SPSO Individual Decisions

C complained about the care and treatment provided to their late adult child (A) during an out-of-hours (OOH) GP visit. A had been experiencing symptoms including exhaustion, vomiting, and lack of appetite. A was examined and given anti-sickness medication, and advised that they should contact their own GP the next day for urgent follow-up review. A died the following day of acute myeloid leukaemia (an aggressive and fast progressing cancer of the white blood cells). We took independent advice from a GP. We found that, because A was clinically stable (i.e. blood pressure, pulse and oxygen levels were normal), it was reasonable for the OOH service to advise for A to see their normal GP the following day for further investigations, particularly given that the OOH GP service cannot undertake investigations such as blood tests. We did not uphold this aspect of C’s complaint. However, we noted that the board had undertaken significant review of the events, and although the conclusion was that the OOH GP service did not act unreasonably in their appointment with A, we considered that the board had taken significant steps to ensure that all learning possible has been taken from this case. C also complained that the board’s handling of their complaint was unreasonable, as they considered that the family should have been more involved before any investigation took place. We considered the board’s actions in relation to complaints handling to have been reasonable and we did not uphold this aspect of C’s complaint. Related reading View Decision Report 201910708 as a PDF (24.48 KB) Updated: December 16, 2020

Mrs C complained about the care and treatment she received at Ninewells Hospital. Mrs C had previously received treatment for breast cancer and had been monitored over the years following this. Mrs C complained that a mammogram (an x-ray test of the breasts) was not performed at a review appointment. The board said that Mrs C had already received the last of the planned annual follow-up mammograms and she did not require one when she attended for a review. We took independent advice from a consultant breast surgeon. We found that Mrs C had received follow-up mammograms in accordance with national and local guidelines. We concluded that it was reasonable that Mrs C was not offered a mammogram at the review. We did not uphold Mrs C’s complaint. Mrs C also complained that she was not offered an emergency appointment for breast imaging following a consultation with the Lymphoedema Service (a service managing problems with the lymphatic system, a network of vessels and glands spread throughout the body). We found that it was reasonable that Mrs C was not offered emergency breast imaging and we did not uphold this complaint. Finally, Mrs C considered that the board’s response to her complaint contained inaccurate information. We reviewed the evidence available and we were unable to conclude that the board had provided inaccurate information. We did not uphold this complaint. Related reading View Decision Report 201705275 as a PDF (24.34 KB) Updated: November 18, 2020

C, an advocacy worker, complained to us on behalf of their client (B) about the care and treatment the board provided to B's spouse (A). During our investigation, we took independent advice from an adviser in respiratory and internal medicine. In 2011, A's GP referred them to the board, after an x-ray showed irregularities in their lungs. For around two years, A was followed up at the respiratory medicine clinic with chest x-rays. Medical staff concluded the lung irregularities were unlikely to be cancerous and A was discharged. Around that time, A was diagnosed with rheumatoid arthritis (a long-term condition that causes pain, swelling and stiffness in the joints). In late 2017, A was diagnosed with small cell lung cancer at Ninewells Hospital that had already spread to their liver. A died shortly afterwards. C complained that between 2011 and 2013, the board failed to diagnose A with lung cancer. We found A was given appropriate follow-up with chest x-rays and it was reasonable the lung irregularities were not considered to be cancerous. We did not uphold this complaint. C complained that between 2013 and 2017, A was experiencing symptoms of lung cancer that were wrongly attributed to rheumatoid arthritis. We found that it was reasonable A was diagnosed with rheumatoid arthritis. We found A had not reported cancer related symptoms at their rheumatology reviews. We also found that as small cell lung cancer is very aggressive, the symptoms would usually develop over months and not years. We did not uphold this complaint. C also complained that A's discharge letter from Ninewells Hospital was unreasonable, as it contained incorrect information about A's condition. The board acknowledged there was an error in the discharge letter. We found the discharge letter was unreasonable due to the error and we upheld this complaint.

