SPSO Individual Decisions

Mrs C complained about the care and treatment that her mother (Mrs A) received prior to her death in University Hospital Ayr. Mrs A underwent major surgery and experienced post-operative complications. She was transferred to the medical high care ward for non-invasive ventilation (NIV, assistance with breathing using a mask). She had difficulty tolerating this treatment and it was recorded that she refused to continue with it. The family were called to come to the hospital and when they arrived they requested that NIV treatment be further attempted. However, the doctor did not agree to this. Mrs C complained that Mrs A had been confused since her surgery and that she did not have the capacity to refuse treatment. We obtained independent medical advice from a consultant physician, who found that the evidence in the records showed that Mrs A had capacity to withdraw consent for further NIV treatment. The adviser explained that while the doctor considered the family's wish for further NIV, it was reasonable for them to decide that this would not be appropriate in view of Mrs A's expressed wishes and her clinical condition. In light of this, we did not uphold this aspect of the complaint. However, we found that the family should have been involved in the decisions about NIV at an earlier stage, which the board had already acknowledged and apologised for. The adviser also noted that the decision not to continue treatment could have been explained more clearly to the family. In particular, it was noted that Mrs A's condition was poor and that further treatment was very unlikely to have been successful. This should have been sensitively communicated to the family, when instead the decision appeared to have been explained to them solely in terms of Mrs A having declined treatment. The adviser noted that national NIV guidelines had since been updated to require an individualised patient plan to be recorded at the start of treatment, which documents the agreed mea

Mr C made a number of complaints about the care and treatment he received from a prison healthcare centre. In particular, Mr C complained that the board had not provided appropriate care and treatment for a particular medical condition he felt he had, and that they had not communicated with him reasonably about this condition. We took independent advice from a GP adviser. We found that a number of investigations had been carried out and that none of these had confirmed the diagnosis of the condition that Mr C felt he had. We did not find evidence that the board had failed to provide appropriate treatment for this condition or that communication was unreasonable. We did not uphold these complaints. Mr C complained further that the board failed to provide timely and appropriate care and treatment for a facial injury he sustained. We took independent advice from a nursing adviser who found that nursing staff failed to carry out a full nursing assessment of this injury and refer the issue to medical staff. We found that Mr C was then assessed by a GP after a two week delay. The GP adviser considered that the GP assessment was appropriate and noted that a timely referral to a specialist was then made. However, in view of the failings in nursing care, we upheld this aspect of the complaint and made two recommendations. Mr C raised concerns about the pain relief medication he was prescribed and said this was ineffective. The GP adviser found that the medical records showed evidence of pain assessment and the GP's discussion with Mr C. The GP adviser said that they had no concerns about the pain relief provided to Mr C and concluded that this aspect of care was reasonable. We did not uphold this complaint. Mr C was also unhappy about the way the healthcare centre responded to his concerns about his diet. The GP adviser found evidence that a GP made a request to the kitchens for a high fibre diet for Mr C and also found that Mr C had received dietary advice on a

Ms C complained to the board about the care and treatment provided to her mother (Mrs A) during an admission at University Hospital Ayr. Mrs A was admitted to hospital after her GP noted that she had low sodium levels. During the admission, Mrs A received treatment for heart failure and low sodium. Her condition did not improve and she died a number of days later. Ms C complained to the board about communication with the family, the nursing care provided to Mrs A, the medical treatment provided to Mrs A and the board's failure to respond to a claim for lost property. In response to Ms C's complaint, the board arranged two meetings with the family to discuss their concerns. The board acknowledged that communication was poor and that nursing care could have been more compassionate, and apologies were offered for these shortcomings. Ms C remained dissatisfied and brought her complaint to us. In the course of our investigation, we took independent advice from a medical adviser and a nursing adviser. The medical adviser found that Mrs A was very unwell and said that staff should have informed the family of this from the time of Mrs A's admission, not just at the time of her deterioration. The nursing adviser did not find evidence that nursing staff had advised the family of the seriousness of Mrs A's condition, although they could not confirm if nursing staff had recognised this themselves. We noted that the board had identified a number of points of learning and improvement in relation to communication, and we asked the board to provide evidence that appropriate action had been taken. We upheld this complaint and made further recommendations based on the advisers' comments. We also investigated Ms C's concerns about nursing care. The nursing adviser noted a number of gaps in the fluid balance and clinical risk assessment recording, but otherwise found that the records were generally of an acceptable standard. However, the nursing adviser was critical that nu

Mr C complained about the care and treatment provided to his mother (Mrs A) at Biggart Hospital. Mr C complained that his mother was not provided with adequate care and treatment, specifically that alternative diagnoses to delirium were not considered and the delirium care pathway was not followed. Mr C also complained that Mrs A had wrongly been assessed as having the capacity to make decisions about her ongoing care, and that staff had acted unreasonably by failing to provide Mr C and his family with information about Mrs A whilst she was in hospital. We took independent advice from a consultant physician and geriatrician. We found that the clinical care and treatment provided to Mrs A was of a reasonable standard. We noted that Mrs A was reviewed on at least a weekly basis, and that her physical and mental health were considered in detail throughout her stay. We also noted that alternative diagnoses were reasonably considered and that the care provided to Mrs A was in line with the board's delirium care pathway. We found that the board's assessment of Mrs A's capacity was reasonable. We also found that Mrs A's wishes regarding the sharing of her health information were documented several times throughout her admission and the board had acted reasonably in keeping information about her health confidential in line with her wishes. However, we did consider that the board could have communicated information regarding a second opinion from another clinician more clearly, and that it may have been useful for board staff to direct Mr C to an organisation that could provide him with advice and support. Mr C also complained about the board's handling of his complaint. We found that whilst the target time for a response was not met by the board, they kept him informed of the delay and explained why it had occurred. We found this reasonable. We did not uphold any of Mr C's complaints, but we did make some recommendations.

