SPSO Individual Decisions

C complained about the care and treatment provided to their late spouse (A). A was suffering from facial pain and numbness and underwent an MRI scan. The MRI reported a benign slow growing tumour at the base of A's skull which can usually be managed with pain killers or sometimes stereotactic radiosurgery (SRS, a high dose of radiotherapy to a small area) is considered. Shortly after, A's local health board referred A to Lothian NHS Board for treatment. A attended a telephone consultation with a neurosurgery consultant (specialist in surgery on the nervous system, especially the brain and spinal cord). A was not considered to have a diagnosis of cancer given the findings of the MRI scan and was referred on a routine basis for consideration of SRS treatment. A's case was subsequently reviewed at a multidisciplinary team meeting by clinicians at Lothian NHS board. It was identified from a review of the MRI report received from A's local health board, that there were other not previously identified lesions in A's brain, which were in keeping with metastases (cancer that has spread from other areas of the body). A was referred on an urgent basis to their local health board for further investigations including an MRI scan and CT scan. A was diagnosed with cancer and died shortly after. We took independent advice from a consultant neurosurgeon. We found that the MRI report did not show any sinister findings which required urgent intervention and that the board took appropriate action. However, the review of the MRI at the subsequent multidisciplinary team meeting identified metastatic lesions. We considered that the review of the MRI took place within a reasonable timeframe. We took additional advice from a consultant radiologist (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) about the findings of the MRI performed by A's local board. We found that the report had not detected tiny abn

C raised complaints about the nursing and medical care their parent (A) received whilst in hospital. English was not A's first language and C also raised complaints about the board's communication with A and their family and whether appropriate follow-up care was provided by the board following C's discharge. The board had accepted that A's nursing care fell below a reasonable standard in several areas, including the standard of record-keeping, the failure to discuss A's personal care with their family, and the assumptions that were subsequently made about A's preferences in relation to this. The board provided us with the nursing action plan they had developed following C's complaint. We took independent advice from a clinical nurse lead and a consultant geriatrician (specialist in medicine of the elderly). We found that the board's actions and action plan had been reasonable overall but there were some areas where the action plan could be improved. We upheld this part of C's complaint. Similarly, the board accepted that the standard of communication with A and their family fell below a reasonable standard and had apologised for this. We found that the board's verbal and written communication could have been significantly improved, including their record-keeping. While the majority of issues were addressed by the action plan, there were some specific issues where staff could receive further feedback. We upheld this part of C's complaint. C had been specifically concerned about modifications to A's medication and monitoring and treatment of A's feet. We found that the board's actions in relation to these had been reasonable and that A's medical care had been, overall, reasonable. We did not uphold this part of C's complaint. Finally, the board had acknowledged their management of A's discharge and the communications associated with it, fell below a reasonable standard and had taken action with the aim of preventing any recurrence of this. We found that the actions p

C, an advocacy worker, complained on behalf of their client (A) about the care and treatment provided by the board during a four day admission to hospital. A, a type 1 diabetic (a condition where blood glucose levels are too high because the body cannot make the hormone insulin), was admitted for lower abdominal pain. A received an ultrasound scan on the following day which proved inconclusive. The next day A received a CT scan which showed free fluid, in keeping with a burst ovarian cyst. A was discharged the following day. C complained that A was discharged, having received no treatment, in pain, and without follow-up referrals. C complained that as a type 1 diabetic, A’s diabetes and food intake had not been correctly managed. The board said that treatment, discharge, and diabetes management were appropriate. The board apologised for not offering meals after breakfast on the day of discharge. We took independent advice from a gastrointestinal and general surgeon (specialist in the digestive system). We found that A’s nutritional intake had been appropriately restricted due to investigations which were necessary to rule out surgery. A's diabetes had been appropriately managed via an insulin infusion called a sliding scale. We found that no treatment or follow-up care would be indicated for a burst ovarian cyst as this would usually resolve itself. We found that prior to discharge, A’s pain had reduced such that they were able to manage it with paracetamol alone and that discharge was therefore appropriate. Therefore, we did not uphold this part of C's complaint. C also complained about the quality of complaints handling. We found that although there was a delay in providing a complaint response, this was because a meeting was being organised and that C was appropriately informed of the delays. Post decision correspondence was also delayed. However, this did not breach the Model Complaints Handling Procedure, which does not specify timescales for post decision corr

