A’s CT scan. We did not uphold C’s complaint in that regard. In relation to A’s subsequent management, we found that there were unreasonable failings. The standard of care and attention the board provided to A following discharge was not reasonable, and we found evidence that follow-up was proposed for A and then not acted on. We also found that there was a failure to respond within a reasonable time to the referral for an oncology review. We upheld this aspect of C’s complaint.

C complained on behalf of their child (A). A attended their GP practice and A&E at University Hospital Hairmyres on a number of occasions before examination by a physiotherapist led to a referral back to hospital, further x-ray and diagnosis of slipped upper femoral epiphysis of the hip (SUFE, where the growing part of the bone in the hip joint moves). C complained that A was advised to continue walking unaided despite being in severe pain. C believes failings in care contributed to A’s condition worsening to the point where significant surgery was required. C was dissatisfied with the board’s response to their complaint and asked this office to investigate. In their response to our enquiry, the board confirmed that A’s case had been discussed at a Morbidity and Mortality review, with learning identified. They said that the initial referral letter from the GP to orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) prompted no red flags from the orthopaedic team and they suggested musculoskeletal physiotherapy in the first instance. A was given an appointment but they attended A&E in the interim. We took independent clinical advice from a consultant in emergency medicine and a consultant orthopaedic surgeon. We found that SUFE was a difficult condition to diagnose and we did not consider the delay in diagnosis to be unreasonable. We were, however, critical of the decision to discharge A without further investigation, when they were unable to weight-bear. We noted that the board had identified learning but considered they also ought to develop a multidisciplinary pathway for the limping child. We also found that the referral from the GP was assessed appropriately in view of the information it contained. On balance, we did not uphold this complaint but provided the board with feedback in relation to the issues mentioned above. Related reading View Decision Report 202001199 as a PDF (24.74 KB) Updated: October 20, 2021

C complained that the board's community mental health team recorded their transgender status in their medical records, without C's knowledge or consent. In their complaint response, the board said that they considered C's gender transition was relevant to their mental health treatment and medical staff would require access to the information when providing C with treatment. We took independent advice from appropriate clinical specialists. We found from a clinical perspective that, at the time the information was recorded, it had been reasonable for staff to conclude that consent had been given as this information was provided by C, and that the information was relevant to the treatment being provided and, therefore, reasonable to record. We did not uphold this complaint. However, we did not make a decision on specific points raised about the ongoing and future management of personal data in the records as we considered these were ultimately more appropriate for the Information Commissioner’s Office. Related reading View Decision Report 201904556 as a PDF (24.19 KB) Updated: September 22, 2021

C complained about the care and treatment provided to their late brother (A). A’s consultations with the practice took place when COVID-19 restrictions were in place and as such, a number of their appointments were held via phone. A had been complaining of a persistent sore throat and tongue. A also said that they had been reporting a lump in their neck. A was referred to the Ear, Nose and Throat (ENT) department and was diagnosed with oropharyngeal cancer (a type of cancer that begins in the cells of the tonsils). C complained that there was a delay in referring A to ENT for further investigation. We took independent advice from a GP. We found that there was a poor standard of record keeping by the practice. The records did not always demonstrate that an adequate medical history was obtained or that adequate safety netting and follow-up advice was provided. We also identified that the wrong antibiotics were prescribed on one occasion and that the wrong test for glandular fever was performed. We were concerned that the practice’s own investigation of the complaint did not identify any of these failings. We considered that there was likely a delay of 15 days in referring A for further investigation. While this was not significant, in light of the other failings identified, we upheld the complaint.

C complained that they were provided with inadequate pain relief following surgery. C has chronic pain and as such required more careful management of pain relief due to their high tolerance of opioids. The board considered that they had appropriately assessed and managed C's pain. We took independent advice from a consultant anaesthetist. We found that while the postoperative pain relief provided was appropriate, there was a lack of true multi-modal analgesia (pain management which combines various groups of medications for pain relief) intra-operatively (during surgery) which increased the chances of immediate pain control problems. We upheld the complaint and made recommendations for learning and improvement.

