SPSO Individual Decisions

C complained about the care and treatment their parent (A) had received from the board. A had a terminal cancer diagnosis and severe arthritis. C complained about a series of admissions A had to hospital. C said A had been discharged without C being consulted, even though they were A’s main carer. This meant A was discharged to a potentially unsafe environment, and did not receive the necessary levels of care. C said A was readmitted to hospital. A was then discharged to a care home, but was not provided with oxygen. C said that A had required oxygen in hospital and the failure to accept that A required long term oxygen support or to provide A with oxygen meant that A required a further hospital admission. C said that when A was readmitted to hospital, they received substandard care. A was put on a busy ward, that did not specialise in palliative care or geriatric medicine (medicine of the elderly) and that this type of care was only provided once C intervened. We took independent advice from a consultant geriatrician. We found that A’s discharge planning was carried out to a reasonable standard. A had capacity and the board’s actions took into account their wishes and included a reasonable assessment of A’s home environment. We found A was very ill during their final admission and that at times A was dehydrated and eating very little and that this would have been very distressing for C and other family members to have witnessed. We noted that dehydration and low food intake were a common feature of this stage of A’s illness and were not evidence of neglect on the part of staff. We found, based on the advice we received, that communication with A was of a reasonable standard and that their pain and condition was monitored and acted on appropriately. In terms of A’s discharge without oxygen support, we found that staff gave appropriate consideration how best to manage A’s low oxygen saturation levels and that on discharge A’s own preference was a factor in the decisi

C complained about various aspects of the care and treatment their late spouse (A) received from the board. A had a history of vascular (relating to a vessel or vessels, especially those which carry blood) surgery and was admitted to hospital for the removal of a benign tumour. The procedure took place, however, A’s condition deteriorated and they were moved to an infectious diseases unit with suspected sepsis (blood infection). A’s condition deteriorated further and they were transferred to a vascular and critical care ward in a different hospital on an emergency basis. Later that day, A underwent surgery to remove an infected synthetic artery graft (a piece of living tissue that is transplanted surgically). A experienced an abdominal bleed and was transferred to a critical care unit. After treatment, A was reviewed by a consultant and returned to the vascular and critical care ward. A experienced a fall on the ward. A later developed a lung infection/sepsis and died. C complained that the board failed to screen, manage or treat A’s infection. C said that A had been discharged from the critical care unit onto the ward too soon. C also complained that the board had failed to properly assess A’s fall risk or treat A properly after their fall. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a registered nurse. We found that the screening, management and treatment of A’s infection and their discharge from the critical care unit was reasonable. We did not uphold these complaints. However, we found that the board had failed to adequately complete risk assessments, including a falls risk assessment, for A. We upheld this complaint. We also considered that the board made an error of communication while responding to C’s complaint when they referred to MRSA (a bacterial infection that is resistant to a number of widely used antibiotics) instead of MSSA (a bacterial infection which is not resistant to certai

C complained to the board about surgery they received on a semi-urgent basis. C complained that the surgery had been inadequate and that they had been unable to fully consent to it due to time pressure and a lack of information. C also complained that the board’s subsequent management of their pain medication was unreasonable. In particular, C complained that they had not been informed of the potential for opiate pain relief to become habit-forming. The board responded that the surgery had been performed correctly and that a lengthy consultation had been held with C prior to surgery by the operating consultant neurosurgeon (a surgeon who specialises in surgery on the nervous system, especially the brain and spinal cord). We took independent advice from a consultant neurosurgeon. We found that the surgery had been performed to a reasonable standard and that the board’s management of C’s pain medication was also reasonable. However, we identified a lack of records illustrating any discussion with C about the potential benefits, risks or complications of surgery prior to the operation. We also identified a lack of records illustrating any discussion with C regarding the potential for opiates to become habit-forming. In the absence of such records we were unable to say whether C received appropriate information. Therefore, on balance, we upheld both complaints.