C had a history of multiple facial trauma and had undergone various procedures over the last decade in relation to their nose and face. C then received further injury which caused damage to their nose. C complained that the board refused to perform any further investigations or the reconstructive surgery they considered was required. This was despite numerous GP referrals to the ear, nose and throat (ENT) department. C stated that they continued to suffer ongoing pain and symptoms associated with their facial injuries. C complained that the board were acting on the basis of a psychological assessment from a number of years ago, which suggested investigation and treatment could be damaging to C. C strongly objected to the content of this assessment. We took independent advice from an ENT surgeon. We found that it was reasonable for the board to take into consideration the psychiatric assessment that warned against unnecessary investigations and treatment unless indicated on objective grounds. However, we considered that given the passage of time since that document was produced, and because C had recently been assaulted potentially causing new injury, it was reasonable for C to be reassessed. Therefore, we upheld C's complaint. We also noted failings in relation to complaint handling and made a recommendation to address this.

C complained that the board failed to provide reasonable care and treatment to their late parent (A). A was admitted and discharged from hospital on two separate occasions. A died shortly after their third admission to hospital. We took independent advice from a consultant in geriatric medicine and general medicine (a specialist in care of the elderly). We found that while some aspects of A’s care were reasonable, particularly in relation to cardiac (heart) care, given the complexity and combination of A’s conditions, age and frailty, A should not have been discharged the day after their first admission. A should have remained in hospital given that a deterioration in their condition was very likely to occur, and as they also required further detailed assessment of their mobility. It was determined that A’s combination of problems would have required inpatient care even for a previously healthy patient and the acute exacerbation of A’s conditions would have been profound and life threatening. We also found that there was a lack of detailed assessment of A’s mobility difficulties prior to being discharged. We found that the board failed to take account of the evidence in A’s records that they had struggled with their mobility and had needed supervision and support. We noted that an assessment of A’s mobility had been part of the medical plan at the time of their first admission. Given the severity of A’s illness, age, and the difficulty with walking, there should have been a specific and detailed assessment of A’s mobility prior to their discharge. We also found that the board failed to provide a full response to C’s complaint. Taking account of the evidence and the advice we received, we upheld C's complaint.

C complained that the board failed to provide appropriate care for their parent (A) when they were admitted to A&E. A had a cut on their leg which was not treated because the board said they had not been made aware of it. C said that this was not acceptable, noting that patients are not always able to make staff aware of their symptoms. We reviewed the medical records and took independent advice from a consultant in emergency and retrieval medicine. We noted that the explanations provided by the board as to why they were not aware of the wound, and did not treat it at the time, did not tally with the information in the medical records, where it was noted that A had been admitted with a cut to the knee. We progressed the complaint to investigation and asked the board to comment on the initial findings and suggested a resolution approach would be welcome. The board responded, stating they wished to move to resolution and would meet the outcomes asked for. We accepted this outcome. Related reading View Decision Report 202106164 as a PDF (24.27 KB) Updated: March 22, 2023

C complained on behalf of their partner (A). A had a telephone consultation with the practice and reported haemoptysis (coughing up blood) and a fever. A also reported that they had taken a lateral flow test for COVID-19 which was negative. A did not take a PCR test for COVID-19 prior to contacting the practice. The practice considered it was likely that A had COVID-19 and advised that they self-isolate for ten days after symptoms started. A's condition deteriorated and several weeks later they were admitted to hospital and diagnosed with bacterial pneumonia. C complained that the practice did not offer A a face to face appointment and subsequently failed to correctly diagnose their condition of bacterial pneumonia, instead focussing on COVID-19 as being the cause of A's illness. The practice considered that they had been following the guidelines in place at the time and had correctly signposted A to the COVID-19 Hub for further assessment. We took independent advice from a GP. We found that there was no evidence in the clinical record that A had been signposted to the COVID-19 Hub and that haemoptysis was never listed as one of the common symptoms of COVID-19 infection. We found there was a failure to offer A a face to face appointment, particularly given they had reported haemoptysis. We welcomed that during our investigation the practice reflected further and accepted that A's complaint of haemoptysis merited further clinical consideration and assessment. Given that the practice have taken appropriate and sufficient action to learn and improve from this complaint, we did not recommended that they take any further action. However, we recommended that they apologise to C and A for not offering A a face to face appointment.