C complained on behalf of B in relation to B's child (A). A was taken to A&E at Wishaw General Hospital and was diagnosed with a broken arm. Staff at the hospital did not consider that the explanation given by A's parents of how the injury happened fit with the injury found. Emergency department staff referred the case to a consultant paediatrician (doctor dealing with the medical care of infants, children and young people) for a forensic medical examination. It was determined that the type of injury sustained by A was highly indicative of a non-accidental injury (NAI). The board followed their child protection procedures, reporting the incident to the appropriate health and social care partnership and provided a forensic medical examination report as part of the child protection investigation. C complained that the diagnosis of NAI was unreasonable. We took independent advice from a medical adviser. We found that the board's assessment and management of A was in keeping with local and national guidance, and that the diagnosis of NAI was reasonable. Therefore, we did not uphold the complaint. Related reading View Decision Report 201911909 as a PDF (24.26 KB) Updated: August 18, 2021

C, an advocate, brought a complaint on behalf of their client (B) about B's child (A). B was unhappy that A was discharged by the Child and Adolescent Mental Health Services (CAMHS) after A was diagnosed with autism (a developmental disability that affects how a person communicates with, and relates to, other people). B felt that the discharge was premature as A was suffering with both behavioural and mental health issues. We took independent advice from an appropriately qualified adviser. We found that A's discharge from CAMHS was reasonable and that their mental health needs were reasonably responded to. It was determined that A did not present with a moderate or severe mental ill health comorbidity alongside their diagnosis of autism and it was reasonable for the board to discharge A, knowing that social work was supporting them and their family. As such, we did not uphold this aspect of C's complaint. C also complained that the board unreasonably refused referrals for A to CAMHS, submitted by A&E after discharge. We found that CAMHS and A&E staff assessed A and concluded that, while A was upset and distressed, there was no evidence of moderate or severe mental ill health that would make intervention from CAMHS appropriate. As such, we did not uphold this aspect of C's complaint. Related reading View Decision Report 202005528 as a PDF (24.37 KB) Updated: August 18, 2021

C underwent sequential cataract surgery (a surgical procedure to replace the eye lens with an artificial one when the cataract makes the vision cloudy, specifically, in this instance, monofocal lens implantation). C complained that the board had failed to communicate reasonably with them prior to the cataract surgery, including that the risks and benefits were not explained to them and that their concerns following first cataract surgery were not taken seriously. We sought independent advice from an ophthalmologist adviser (specialist in the branch of medicine that deals with the anatomy, physiology and diseases of the eye). We found that there was no record that C was given information about the risks and benefits of the surgery. The lack of written information about the risks and benefits of the procedure was unreasonable. We noted that this was contrary to the General Medical Council's guidance to keep an accurate record of the exchange of information. We also found that there was no record of what was discussed with C following the first cataract procedure. As there is no written record, we were unable to determine what was discussed with C when they raised concerns. In light of the above, we considered that there was a failure to communicate reasonably with C prior to the cataract surgery and we upheld C's complaint.

C complained about the psychiatric care and treatment that they received during an admission to University Hospital Wishaw. They complained about the way they had been treated by staff, claiming to have been assaulted and injured. C also complained about their medication regime, stating that they had been given too much medication which caused them to become ill. In their response to our enquiries, the board set out the circumstances in which C had been restrained, explaining that C tried to run away from the ward and became verbally and physically aggressive. As C was detained under the Mental Health Act, their refusal to return to the ward resulted in the use of restraint using prevention and management of aggression techniques. The board said that the restraint techniques utilised by staff were appropriate and all staff involved were appropriately trained. They expressed regret that C's jacket had been damaged, advising that reimbursement for C's loss had not been paid because C had failed to provide a receipt as requested. While C complained about a separate incident in which they said that they were injured, there was no record of this and as such we could make no finding on this. We took independent advice from a consultant psychiatrist. We found that the assessment and management of C's symptoms were appropriate. After review of C's medication regime, we found that there was no link with C becoming ill and vomiting. We noted signs of infection which were considered a more likely explanation for C vomiting. We found that C's care and treatment were reasonable and we therefore did not uphold this complaint. Related reading View Decision Report 202002453 as a PDF (24.54 KB) Updated: July 21, 2021