C was removed from their GP practice patient list. The practice were contacted by Practitioner Services (part of NHS National Services Scotland who support primary care providers) after this and suggested the practice refer C to the board's Challenging Behaviour General Practice (CBGP). The practice referred C to the CBGP. C complained that the practice had unreasonably referred them to CBGP. C said the practice were not required to refer C to CBGP, did not have a good reason to refer them and did not follow the correct procedure. We found that once the practice’s request to have C removed from their patient list was actioned, they were not obliged to arrange any future care for C. However, Practitioner Services found themselves unable to place C on a patient list of another GP practice in the area. They went back to C’s most recent practice and asked them to refer C to the board’s CBGP. The referral the practice sent meant C might (if the referral was accepted) have access to primary care services. We decided that the decision to refer C to CGBP was reasonable in the circumstances. As such, we did not uphold this complaint. However, we found that the processes in place were not helpful to guiding the situation C found themselves in. Understandably C was left confused about why the referral was made and had to contact the practice themselves to find this out. We passed on our feedback to the relevant health board. Related reading View Decision Report 201910147 as a PDF (24.43 KB) Updated: September 22, 2021

C complained about the treatment provided at the Royal Infirmary of Edinburgh to their late parent (A) after they were admitted having suffered a stroke. C complained that the board failed to discharge A in a reasonable timescale. We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We considered that, while medically well, A was not fit for discharge, requiring a further period of in-patient care to recover prior to being ready to return home. As such, we did not uphold this aspect of C's complaint. C complained that the board failed to provide reasonable care to allow A to maintain function in their legs. We found that board staff were trying to maximise what A could do, however due to their stroke, pre-existing conditions and subsequent infection, their attempts were unsuccessful. Physiotherapy input started two days after A's admission, which we considered to be prompt. We also found evidence that A attended sixteen physiotherapy sessions, with more offered but A was not well enough to accept them. This indicated that there was regular input by physiotherapists. As such, we did not uphold this aspect of C's complaint. During A's admission, they contracted influenza (flu). C complained that the board failed to provide reasonable treatment after they contracted influenza. We found that antibiotics were administered reasonably and A's condition was appropriately monitored. We noted the challenges in determining if a worsening of someone's condition was related solely to the initial influenza infection, or if an additional (secondary) infection with another organism was involved. Therefore, we did not uphold this aspect of C's complaint. However, we noted that consideration should have been given to anti-viral treatment for A, as indicated by the guidance available at the time and we fed this back to the board. Related reading View Decision Report 202002290 as a PDF (24.67 KB) Updated: August 18, 2021

C complained that the practice failed to appropriately investigate their urinary symptoms over a two-month period; in particular, that they failed to take blood tests and arrange a prostate check. C was later admitted to hospital with an acute kidney injury and urinary retention. We took independent medical advice from a GP, who considered that the practice had unreasonably failed to examine C's prostate in light of their persistent urinary symptoms and repeated negative results for infection. Therefore, we concluded that there was a failure to reasonably investigate C's urinary symptoms and we upheld this complaint. However, the practice provided us with evidence that reflection and learning had already taken place through a Significant Event Analysis and we were satisfied that appropriate learning had been demonstrated. We recommended that the practice should apologise to C for the identified failings but made no further recommendations.

C complained that the board failed to provide their child (A) with reasonable care and treatment. C understood that A had a condition known as paediatric acute-onset neuropsychiatric syndrome (PANS) or paediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS, infection-induced autoimmune conditions that disrupt children's normal neurologic functioning). A had been given intravenous immunoglobulin (IVIG, the use of a mixture of antibodies to treat a number of health conditions) treatment but this had been discontinued and stopped suddenly. C stated that the treatment should not have been stopped and wanted this treatment to be available to A in the future if A needed it. We took independent advice from a consultant neurologist (a specialist in the diagnosis and treatment of disorders of the nervous system). We found that the treatment was not suitable for A and the possible diagnoses for A's condition. We considered that it was appropriate the treatment stopped. However, we noted that it should never have been given as a treatment at any stage. We also found that the board sent spinal fluid for testing to a laboratory in England that did not arrive there. While this was not the outcome C was seeking, we upheld the complaint on the basis that IVIG should not have not have been given to A at all.