C complained that the practice failed to refer them for an x-ray following a fall, which contributed to a delay in diagnosing fractured vertebrae. C attended A&E following their injury and then attended the practice a few days later (first consultation). C then had a GP telephone appointment the next day due to ongoing pain (second consultation), and subsequently attended the practice again in person some weeks later (third consultation). C complained that their symptoms were not fully investigated and an obvious bend in their neck was overlooked. We took independent medical advice from a GP. We found that the practice’s actions at the first and second consultations were reasonable in relying on the outcome of the recent A&E assessment, and that an onward referral for x-ray imaging was not indicated at that point. We found, however, that C’s ongoing pain should have been considered persistent by the time of the third consultation, and that their spinal tenderness should have been regarded as significant. We found that these symptoms should have been regarded as ‘red flag’ symptoms (possibly indicative of a more serious pathology), and should have triggered onward referral for imaging assessment. Instead, C was referred for physiotherapy following the third consultation. C subsequently contacted the practice on a fourth occasion to request that this referral be expedited. A GP received this message and concluded that C did not meet the criteria for an urgent referral. The GP did so without taking a history and/or examining C. We found that it was unreasonable to make this decision without evidence. If an examination had been arranged following this fourth contact by C, it may have given rise to an x-ray referral. We concluded that the practice unreasonably missed opportunities to refer C for an x-ray at the third consultation, as well as at the time of C’s subsequent contact regarding the physiotherapy referral. On balance, we upheld this complaint. We no

C complained about the care provided to their late parent (A). The practice visited in the morning and found them to be coherent and capable of declining a full examination. A's carers left around midday and did not have any specific concerns about A. By the evening, A's condition had deteriorated and they were taken to hospital. A died two days later. We took independent advice from a GP adviser. We found that there was evidence of appropriate communication between the GPs and other professionals and agencies involved in A’s care. Therefore, we did not uphold the complaint. Related reading View Decision Report 202007688 as a PDF (24.11 KB) Updated: February 15, 2023

C complained about the care and treatment provided to their late adult child (A). A had been admitted to hospital from police custody due to cellulitis in their hand. A was monitored overnight and discharged the following day. A was readmitted several days later following a cardiac arrest. On resuscitation, a cannula (a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of samples) was found in A’s arm dated the day of their initial admission. A’s condition deteriorated and they died a few days later. C was concerned that A’s mental health issues were not taken into consideration and that it had been unreasonable to discharge A without these being assessed. C also believed it was unacceptable for A to have been discharged with a cannula in place given A’s known drug misuse. C believed that these failings led directly to A’s death as they had used the cannula to administer drugs immediately before suffering a cardiac arrest. The board had carried out an Adverse Event Review (AER) following C’s complaint. This found a number of failings in A’s care. It made recommendations to try and address these. We took independent medical advice from a consultant in emergency medicine. We found that there had been a full investigation of the case. The key learning points had been identified and actions were being taken to reduce the likelihood of a similar incident occurring in future. There was no evidence of failings which had not been addressed by the AER. We upheld C’s complaints due to the acknowledged failings in A’s care.

C complained about the orthodontic care (dentistry dealing with the prevention and correction of irregular teeth) provided to their child (A), particularly that A's treatment had been unreasonably discontinued. The dental practice's decision to discontinue was based on a failure to comply with the requirements of the orthodontic treatment. C complained that the orthodontist had not raised any significant concerns previously, and that there had been a lengthy period without review due to Covid-19 restrictions. We took independent clinical advice from an orthodontic adviser. We found that the records evidenced only intermittent or periodic poor oral hygiene, as opposed to the consistently poor oral hygiene noted by the orthodontist. We also found that there was evidence of valid clinical grounds to support the stoppage of A’s treatment. However, we also found that there were significant failings regarding the way the decision was communicated. At the last appointment A attended, the records give the expectation that treatment was continuing. C tried to contact the orthodontic practice following this appointment to find out when the next review appointment would take place. When they did not receive a reply they submitted a complaint, the response to which communicated the decision to discontinue treatment. This was several months after A had last been seen. The orthodontist failed to clarify in the response why they had not replied to C’s communication after the last appointment, and it was not made clear specifically when it had been decided A’s treatment should be discontinued. We found that the orthodontist’s actions were not compliant with General Dental Council standards for communicating with patients. We found that the orthodontist’s decision to discontinue A’s treatment was unreasonable, particularly in relation to the way it was communicated. As such, we upheld the complaint.