C complained about the care and treatment that they received from the board when they were admitted to Hairmyres Hospital with a psychotic episode. C raised a number of issues, including that the nursing and clinical staff at the hospital failed to adequately explore the possible link between the unpleasant/harmful physical symptoms C was experiencing, which they said they reported on a daily basis, and the medication they were given. We took independent advice from a mental health nurse and a consultant psychiatrist. We found that, generally speaking, staff responded appropriately to C's complaints; observations, examinations, investigations and onward referrals were appropriately initiated when C voiced concerns. However, there was a clear failure to carry out daily monitoring of C's pulse and blood pressure in a consistent and reasonable manner, and record the readings and C's resulting National Early Warning System (NEWS, a pro forma for recording patients' physical observations that generates a score to alert staff to potential changes in a patient's physical condition) score on the NEWS chart. We noted that the failings in recording of C's pulse and blood pressure on the NEWS chart and the resulting NEWS score was a potential contributory factor to C developing hypotension (low blood pressure). Interventions to manage this, such as the withdrawal of Olanzapine (an antipsychotic drug), were delayed at a time when this would have been beneficial in alerting the clinical team to physical issues experienced by C. This resulted in C experiencing short term discomfort and distress from hypotension. Therefore, we upheld C's complaint.

C complained about the care and treatment provided to them and their child (A) by the board during their pregnancy and after A's birth. A was diagnosed with microcephaly (a condition where the head circumference is smaller than normal) and associated issues around six weeks after their birth, and C felt that the diagnosis could have occurred at an earlier point. During our investigation, we took independent advice from a midwife, an obstetrician (a doctor who specialises in pregnancy and childbirth) and a neonatologist (a doctor who specialises in the medical care of newborn infants, especially ill or premature newborns). In relation to the care and treatment provided to C during their pregnancy, we identified the following failings: A lack of documentation in the care plan in relation to detail surrounding verbal discussions midwives had with medical staff during the antenatal period. A lack of a planned schedule for obstetric reviews as per the 'Keeping Childbirth Natural and Dynamic' (KCND) pathways. No scan carried out at 36 weeks as per the plan and no documentation to support the reasons for not adhering to this planned care pathway. Lack of clear documentation resulting in it being difficult to accurately determine if or when an obstetric doctor saw C, and what they communicated to the midwives or C. Lack of documentation regarding information given to C about the External Cephalic Version (ECV) procedure (a process by which a baby in the womb can sometimes be turned from buttocks or foot first to head first), delivery options, and induction. No evidence within the files that there were discussions about risks associated with shoulder dystocia (when one or both of a baby's shoulders get stuck inside the mother's pelvis during labour) or that risk assessments in relation to previous pregnancy outcomes were undertaken. As a result of an external Significant Clinical Incident Review (SCIR) carried out by the board, some improvement actions had been taken to add

C held power of attorney for their parent (A) and complained about the management of A's medication during a hospital admission for treatment of a chest infection. A's medication Furosemide and Ramipril (both used to treat heart failure) were stopped for eight days. A was readmitted to hospital again having suffered a heart attack and died. The board acknowledged it was not recorded who stopped A's medication and why they did so, and that there were failings in how A's medication was reviewed and managed prior to discharge. We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly). After review of relevant medical records and statements, we found that while it may have been reasonable to stop A's medication at the time, there was a failure to record who made the decision and their rationale for the decision. We also found the board did not give adequate consideration as to whether the cessation of A's medication may have had an impact on A's readmission, further heart problems and subsequent death. We also found that A's discharge letter was not appropriately updated prior to discharge. We upheld three of C's complaints, however we concluded that the board's communication with C about the changes to A's medication was not unreasonable in the circumstances and this complaint was not upheld.