C complained about the care and treatment provided to their spouse (A). A suffered from progressive lung disease and required prostate surgery. There was a significant delay in performing A's surgery, during which time A's health deteriorated. A was discharged home following their operation, but was readmitted the following day and died shortly afterwards. C believed that A would have survived had the operation been performed sooner, as their health would have been better. C also said that A's death certificate was inaccurate, as it stated that A had died from community acquired pneumonia. C said that A had not been well when they were discharged, had been at home for less than 24 hours and had spent the majority of that period in bed. We took independent medical advice. We found that A's condition had not been properly monitored following their operation, as the board's assessment had been based on assumptions about A's condition prior to admission. This meant that A had been discharged without evidence of a deterioration in their condition being properly considered. We also noted that it was not possible to determine that A's pneumonia was 'community acquired'. We considered that A's care and treatment had fallen below a reasonable standard. However, we noted that it is not possible to be certain what the outcome would have been had A been operated on sooner. We also found that C's complaint had not been handled to a reasonable standard. The board had initially informed this office that it had nothing to add to its response to C's complaint. However, following our enquiries, the board accepted that it was unlikely that A had acquired pneumonia in the community. Additionally the board's complaint investigation had failed to identify that A's condition was not properly assessed prior to discharge. We upheld both of C's complaints.

C complained about a failure to diagnose that their new born baby (A) had a dislocated hip from birth. A was reviewed by a physiotherapist (a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) at the Royal Hospital for Sick Children, and C raised concerns that their request for an ultrasound scan was refused despite the presence of a number of red flag risk factors for hip dysplasia (where the 'ball and socket' of the hip are not properly formed). A's condition was not diagnosed until some months later. The board noted that the physiotherapist found A's hips to be functioning normally. They accepted that initial screening will always have the opportunity for human error. They said that this is mitigated by regular teaching and peer review, and ensuring staff are competent in examination before reviewing patients. However, as a result of this complaint, they made changes to their hip screening procedures. We took independent advice from a paediatric physiotherapy specialist. We considered that the presence of a number of recognised risk factors of hip dysplasia, together with a doctor's prior positive clinical assessment of hip instability, should have led the physiotherapist to arrange an ultrasound. The decision not to carry out a scan of A's hips was unreasonable and resulted in a delayed diagnosis. We upheld this complaint. We were advised that the changes already made by the board to their hip screening procedures should improve the clinical process going forward.

C complained to us on behalf of their late relative (A) regarding treatment A received from the board leading up to their death. C said that the board had failed to provide reasonable nutritional care and treatment after A was admitted to the Royal Infirmary of Edinburgh suffering from complications due to poor nutritional intake. They considered that the board had unreasonably delayed in diagnosing the likely cause of this nutritional deficit. C also said that the board had failed to reasonably communicate with A and their family, as they were only informed of the likelihood that A would die with around 48 hours' notice, previously believing A was due to be discharged. We took independent advice from an appropriately qualified adviser. We found that the board had provided reasonable nutritional care and treatment, with no delay in diagnosis. We therefore did not uphold those aspects of the complaint. However, we also found that the board had failed to appropriately assess A's likely prognosis and communicate this to them or to their family. As such, we upheld this aspect of the complaint.