C attended the A&E department at the Royal Infirmary of Edinburgh having suffered a fall and was diagnosed with muscular pain. They re-attended four months later, when a diagnosis of fractured vertebrae was made. C complained to the board that there were failures to fully investigate their symptoms and arrange appropriate x-ray imaging at the initial attendance. When responding to the complaint, the board had initially concluded that a ‘red-flag’ symptom had been missed which should have prompted imaging. They upheld C’s complaint, apologised and outlined the steps that they would take to learn from this. They subsequently reviewed their position with neurosurgery colleagues and decided that C had been managed appropriately. We took advice independent advice from an emergency medicine consultant. We found that C was appropriately assessed and did not meet the criteria in the relevant guidelines for their injury to have been considered high-risk and requiring imaging. We did not uphold the complaint. We found that we weren’t critical of the board for reviewing and revising their decision. However, we were critical that they had not communicated this to C and shared recommendations.

C complained on behalf of their client (B) about the care and treatment provided to B’s late sibling (A). A had attended the A&E in mental distress, had attended their GP the same day, and had a hospital appointment with the crisis team a few days later. At this appointment it was considered that hospital admission was not required. A completed suicide a short time later. B felt that the board had failed to provide reasonable care and treatment to A. We took independent advice from a mental health nursing adviser. We found that the board had carried out a detailed review of A’s care and had taken some action which was reasonable. However, we found that the risk assessment carried out by the board when A presented at A&E lacked transparency and rigour. The assessment carried out a few days later provided more detail, however, it lacked a structured risk assessment and the clinical reasoning behind not offering any ongoing planned follow-up and the weighing of current and historical risk indicators against protective factors was not fully transparent. The record keeping of the risk management decisions was also not sufficient to show the way in which risks factors and protective factors were balanced. We also found that it was unreasonable that the board’s administrative systems resulted in an erroneous early diagnosis of borderline personality disorder being recorded. We found that the Adverse Event Review process did not appear to attempt to establish why things occurred as they did, rather than simply establishing what occurred. Therefore, we upheld the complaint

C complained on behalf of their partner (A) about the care and treatment provided by the board when A had hip replacement surgery. Specifically, C complained about the management of A’s pain in the post-operative period. The board acknowledged the discomfort experienced by A, but when it became apparent that surgeons could not manage A’s pain effectively, the Pain Management Team was involved. The board considered the care delivered following surgery, and in reducing medication after discharge, was reasonable. We took independent advice from an anaesthetics and pain management adviser. We found that whilst pain management in the post-operative period is challenging, the board’s management of A’s pain was reasonable following surgery. We did not uphold this aspect of the complaint. Additionally, we found that, with respect to reducing A’s medication, the advice provided by the board to A following discharge was appropriate. On this basis, we did not uphold this aspect of the complaint. Related reading View Decision Report 201911968 as a PDF (24.23 KB) Updated: December 21, 2022

C complained about the care and treatment that their grandparent (A) received at the Royal Infirmary Edinburgh (RIE). A was admitted to the RIE following a fall. Following a period of recovery, A was discharged to their home. A was subsequently readmitted to the RIE a short time later and died in hospital following this second admission. C complained to the board about aspects of A’s care during their first admission to RIE, including the board’s management of A’s nutrition and hydration, the physiotherapy A received, and the planning for A’s discharge, but the board did not identify any failings. We took independent advice from a geriatrician adviser. We found that the management of A’s nutrition and hydration, the provision of physiotherapy to A, and the planning for A’s discharge was reasonable. We did not uphold C’s complaints. Related reading View Decision Report 202000048 as a PDF (24.18 KB) Updated: December 21, 2022