C complained about the care and treatment they had received from the board and that the board failed to communicate reasonably with them. C was diagnosed with breast cancer and felt they were not able to have a full discussion of the treatment options for their condition and that they were not being given the opportunity to make informed decisions about their care. C sought a second opinion from a different health board and said they were offered a much fuller discussion of their treatment options, including some tests which were not offered by Tayside NHS board. C complained to the board about the differences in the treatments offered. C noted that the board appeared to be alone in not using a specific test and that their approach was outdated and not patient centred. C did not feel the board’s justification, that the test might cause anxiety amongst its patients, was in line with patient centred medicine. C also pointed to a Healthcare Improvement Scotland (HIS) report into practices within the board’s oncology (study and treatment of tumours) department. This had found areas for improvement, including communication with patients and the use of the test in question. The board said they did not agree that the tests offered to C when they received their second opinion were necessary or required by clinical guidance. The board had accepted the findings of the HIS report, but did not agree that the test should have been offered in C’s case. We took independent medical advice from a consultant oncologist. We found that the majority of oncologists would have offered the test in dispute, as it would have helped to guide discussions with C. In addition, the medical records did not record whether a detailed discussion was held with C about their treatment options. We found that C’s care and treatment had fallen below a reasonable standard as they were not able to have a full discussion of all the treatment options available to them and because they were not offered testing

C complained about the care and treatment provided to their child (A) by the board when A had various ear, nose and throat symptoms. A was admitted to Ninewells Hospital following a number of visits to their GP, and received treatment with steroids, antibiotics and oxygen. A was discharged after two nights with a plan for a follow-up sleep study. C complained that the board had not provided A with appropriate oxygen treatment, and that it was unreasonable for them to be discharged. We took independent advice from a consultant paediatrician (a medical practitioner specialising in children and their diseases). We found that, overall, the care and treatment provided to A was reasonable, and that there was appropriate monitoring, documentation, and escalation of care. We considered the oxygen treatment and discharging A to be reasonable. We, therefore, did not uphold C's complaint. Related reading View Decision Report 201904552 as a PDF (24.13 KB) Updated: October 21, 2020

Mrs C complained that the practice had failed to properly investigate a series of complaints she had made about entries in her and her children's medical records. Mrs C believed the practice's conclusions were unreasonable given the available evidence. Mrs C also complained that the practice failed to communicate appropriately with her. We took independent advice from an adviser on general practice medicine. We found that the practice had reasonably and appropriately investigated the complaints brought to it by Mrs C and had communicated reasonably with her. Some of the medical record entries that Mrs C objected to were the opinions of the GP following their encounter with her. We considered that it was reasonable for medical records to contain subjective opinion and it was not possible to amend or delete the entries Mrs C was concerned about. In addition, the practice had offered Mrs C the opportunity to place notes in her medical records, indicating that she disagreed with the content or tone of the entries. Mrs C had not responded to these offers. We did not uphold any of Mrs C's complaints. Related reading View Decision Report 201804064 as a PDF (24.23 KB) Updated: October 21, 2020

C brought a complaint to us about the care and treatment given to their late spouse (A) who had a diagnoses of myeloma (a type of cancer arising from plasma cells found in the bone marrow). C told us the reasons they considered the board had provided A with unreasonable clinical care and treatment were that there had been a delay in the diagnosis and treatment of endocarditis (an infection of the endocardium, which is the inner lining of the heart chambers and heart valves); there had been a lack of communication about A's state of health, and their prognosis was not communicated until three days before they died. Finally, A had been discharged home although they were very ill. C also raised a number of concerns about the nursing care and treatment given to A, in particular that there had been a lack of communication and that the level of general nursing care and treatment was unreasonable. We took independent advice from a consultant in cardiology, a consultant in acute medicine, a haematology consultant and from a nurse. We found that overall the cardiology care and treatment was reasonable, also that the care and treatment from an acute medicine perspective was appropriate. We also found that the haematology care given to A was reasonable and in line with the British Society of Haematology and UK Myeloma forum 'Guidelines for screening and management of late and long-term consequences of myeloma and its treatment'. However, we considered that there had been poor communication with A's family, in particular around the significant risk associated with their illness and the risk that their condition would ultimately prove to be untreatable. The board had accepted there were gaps in communication and detailed the action taken to improve communication with the patient and their family. As such we upheld the complaint. In relation to the nursing care and treatment given to A, we found that there was clear documentation of care needs, ongoing evaluation and asses

C complained to us about the board, as they held a number of concerns regarding the board's management of their medication for ADHD, pain (they suffer from fibromyalgia), and insomnia. C also considered that the board had failed to take reasonable account of their needs in the way they had communicated with them. We took independent advice from a consultant psychiatrist. We found that C's medication was appropriate for the management of their diagnosed conditions. We did not consider that there was any evidence of unreasonable communication which failed to take account of C's needs. Therefore, we did not uphold C's complaints. Related reading View Decision Report 201902399 as a PDF (24 KB) Updated: September 23, 2020