C complained on behalf of their late spouse (A) about the treatment provided to them. A had a history of breast cancer and attended the practice with back pain. A was treated for simple back pain with some sciatic nerve irritation (nerve in the lower back area) and prescribed pain relief. A was later diagnosed with kidney failure caused from metastatic disease (secondary cancer) and died. C complained that the practice had failed to give proper consideration to A's history of cancer when assessing their back pain. C considered that an earlier diagnosis may have increased A's life expectancy as treatment could have been commenced earlier. We took independent advice from a GP. We considered that A's symptoms had been reasonably assessed and that A's reoccurrence of cancer was not foreseeable any earlier than diagnosed. When A's presentation changed, appropriate steps were taken, with further investigations and referrals to hospital speciality care. As such, we did not uphold this complaint. Related reading View Decision Report 202003476 as a PDF (24.23 KB) Updated: June 23, 2021

C attended hospital on a number of occasions for the removal of some teeth. At one consultation staff said C was aggressive and asked C to leave the department. C complained about the care and treatment provided to them and that the zero tolerance policy was applied unfairly to them. At a further consultation, C said they were told the hospital would not be able to provide further treatment for them. We took independent advice from a dentist. We found that the care and treatment provided to C was appropriate and the record-keeping was of high quality. There was good evidence of staff spending time with C to explain their treatment options. We found that staff were entitled to ask C to leave when they perceived C's behaviour to be aggressive and threatening. We also noted that the board had reassured C that they could receive treatment at the hospital, but this would be reviewed if C behaved aggressively again in the future. We did not uphold C's complaints. Related reading View Decision Report 201904087 as a PDF (24.18 KB) Updated: June 23, 2021

C, a support and advocacy worker, complained on behalf of their client (A) about the board's failure to share confidential patient information with A. C said that information was unreasonably withheld and should have been shared as their safety was at risk. C also complained that the board wrongly treated A's complaint as a 'concern' and they took an unreasonable length of time to respond. The board said that they were not in a position to share the information A had requested, however they recognised there was some learning for the clinical team and they took steps to address this. The board also said they did not treat C's initial email as a complaint as it clearly stated A wanted to “discuss their experience and concerns”. The board recognised their written response was not issued within a reasonable timescale. We took independent advice from a mental health nurse. We found that it would have likely been reasonable and legally justifiable for some of the information A requested to be shared with them. We identified that staff were not fully familiar with the national guidance on consent, confidentiality and information sharing. We upheld the complaint. In relation to complaint handling, we concluded that it was reasonable to treat A's initial email as a concern and a request for a meeting. However, matters became confused when the board's written response following the meeting included SPSO referral details, which inferred it was a complaint response. When C submitted a formal complaint, we noted that the board did not meet the required timescales. On that basis, we upheld the complaint.

C complained that the board failed to appropriately triage their relative (A) when A self-presented to the Medical Assessment Unit (MAU) at Western General Hospital feeling unwell. A spoke with the receptionist who took details of their symptoms and, having discussed A's symptoms with clinical staff, the receptionist advised A that they should contact NHS 24. A left the hospital and contacted NHS 24 who advised A to take paracetamol for the pain. A was taken to another hospital in the early hours of the next day and had an emergency operation for a ruptured appendix. In response to the complaint, the board explained that the receptionist acted in line with their normal processes. C was not satisfied with the response provided and brought the complaint to our office. We found that the board were unable to evidence that A was reviewed by a triage nurse or doctor in person as per their protocol. Given there was no evidence that the appropriate protocol was followed, we upheld the complaint. In addition, having reviewed the handling of C's original complaint, we concluded that the board failed to appropriately investigate and respond to C's complaint.

C complained on behalf of their partner (A) about surgery they had on their hip. A, who had previously had their hip replaced, was admitted to hospital with an infection which was found to have originated in their hip and required surgery (the first surgery). The following year, A developed pain in their hip again. Scans confirmed that this would again require surgery, which was carried out later that year (the second surgery). A was discharged shortly after, but required to be readmitted twice due to pain. On the second readmission a fracture was identified above their knee, requiring additional surgery. C complained about the first surgery, the second surgery, the aftercare A received and how the board responded to their complaint. We took independent advice from a consultant orthopaedic surgeon (a surgeon who specialises in the musculoskeletal system). We found that the first surgery was carried out appropriately. C had been concerned that the surgeon had used an incorrectly sized piece of orthopaedic equipment (a stem), however, we noted that the surgeon either used an identical, or slightly smaller stem as they decided not to remove the original cement. We found that this was reasonable. We found that the second surgery was also carried out appropriately. The surgeon cut a small ‘window’ in the bone to facilitate removal of the cement which was established practice. We considered that this was probably the source of the fracture which A was later found to have, however, there was no indication of a fracture at the time of the surgery. We were satisfied that the care and treatment A received after their second surgery was reasonable. As the evidence indicated that the clinical care provided was reasonable, we did not uphold these complaints. In relation to complaint handling, we found that there was miscommunication regarding delays and a failure to clarify all the issues of complaint. We upheld this aspect of C's complaint.