C complained about the care and treatment provided to their parent (A) by the board. A was admitted to the hospital due to a catheter blockage. On examination, it was determined that A required specialist treatment and an ambulance transfer to another hospital within the board was arranged. It took approximately six hours for the ambulance to arrive by which time A was showing signs of sepsis (a life-threatening reaction to an infection). Antibiotics treatment was initiated on A’s arrival and they had regular washouts of their catheter and continuous irrigation due to blockages and bleeding. A had ongoing uro-sepsis and required blood transfusions. A suffered a heart attack during their admission and blood-thinning medication was prescribed. However, this made the bleeding at the catheter site increase. A died in hospital several days later. C complained to the board about A’s care and treatment but the board did not identify any failings. The board did identify and apologise for failure in communication with C. C remained unhappy and asked us to investigate. C complained that the staff in the first hospital had unreasonably delayed in treating A with antibiotics. C complained that staff in the second hospital subjected A to unnecessary pain while irrigating their catheter. C also complained that staff failed to identify that A’s catheter had been incorrectly placed. C complained about a decision to prescribe A with the anti-coagulant. C also complained about the palliative care given to A. We took independent advice from a consultant in emergency medicine and a consultant urological surgeon (specialist in the male and female urinary tract, and the male reproductive organs). We found that staff in the first hospital had unreasonably delayed in treating A with antibiotics and we upheld this aspect of C’s complaint. We found that the care and treatment given to A in the second hospital was reasonable. However, we considered that staff had failed to re

C complained that the board took too long to offer them steroid/local anaesthetic injections for vulvodynia (chronic pain or discomfort in the vulva). C felt this was dismissive and unsatisfactory. The board said that C did not receive the treatment initially as it was not clinically appropriate at that time. They said in order for the treatment to be effective, there should be a locally tender area to inject which C did not have. The board added that it was important to note that the treatment is unlicensed and so is only to be considered for use when definitely clinically indicated. We sought independent clinical advice from a consultant. We found that it is right for the board to have a cautious approach to the use of unlicensed treatment. We noted that the treatment C received for many years was reasonable. However, it was later indicated that C had developed a localised area of pain and it would have been reasonable to discuss the treatment with C at that point. We considered that whilst the care and treatment provided to C was generally reasonable, the board should have discussed the treatment option of steroid/local anaesthetic injections earlier than they did. For this reason, on balance, we upheld C’s complaint.

C complained that the medical practice failed to provide reasonable care and treatment to their spouse (A) after they presented with a lump in their right breast. We took independent advice from a GP. We found that the time taken to refer A to hospital when they first consulted the medical practice with the lump in their right breast was unreasonable. It was also unreasonable that the referral was not marked as urgent. The medical practice had carried out a detailed review of A’s care and had accepted that there was a complete systems failure in the care and treatment provided to A. They had made a number of changes which we welcomed and considered were appropriate. Nevertheless, we found that they had not fully acknowledged their specific role and responsibility in relation to the failings which had occurred given their responsibilities for the supervision, training and actions of their employed staff. We also identified additional issues not addressed by the medical practice in their consideration and response to the complaint. In particular, that the medical practice should have a system in place to ensure any outstanding referrals were identified when a colleague is unexpectedly absent due to sickness or ill-health and that it was unreasonable that A was not contacted by the medical practice after the cancer diagnosis given the significance of the diagnosis and their delay in sending the referral and marking it as urgent. We also found that the medical practice did not appear to have considered their duty of candour responsibilities in this case. Therefore, we upheld C’s complaint.

C complained about the standard of medical treatment provided to their late spouse (A) by the board following diagnosis and treatment of upper tract urothelial cancer (a type of kidney cancer). A’s condition deteriorated and they died. C complained that clinicians failed to, amongst other things, communicate with them in a reasonable way about treatment options and take reasonable action in response to A’s clinical condition. We took independent advice from a urology specialist (concerning the male and female urinary tract, and the male reproductive organs) and a renal specialist (concerning the kidneys). We found that A’s cancer had likely been more aggressive than originally suspected. However, given the information available at the time, the option of treatment offered to A had been a reasonable approach. We also found that the board had failed to adequately document that all treatment options had been discussed with A, and that a specialist renal cancer nurse should have been available to the family sooner. We found that had A’s treatment been carried out sooner (and in line with cancer waiting time standards), it may have improved their health outcomes. For these reasons, we upheld this aspect of C’s complaint. C also complained that during a hospital admission the board had failed to reasonably manage the removal of A’s nephrostomy tube (a catheter inserted through the skin and into the kidney) causing them to suffer an arterial trauma (or bleed). We found that bleeding is a recognised complication of such a procedure and there was no evidence to indicate any failings in the removal of the tube. We did not uphold this aspect of C’s complaint. C further complained that when A’s condition deteriorated following dialysis, unit staff advised the family to take A home, or to take them to the emergency department themselves. C also complained that there had been no end-of-life plan in place for A. We found that there was insufficient evidence to determine