C complained about the care and treatment they received from the board. C’s local NHS board referred them to a consultant bariatric (branch of medicine that deals with the causes, prevention, and treatment of obesity) surgeon at Tayside NHS Board. C complained that, although they had made lifestyle and health changes as requested by the multidisciplinary specialist weight management team, they were not put forward for surgery on a number of occasions. C complained that a consultant bariatric surgeon acted inappropriately during consultations with them and that information C provided upon request was ignored when considering their suitability for surgery. C considered the delays to their surgery to have been unreasonable and raised further complaints about the board’s handling of their concerns. We found that the consultant bariatric surgeon inappropriately required C to bring their test results to a consultation and inappropriately referred to them having made a complaint during a consultation. We found that the decision to postpone the surgery until such time as C’s diabetes was being better managed was reasonable. However, in relation to the decision to postpone surgery, we found that the board’s poor administration of C’s case and poor communication with them led to C not being suitable for surgery. We found, therefore, that this had led to C’s request for later surgery being denied and that the board had contributed to this situation. We found that the board had taken reasonable action in response to C’s complaint but that they had unreasonably failed to advise C of the outcome of a multidisciplinary team meeting. We, therefore, upheld the complaint.

Mr C sustained a serious pelvic injury with internal bleeding following a road traffic accident and was admitted to Ninewells Hospital where he underwent surgery to repair the internal bleed and his fractured pelvis. Mr C suffered a further internal bleed and complained that there was a delay in identifying this bleed. Mr C also complained that the physiotherapy input he received following his surgery was unreasonable and may have caused his fracture to move; and that he was provided with inappropriate pain relief and his respiratory rate was not monitored properly. The board considered that Mr C was monitored appropriately and that any delay in identifying the internal bleed was due to the fact that the CT scan was occupied by another patient. The board also considered that the physiotherapy input and pain relief provided were reasonable. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system), a physiotherapist and a general physician . We found that Mr C was appropriately reviewed and monitored and that there was no unreasonable delay in identifying the internal bleed. We also considered that the pain relief provided was appropriate and Mr C's respiratory rate remained stable. We did not uphold these complaints. However, with regards to the physiotherapy input, we found the standard of record-keeping to be poor and there was a failure to establish a treatment plan with agreed goals. As such, we upheld this complaint.

C is the parent of a teenaged adult (A). A was admitted to an acute admissions ward of a mental health unit as an informal patient. The following day, A contacted C from the ward. A told C that they were in possession of razor blades and intended to self-harm. C contacted the ward to advise them of this and ward staff obtained the razor blades from A. A day later, A contacted C and told C they had left the hospital. C contacted the ward and the police, and A was returned to the ward. A was transferred to another location shortly afterwards. C complained that A had not been properly searched or reasonably assessed on their first arrival at the ward. The board told C that the routine risk assessment at admission had shown no indication A was at risk of absconding, and that this had led to the decision not to lock the ward door. They also said that a check of A's belongings when they were admitted had led to razor blades being taken from A's possession. C was dissatisfied with the board's response and brought their complaint to us. We took independent advice from a mental health nurse. We found that A had not been properly searched upon their arrival, that it was unreasonable that the board had not carried out a medical, nursing or joint assessment on the day of A's admission and that the standard of assessment and care-planning at the point of admission fell significantly below professional expectations. We upheld C's complaint. C also complained that the board unreasonably failed to call C, as they had promised, following C reporting A was in possession of razor blades and intended to self-harm. We found that the available written evidence and staff recollection did not support C's recollection that they had been promised someone would call them back. Therefore, we did not uphold C's complaint.

Ms C complained to us about the care and treatment she received from her GP practice. She said that staff at the practice had not listened to her and had not provided reasonable care and treatment for her adhesions, diarrhoea and Myalgic Encephalomyelitis (ME; a long-term illness with a wide range of symptoms including extreme tiredness). She also said that the practice seemed fixated by her having depression and that she needed bereavement counselling or antidepressants without understanding her situation. We took independent advice from a GP. We found that there was no evidence that staff had not listened to Ms C and that they had provided reasonable care and treatment in relation to her adhesions, diarrhoea and ME. It was also reasonable for the practice to offer Ms C bereavement counselling along with other treatment in relation to this. We considered that the care and treatment provided to Ms C was reasonable and we did not uphold the complaint. Related reading View Decision Report 201807031 as a PDF (24.15 KB) Updated: July 22, 2020