C complained on behalf of their late sibling (A). A was admitted to hospital to have their pacemaker and the leads, which attach it to the heart, extracted. There was a 2-3% risk of major bleeding and A signed a consent form for the procedure. During the operation, the surgeon successfully removed one of the pacemaker leads but whilst attempting to remove the final two, A's blood pressure suddenly dropped. This was recognised by the anaesthetist and the major haemorrhage protocol was activated. An emergency call for surgical assistance was placed. Despite chest compressions and fluids, staff were unable to stop the bleeding and A died. When the surgeon had tried to remove one of the leads, a tear had been created in one of the major veins around the heart. C complained that the surgery had not been carried out to a reasonable standard. We took independent advice from a consultant cardiologist (a doctor that specialises in diseases and abnormalities of the heart). A's pacemaker, at several years old, would be well embedded in scar tissue. There was infection at the site, and the device was pushing through the front wall of A's chest. There were other options for treating this, but laser lead extraction was the best option for a long-term recovery. The operation appeared to have been carried out reasonably, with staff taking prompt and appropriate action when A's blood pressure dropped. There was nothing more the staff could have done to save A's life once the bleed occurred. We did raise concerns about the consent process. We noted that A had signed a consent form on the day and the risk of major bleeding was noted. However, the board should have used a more detailed consent form with other fields, including alternative treatment options, and that consent should have been obtained prior to the day of surgery as well as the day of it. On balance, we did not uphold the complaint as the evidence indicated that the standard of A's surgery was reasonable.

C complained about the clinical care provided to their child (A) by the board, specifically, that a Chiari malformation (where the lower part of the brain pushes down into the spinal cord) was visible on a magnetic resonance imaging (MRI) scan performed by the board and that the abnormality was not noted until they insisted on a further MRI scan being carried out many years later. A suffered from a number of symptoms including headaches, tinnitus (ringing or buzzing in the ears), vertigo (a sensation of loss of balance or that objects around you are spinning) and drop attacks (sudden falls to the ground) for a number of years. A had MRI scans performed by the board to try to determine the cause of these symptoms. A had a further MRI scan performed by a different health board and it was found that A had a Chiari malformation. 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). We found that it was reasonable to ask only about a possible tumour, and that it would not be possible to make a definitive diagnosis of Chiari malformation from the first MRI images. We concluded that the MRI scan performed then was performed and reported to a reasonable standard. We, therefore, did not uphold the complaint. Related reading View Decision Report 202002582 as a PDF (24.42 KB) Updated: January 20, 2021

C was an in-patient in a general adult psychiatry ward at a hospital outwith the Lothian NHS board area. A referral was made to transfer C and their baby to the Parent and Baby Psychiatric Unit at St John's Hospital but this was refused. C said that they were finding caring for their baby difficult in an adult environment and complained that the refusal was unreasonable. We took independent advice from an appropriately qualified adviser. We found that the decision not to approve the transfer was reasonable from a clinical perspective. We did not uphold the complaint. Related reading View Decision Report 202001512 as a PDF (23.99 KB) Updated: January 20, 2021