C complained about the care and treatment provided by the board to their late spouse (A) who was diagnosed with muscle-invasive bladder cancer. C complained about various aspects of the care that A received. These included delay, and ultimate failure, to carry out surgery to remove A's bladder, inappropriately high and missed doses of medication, and initial refusal to offer chemotherapy (a treatment where medicine is used to kill cancerous cells). C also complained about a failure by an out of hours doctor in identifying a deep vein thrombosis (DVT, a blood clot in a vein) that A developed and subsequent provision of insufficient information on medication used to treat the DVT. C further complained about various failures of communication as well as concerns about arrangements for visiting A due to the Covid-19 pandemic and end of life care. We took independent advice from medical advisers with expertise in oncology (cancer specialist), urology (a specialty in medicine that deals with problems of the urinary system), general practice and community nursing. We found that A's pain medication regimen was reasonable and that the timescale for the scheduling of A's bladder removal surgery had been appropriate. We also found that decisions made about the timing of chemotherapy and communication with A had been reasonable. This included communication about A's end of life care and how rules relating to visiting A during the pandemic had been applied. However, a number of failings in the treatment provided to A were also identified. We found that A had not been given appropriate information on the extent of their cancer, the prognosis and the potential treatment options. We also found that there had been an unreasonable delay in the discussing of A's case by the board's multi-disciplinary team, which also understated the extent of A's cancer. Furthermore, we found that A missed doses of regular medication when attending for palliative chemotherapy, that the DVT A

C complained about the care and treatment provided to their late parent (A) by Dr Gray's Hospital. C complained that A's colorectal symptoms and weight loss were not properly investigated and that a planned scope investigation wasn't arranged on an urgent basis. C also complained that a head injury A sustained in a fall was not properly investigated and that A was inappropriately discharged when they were unfit to return into C's care. A was re-admitted the following day and died in hospital around two and a half weeks later. C complained about the standard of medical treatment provided during this admission. Furthermore, C complained about the nursing care provided during A's final admission. They complained that visits did not take place in an appropriate location to ensure A's comfort and privacy, and in particular that A was not transferred to a side room in light of their condition. C also considered that A was denied adequate nutrition and hydration. Finally, C complained of difficulties obtaining information from the ward and more generally about communication with the family and the lack of visiting opportunities that they were afforded. We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly). We found that there was no evidence to indicate the need for urgent investigation. We did not uphold this aspect of the complaint. We found that A's care surrounding the head injury was reasonable and that they did not meet the criteria for a head scan. However, we noted that there was a lack of care and attention to A's confusion and falls risk and that they should have been kept in hospital. On balance, we upheld this aspect of the complaint. We noted that A received an appropriate medical review and treatment, apart from a delay in initially being reviewed by a consultant and a lack of attention to A's deterioration prior to their death. We also noted a failure to communicate the DNACPR process t