C underwent an operation to their eye at Ninewells Hospital. C considered that they were not provided with information about the medical reasons why an operation to their eye was necessary. There were complications following this surgery. C raised concerns about what happened and why there was a failure to involve them in discussions about subsequent treatment options. C was concerned that the operation was not necessary and put them in a worse position than they had been before the operation. We took independent advice from an ophthalmologist (a specialist in the branch of medicine concerned with the study and treatment of disorders and diseases of the eye). We considered that the operation was necessary. However we found that: there was no evidence in the clinical notes that C was informed about the reasons for their options for treatment when they attended the hospital; there was no evidence in the clinical notes that the risks of surgery were specifically discussed with C. There were the usual risks of bleeding and infection, but in this case there were also extra risks; when C presented with severe pain after the initial eye surgery they should have been able to attend Ninewells Hospital within the same day to obtain advice from the surgical team who carried out the operation. We found that there was an unreasonable delay in C obtaining definitive treatment from the hospital after they suffered a complication from the original surgery; and there was an unreasonable failure to include C in any subsequent discussions about treatment options after the first operation. We upheld C's complaint.

Mr C complained about the care and treatment his partner (Mr A) received from the board. Mr A was diagnosed with Functional Neurological Disorder (FND, a condition in which patients experience neurological symptoms such as weakness, movement disorders, sensory symptoms and blackouts) and depression. Mr A was seen by a consultant neurologist (a specialist in the diagnosis and treatment of disorders of the nervous system) at a neurology clinic. Mr C complained about the length of time it took to arrange appointments for the joint Functional Neurological Clinic (the joint clinic); the communications surrounding these appointments; the changes in medication and the lack of subsequent review. Mr C also complained about the length of time it took the board to respond to the complaint. We took independent advice from a consultant psychiatric adviser. We found that, whilst the clinic appointment waiting time was not ideal, there was no unreasonable delay in the circumstances. We also did not identify any unreasonable delays in Mr A's follow-up appointments being arranged. Whilst there was some communication shortcomings, we did not consider that these amounted to unreasonable failings. However, given there was no record of a discussion with Mr A about the potential adverse effects of increasing his medication, on balance, we upheld this complaint. We also found that the board had accepted that the delay in responding to the complaint was excessive and that they had apologised accordingly. We upheld this aspect of the complaint but made no further recommendations.

Mr C complained to us on behalf of his late father (Mr A) who was diagnosed with, and subsequently died as a result of, septic arthritis (a serious type of joint infection). Mr C complained that the board failed to provide reasonable care and treatment in relation to Mr A's shoulder pain at a minor injuries unit (MIU) consultation and at 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) consultation. Mr C also complained that the board did not refer Mr A for x-ray or to orthopaedics (conditions involving the musculoskeletal system). Mr C considered that this had caused delays with Mr A being ultimately diagnosed with joint sepsis. We took independent advice from an emergency nurse practitioner and from a consultant physiotherapist. We found that the board's consultations with Mr A were unreasonable in that Mr A should have been referred for an x-ray at the MIU consultation and that Mr A's presenting symptoms were not appropriately assessed at the physiotherapy consultation; it also had not been demonstrated that infection had been ruled out as a differential diagnosis. We found that Mr A should have been referred for further investigations/assessment at the physiotherapy consultation. Therefore, we upheld this complaint.

C arrived at Ninewells Hospital's emergency department by ambulance. After an initial assessment C was transferred to a mental health unit. C complained about the treatment provided at both locations. We took independent psychiatric advice. We found that the treatment provided at Ninewells Hospital was reasonable, C was appropriately assessed and managed, with an appropriate referral to psychiatric services and appropriate steps taken to maintain C's safety. We did not uphold this aspect of the complaint. We found the treatment provided at the mental health unit was also reasonable. A thorough examination of C was undertaken and during C's admission adequate monitoring and care of C was provided. We did not uphold this complaint. Related reading View Decision Report 201803809 as a PDF (24.03 KB) Updated: June 17, 2020

Ms C complained to us about the practice after she was diagnosed with secondary breast cancer in her lymph nodes. She had been attending the practice with a number of separate symptoms including a drooping right eye, fatigue; pain in her right shoulder, a rasping voice, vomiting and fainting. She did not consider that these symptoms were ever properly considered as a whole, which may have prompted an earlier diagnosis. She was also concerned that there was a failure to appropriately ready her for the diagnosis, claiming she had been repeatedly reassured her symptoms did not point towards a serious diagnosis. We took independent advice from a GP. We found that the symptoms were relatively common and were not suggestive of a cancer diagnosis. Given this, we considered that the practice's communication with Ms C had been reasonable. We did not uphold either of Ms C's complaints. Related reading View Decision Report 201903361 as a PDF (24.16 KB) Updated: June 17, 2020