Ms C complained about the care and treatment she received from the board for her ongoing health problems. She said that the board initially failed to appropriately diagnose and treat her health condition and then failed to provide her with appropriate care and treatment for her condition. Ms C said she was advised by the board that she had multiple sclerosis (MS) and she never had any reason to doubt the diagnosis, until ten years later she discovered she had a condition which inhibited the absorption of vitamin B12, when she found that supplementing her diet with liquid vitamin B12 resulted in her experiencing improvements in many of her symptoms. We took independent medical advice from a consultant neurologist (a specialist in the diagnosis and treatment of disorders of the nervous system). We found that Ms C’s initial diagnosis of probable MS was appropriate. The evidence suggested that the description given to Ms C of the level of certainty of her MS was reasonable and in line with the actual status of her diagnosis at that time. We found that vitamin B12 deficiency would not be expected to have presented with the pattern of relapsing–remitting disease in Ms C’s case. We considered that there was no indication to have administered vitamin B12 injections in the early stage of Ms C’s illness, as there was no evidence that her condition related to vitamin B12 deficiency. Therefore, we did not uphold this part of the complaint. In terms of Ms C’s subsequent treatment, Ms C raised a number of issues, including that the board did not order a further spinal MRI to compare with the spinal MRI done at the time of her diagnosis. We found that the main purpose of MRI scans in a case such as this was to secure the diagnosis, rather than to monitor progress and there was, therefore, no clear indication to repeat the scans any more regularly than was actually done. We considered that the board provided Ms C with appropriate subsequent care and treatment and did not uphold thi

C, a prisoner, complained about the decision by the prison health care team to discontinue their prescribed pain medication. The decision to discontinue the medication was made after C failed a medication spot check. It was recorded that C did not cooperate and C was deemed to have failed the spot check. We took independent medical advice from a GP. We were unable to reconcile the conflicting accounts provided by C and the board regarding what happened during the spot check. We were unable to conclude that the spot check was not conducted appropriately. In the context of a failed spot check, we concluded that it was reasonable that C’s medication was discontinued. We did not uphold C’s complaint; however, we made a recommendation after we identified an issue with the board’s complaint handling.

C, who had a history of breast cancer, complained that the board failed to provide them with appropriate care and treatment at the Western General Hospital for a lump on their breast. The lump was investigated but found to be of no concern. Two years later, a clinically suspicious lump was identified and investigations showed evidence of an invasive carcinoma (cancer). C raised a number of issues including why a trainee doctor was allowed to perform a biopsy on the first lump identified on their breast and whether the doctor performed the procedure correctly. C also questioned why the lump in their breast was not removed or investigated further. We took independent advice from a consultant breast surgeon. We found that it was acceptable for the trainee doctor to perform the procedure under the supervision of the consultant surgeon, as was the case here, and that there was no evidence that the procedure was performed incorrectly. We also considered that the decision taken by the board at that time not to remove the lump or carry out further investigation was reasonable. C’s case went through the correct process and we determined that C’s treatment was reasonable. We did not uphold this part of the complaint. C also complained that the board failed to provide them with a reasonable response to their complaint. C raised a number of issues, including that the board’s response did not address their specific concerns. We considered that the board’s response generally addressed the questions raised by C and we did not uphold this part of the complaint. Related reading View Decision Report 201900490 as a PDF (24.43 KB) Updated: November 18, 2020

C complained about the care and treatment provided to their parent (A). A, who has vascular dementia and Alzheimer’s, suffered from ill health and C sought medical care and treatment from A’s practice on numerous occasions for what they suspected were urinary tract and chest infections. A had three hospital admissions during this period and C was concerned about the care and treatment provided in particular in the time leading up to each hospital admission. C said that the GPs at the practice focused too much on A’s dementia and unreasonably failed to take C’s concerns about A’s condition seriously. As a result, C said the GPs had failed unreasonably to investigate and treat A’s deteriorating condition including a number of serious infections. We took independent advice from an adviser who specialises in general practice. We found that GPs at the practice had taken C’s concerns seriously and assessed and treated A in a reasonable way. We did not uphold the complaint. Related reading View Decision Report 201803542 as a PDF (24.19 KB) Updated: November 18, 2020