C complained about the care and treatment provided to their spouse (A) when they became unwell with severe lower abdominal pain and vomiting. A was visited and examined by an out-of-hours (OOH) GP, who administered an injection for vomiting and left some medication for A. A's condition worsened and a different OOH GP attended the same evening. A was taken to hospital by ambulance and was found to have a perforated bowel (hole in the large intestine) and kidney failure. Medical intervention was not considered appropriate and A's care was redirected to palliative care. A died in hospital two days later. C complained that the first OOH GP missed important aspects of A's condition during their home visit. C further complained that when A was admitted to hospital, A was left in pain and discomfort for many hours and it was only when C raised concerns that A was given stronger pain relief. We took independent advice from a GP adviser, as well as a registered nurse and a general physician in acute medicine. We found that overall, the assessment and examination carried out by the first OOH GP was reasonable and appropriate. It was determined that there was nothing suggestive of an acute abdomen (sudden, severe abdominal pain) which would have necessitated admission to hospital. We did not uphold this aspect of C's complaint. C also complained that A was given unreasonable care and treatment in the hospital, in relation to managing A's pain. We considered that overall, the approach to A's pain management by nursing staff was reasonable. Nursing staff identified A's level of pain from first admission and throughout and took appropriate action to try and address this. However, we found that given the very high doses of morphine administered, medical staff should have checked the medication prescribed to see if it was working, and review or prescribe something else. Furthermore, given that the medical team would have been aware that A was on the ward round for comfor

C complained to the board about the treatment provided to their late relative (A) who died of a ruptured bowel. A had been in University Hospital Ayr two weeks previously with symptoms of severe pain. Staff had carried out tests and a scan, and discharged A home without follow-up. C believed that the board should have carried out more intensive investigations, which may have discovered A was still having bowel problems and provided additional treatment. The board believed that appropriate treatment had been provided. We took independent advice from a consultant in acute medicine (a specialist in the immediate and early management of adult patients with a wide range of medical conditions who present in hospital as emergencies) and a consultant radiologist (a specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that staff at the hospital provided a reasonable standard of treatment based on A's reported symptoms. We also found that it was not unreasonable to discharge A home with antibiotics based on the diagnosis of pyelonephritis (kidney infection) following a CT scan. Although a subsequent CT scan carried out on readmission showed evidence of infarct (a small localised area of dead tissue resulting from failure of blood supply) which might have been evident on the original scan, it was not unreasonable to have diagnosed pyelonephritis following the original scan. We therefore did not uphold the complaint. Related reading View Decision Report 202102504 as a PDF (24.5 KB) Updated: July 20, 2022

C is an advocate who complains on behalf of A. A has a brain injury which impacts on their daily living tasks and functioning. C complained that A received poor treatment from their GP practice and that there were delays in making referrals for specialist input following a fall down stairs which made A’s existing health conditions worse. We took independent advice from a GP adviser. We found that A's treatment had been reasonable. We noted that A had come to the practice with a number of previous unresolved problems. We considered that A's new GPs were right to be mindful that A's neurological symptoms had already been assessed as 'functional', meaning they had no known physical cause. C also complained about repeated prescription of antibiotics. We found that this did not seem excessive given the poor general state of A's health and that referrals for specialist input had been appropriate. Therefore, we did not uphold C's complaints. Related reading View Decision Report 202008029 as a PDF (24.23 KB) Updated: July 20, 2022

C complained to the board about an incident during which they were restrained by staff to receive emergency treatment when they experienced a life-threatening complication of their health condition. At the time, C was being detained under a Compulsory Treatment Order by the board when the complication arose necessitating their transfer to the acute hospital site for further treatment. C complained about several aspects of this episode including the conduct of the staff when restraining them, the failure by the board to contact or seek appropriate consent for the treatment from their court appointed welfare guardians, failure to maintain their privacy and dignity, and failure to tend to their comfort or basic hygiene needs. C also complained about the board’s suggestion that a pattern was emerging of them making unfounded complaints due to them previously complaining about a separate episode of care. We sought independent advice from a senior mental health nurse on the care and treatment provided by the board to C. We found that C's treatment was of a reasonable standard. We noted that the emergency nature of C's condition allowed treatment without their guardians’ consent, and the steps taken to ensure their privacy, dignity and comfort had been reasonable in the circumstances. On considering the conduct of staff during the episode of care, the likelihood of having to restrain C for treatment had been anticipated in advance and plans were made to do so in line with board-approved techniques. We did not uphold this aspect of C's complaint. In respect of the board suggesting that there was a pattern emerging of C making unfounded complaints, we referred to the rights of patients outlined within The Patient Rights (Scotland) Act 2011 and the Charter of Patient Rights and Responsibilities. As this legislation ensures the rights of patients to complain or give feedback about their healthcare encounters, we considered the board's response to C to be unreasonable and