Mr C, an MSP, complained on behalf of his constituents Ms B and Ms A (Ms B's daughter) about the service provided by a community mental health team (CMHT). Ms A was a young adult with Asperger's Syndrome (a form of autism, in which people may find difficulty in social relationships and in communicating) and she received treatment for obsessive compulsive disorder (OCD, a common mental health condition where a person has obsessive thoughts and compulsive behaviours) and depression. During our investigation of Mr C's complaint, we considered the evidence provided by Mr C and the board. We also received independent advice from a consultant psychiatrist. Mr C raised concern that the CMHT did not provide Ms A with reasonable mental health care and treatment. We considered that the doctors involved in Ms A's care appropriately took into account her Asperger's Syndrome and we found that the treatment provided for Ms A's OCD and depression was reasonable. We did not uphold this complaint. Mr C complained that the CMHT failed to provide Ms B with reasonable advice and information to support her as a carer for Ms A. We found that Ms B and Ms A were given details of support organisations and Ms B was offered a carer's assessment. However, we did not find sufficient evidence that general information about management of conditions was provided to Ms B. On balance, we upheld this complaint. Finally, we considered whether the board provided a reasonable response to Mr C's complaint. We found that the board had accurately identified and responded to many of the complaints raised. However, we noted that the board did not address all the points that Ms B raised separately. We were unable to conclude that the board provided a full response to the points Ms B raised in line with the requirements of the NHS Scotland Complaints Handling Procedure. On balance, we upheld this complaint.

Mrs C complained that she had not been provided with appropriate treatment at a dental hopsital. Mrs C said that she had been suffering from severe pain for an extended period, due to a poorly fitting denture. We took independent advice from a dental advisor. We found that Mrs C had been reviewed appropriately and when she had expressed concerns, her care and treatment had been assessed by a number of different specialists. Mrs C had been treated reasonably and appropriately. Mrs C also complained that a referral to a specialist at a different health board had been cancelled by Tayside NHS board. Mrs C felt this was also unreasonable. We found that Mrs C had not met the criteria for a referral to a different board, as her treatment could reasonably be provided locally. We also found that Mrs C's complaint was handled by the board in line with their complaints handling process and whilst we recognised that she did not agree with the outcome, this did not constitute evidence of maladministration on the part of the board. We did not uphold Mrs C's complaints. Related reading View Decision Report 201801062 as a PDF (24.19 KB) Updated: March 18, 2020

Miss C complained about the care and treatment she received from Ninewells Hospital in relation to the birth of her child. Miss C highlighted that her child has brain related problems. Miss C also complained about the time it took for the board to respond to her complaint. Following the birth of Miss C's child, the board conducted a Local Adverse Event Review (LAER) to detail the root causes and key learning from an adverse event. The LAER found that the root cause was that Miss C had hyponatremia (low sodium concentration in the blood - a rare complication in low-risk labouring women). The LAER identified a number of concerns in terms of the administration of intravenous (IV) fluids on the midwifery unit, timing of blood tests, confusion surrounding the need to transfer Miss C due to her behaviours and significantly altered conscious state, and the obstetric (pregnancy and childbirth) team not being informed of the transfer and associated concerns. As a result, the board took action to address these issues to ensure learning and improvements. We took independent advice from a consultant obstetrician and a midwife. We noted that Miss C was a low-risk patient at the beginning of her labour in the midwifery unit. We found that the progress of the first stage of Miss C's labour was unreasonable and she was given excessive fluids orally and by IV infusion which was not recorded on a fluid balance chart or reviewed by medical staff prior to IV fluids being given, after which she became unresponsive. We also found that, despite not having any sedating analgesia (pain relief), the deterioration in Miss C's condition was not recognised and assistance was not requested. There was an unreasonable delay in transferring her to the labour ward, with unfamiliar staff being involved in the transfer and key information not communicated effectively to the new team. However, we were unable to say what effect earlier detection and treatment would have had on the outcome for h