C complained about the care and treatment their parent (A) received at St John's Hospital. C considered that A did not receive reasonable medical or nursing care and treatment; in particular, that their ward placement on a ward which was only used during the winter period to provide additional medical capacity was inappropriate and resulted in A not receiving continuity of care. C raised concerns about A’s weight management and the board’s response to A’s concerns about their vision. The board indicated that they considered that A was appropriately placed and received the same standard of care they would have on any other ward. The board acknowledged that one weekly weigh-in had been missed for A but indicated that improvements had been made in the form of more robust processes in this area of patient care. We took independent advice from a geriatric (medicine of the elderly) and general medical adviser and a nursing adviser. We noted that the board had missed one weekly weigh-in for A and that there had been a delay in ophthalmologist (a specialist in the branch of medicine concerned with the study and treatment of disorders and diseases of the eye) input. However, we concluded that overall A received reasonable care and treatment. Whilst some shortcomings were identified, A was placed in an appropriate ward that, on the whole, appropriately met their needs and they received the same care and treatment that they would have had they been on a general medical ward. Therefore, we did not uphold C’s complaints. Related reading View Decision Report 201810161 as a PDF (24.48 KB) Updated: November 18, 2020

Mrs C complained that the board failed to deal with her complaint in a reasonable way. Mrs C made a complaint and received an acknowledgement but did not hear anything back for seven months. Mrs C asked for an explanation about the delay in keeping her informed and when the health board expected to be in a position to respond to the complaint. In all emails, Mrs C asked to be contacted by email. The health board responded the following month by letter saying that the matters raised were not new (as Mrs C had made several complaints previously) and they were handling the complaint under their unacceptable actions procedure. In reaching our decision, we did not reach a judgement on whether the issues raised were new, but considered whether the health board handled the complaint in a reasonable way and whether their actions were in line with their unacceptable actions procedure. During our investigation, the health board acknowledged their response to Mrs C was insufficiently clear about why they had determined that no further response to the complaint was required and that there was an unacceptable delay in responding to her complaint. Moreover, whilst we appreciated the health board did not email because of concerns about security, we considered that as long as complainants are made aware of any data protection concerns when receiving confidential information by email, then staff should respect a complainant's preferred method of contact. In addition, we found that staff should have signposted Mrs C to this office in their response in line with the NHS Model Complaints Handling Procedure (MCHP). Furthermore, there was no evidence that the health board complied with their unacceptable actions procedure in a number of respects. Overall, we found that the health board did not deal with Mrs C or her complaint in line with their procedure and we upheld the complaint.

C complained that the board failed to carry out further tests when they became aware of the fact that their partner (A) had polyhydramnios (excess amniotic fluid) during pregnancy before giving birth to their baby (B). B was diagnosed with Noonan Syndrome (a genetic disorder that causes a wide range of features, such as heart abnormalities and unusual facial features) after birth. C considered that, if the board had carried out further tests, this may have led to the detection of Noonan Syndrome prior to the birth of B. We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in the female reproductive system, pregnancy and childbirth). We found that the board's staff followed recognised practices when carrying out ultrasound scans and assessing the unborn child. During the 30th week of A's pregnancy, polyhydramnios was first raised as an issue. At that time it was a mild case and no abnormalities were identified with the foetus. By the 36th week of A's pregnancy, polyhydramnios had increased to a moderate case. We found that, whilst polyhydramnios is a feature of Noonan Syndrome, it can be caused by a number of other factors, and no other features of Noonan Syndrome were present. We found that there was no indication for an amniocentesis (a test offered during pregnancy to check if the baby has a genetic or chromosomal condition) to be carried out. If an amniocentesis had been offered, Noonan Syndrome would not have been identified, unless a specific test for this had been carried out. We did not uphold this complaint. Related reading View Decision Report 201901919 as a PDF (24.52 KB) Updated: October 21, 2020