Mr C complained to us on behalf of his late father (Mr A) who was diagnosed with and subsequently died as a result of septic arthritis (a serious type of joint infection). Mr C complained that the practice failed to provide reasonable care and treatment in relation to Mr A's shoulder pain, including providing phone consultations rather than face-to-face assessments and that the practice did not refer Mr A for x-ray or to orthopaedics (specialism that deals with diseases and injuries of the musculoskeletal system). Mr C considered that this had caused delays with Mr A being diagnosed with joint sepsis. We found that the practice's consultations and care and treatment that Mr A received were reasonable, including referring Mr A to physiotherapy. Therefore, we did not uphold this complaint. Related reading View Decision Report 201808146 as a PDF (24.1 KB) Updated: March 18, 2020

Ms C complained on behalf of her late uncle (Mr A) about the care and treatment he received from his GP practice. Ms C complained that the practice failed to treat Mr A as an urgent patient, even though he was experiencing symptoms that could have been caused by a stroke. We took independent medical advice from a GP. We found that when Mr A contacted the practice, he did not provide information that suggested it was an emergency and it was reasonable that the GP arranged to see him later that week. However, the next day, Mr A's wife (Ms B) contacted the practice with concerns about Mr A's condition worsening and she spoke to another GP. Ms B asked for Mr A to be seen earlier but this was refused. We found that during this phone call, the GP failed to carry out an appropriate assessment of Mr A's condition, did not communicate reasonably, and inappropriately failed to see Mr A urgently, even though the symptoms Ms B described could have been caused by a stroke. We upheld Ms C's complaint.

Ms C complained that Ninewells Hospital failed to provide her with reasonable care and treatment when she was admitted for investigations by the gastroenterology (branch of medicine which deals with disorders of the stomach and intestines) team. We took independent advice from a consultant gastroenterologist. We found that the treatment Ms C received was reasonable and that it was appropriate for a senior gastroenterologist to review her situation before determining what other investigations should be carried out. We did not uphold this aspect of the complaint. Ms C also complained about a failure to provide her with a reasonable response to her complaint and within a reasonable period of time. We found that communication with Ms C regarding a change to her care management plan was unreasonable; there was a failure to let her know what was happening as she received an appointment for a clinic review rather than a colonoscopy. This was a communication error in the internal referral process. Therefore, we upheld this aspect of the complaint. Wenoted that the board have already taken action to address this failing so madeno further recommendations. Related reading View Decision Report 201804379 as a PDF (23.9 KB) Updated: November 20, 2019

Mr C complained about the clinical and nursing care and treatment provided to his late wife (Mrs A) during her admission to Ninewells Hospital. Mrs A was admitted with a history of leg swelling and a failing liver. We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines) and from a nurse. In relation to the clinical care and treatment given to Mrs A, we found that the majority of the clinical management of Mrs A had been reasonable. However, we found that Mrs A's infection could have been handled better and that antibiotic therapy should have been started earlier. Given the failings identified, we upheld this aspect of the complaint. In relation to the nursing care and treatment given to Mrs A, we found that the care delivered, documented and communicated was lacking at times. Also the specialist knowledge of nurses managing a patient with decompensated liver disease was lacking and the interventions needed to ensure a clear treatment plan was in place. We upheld this aspect of Mr C's complaint. However, we noted that the board has accepted and apologised for the failings in communication. Mr C also complained that the board had failed to record an incident on the ward, in a reasonable way. The board accepted that on this occasion the actions of the nursing team fell below the standard they aimed to provide and apologised to Mr C. Therefore, we upheld this aspect of the complaint.

Mr C complained about the care and treatment the board provided to his late wife (Mrs A). In particular, he was concerned that there had been a delay in diagnosing an occurrence of cancer. In response to Mr C's complaint, the board did not identify any delay in the diagnosis. Mrs A was initially diagnosed with bowel cancer. Surgery was performed to remove part of Mrs A's bowel, and she also received chemotherapy treatment. Mrs A received follow-up care from the colorectal (conditions of the colon, rectum and anus) and oncology (cancer) teams. In this period, she continued to experience abdominal symptoms. Following an annual surveillance scan, peritoneal cancer (a cancer that develops in a thin layer of tissue that lines the abdomen) was diagnosed. Mrs A received palliative treatment until she later died from her illness. We received independent advice from a colorectal surgeon and a 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 the abdominal symptoms Mrs A experienced were associated with the treatment she received for bowel cancer. We also noted that development of primary peritoneal cancer was very rare. Therefore, we concluded that there was no failing by the board to have identified peritoneal cancer at an earlier stage. We did not uphold this complaint. Related reading View Decision Report 201804687 as a PDF (24.02 KB) Updated: November 20, 2019