Mrs C complained to us about the care and treatment her late mother (Mrs A) had received at Biggart Hospital and University Hospital Ayr. Mrs C said that staff at Biggart Hospital had failed to treat her mother's deteriorating condition. We took independent advice from a consultant in acute medicine and from a nursing adviser. We found that there had been prompt recognition of Mrs A's deteriorating condition and that the care and treatment provided to her had been reasonable. We did not uphold this aspect of Mrs C's complaint. During her treatment Mrs A was transferred from Biggart Hospital to University Hospital Ayr. She was subsequently transferred back to Biggart Hospital. Mrs C complained about the decision to transfer Mrs A back to Biggart Hospital given that she had tested positive for sepsis, MRSA (a bacterial infection that is resistant to a number of widely used antibiotics) and E.coli (bacteria found in the digestive system). We found that Mrs A's condition had improved at the time to the point that it was reasonable to consider her transfer back to Biggart Hospital. We did not uphold this aspect of the complaint. Mrs C also complained that the communication between Biggart Hospital and University Hospital Ayr was unreasonable. We found that there was no clear documentation of communication between the hospitals about the fact that Mrs A had E.coli and MRSA. We therefore upheld this aspect of the complaint. Mrs C further complained that Biggart Hospital had prescribed her mother a form of morphine, despite the fact that Mrs A had previously had an adverse reaction to morphine. We found that Mrs A's allergies, drug intolerances and drug interactions could have been better documented, and we made a recommendation in relation to this. However, we found that it had been reasonable to give Mrs A small doses of morphine, as the effect on her was being monitored. We did not uphold this complaint. Finally, Mrs C complained about the medication Mrs A r

Mr C complained about the care and treatment his late wife (Mrs A) received at Crosshouse Hospital. Mrs A had been a patient there for 12 days when she was discharged home. Mrs A was readmitted to the hospital later the same day and died shortly thereafter. We obtained independent medical advice and we found that although Mrs A was in an orthopaedic ward during her admission, she should have been admitted to a medical or rheumatology ward, or transferred to one as soon as possible after her admission. There was also a lack of a senior review of Mrs A by a consultant and a failure of early input from rheumatology, general medicine and microbiology. We found that the choice of antibiotics prescribed to Mrs A was a deficiency in her treatment, although we found no evidence that the antibiotics contributed to her decline. Furthermore, we found that there was a failure to act promptly on test results that showed Mrs A had E.coli. We also found that there were failures in communication with Mr C and Mrs A. While we found failings in Mrs A's treatment, we accepted that there were certain features that had masked the serious nature of her illness and that there was no significant error to blame for Mrs A's outcome. Given the failings identified, we upheld this part of Mr C's complaint. Mr C was also dissatisfied that despite a post-mortem being carried out, Mrs A's death was recorded as unascertained. We found it was reasonable to record Mrs A's death as being unascertained given the advice we received that a post-mortem does not always provide a definite cause of death. We did not uphold this part of Mr C's complaint.

Mr C complained about the care and treatment received by his sister (Mrs A) at University Hospital Ayr. Mrs A was referred to the hospital for a respiratory opinion with a chronic cough. Mr C felt that there were delays in carrying out investigations and a lack of communication with Mrs A about her condition. Mr C also raised concerns about the board's complaints handling. During our investigation we took independent medical advice from a consultant in respiratory medicine. We found that there were delays in Mrs A receiving follow-up respiratory appointments and that there was a failure to communicate appropriately with Mrs A about her diagnosis and treatment. We upheld this aspect of the complaint. We also found that the board failed to provide a reasonable response to Mr C's complaint, therefore, we upheld this aspect of the complaint.

Mr C complained about the care received by his sister (Miss A) at University Hospital Ayr, in particular that there was a delay in her being scanned and a delay in transferring her to the Beatson West of Scotland Cancer Centre, which is in another board area. Miss A had a history of Crohn's disease (a long-term condition that causes inflammation of the lining of the digestive system) and became unwell. Further tests showed that Miss A had tumours in her liver and bone marrow. She died two days after being transferred to the centre. We took independent medical advice and found that Miss A had been reviewed urgently when abnormalities were identified. We found that she was offered admission to hospital to undergo further tests including a specialist scan. However, it appears Miss A opted to wait for an out-patient appointment. Whilst cancer was not initially suspected we found that the time taken to carry out a specialist scan was reasonable. We concluded that Miss A's care was reasonable and did not uphold Mr C's complaint. However, we were critical of the board's communication about Miss A's transfer to the centre, which caused Miss A and her family additional distress. The board apologised for this and we made a recommendation to identify any further learning and improvement.

Mrs C complained about the medical practice with regards to the care and treatment provided to her husband (Mr A). Mrs C said that the GP failed to ensure that Mr A's diagnosis of a rare type of cancer was followed up and that had the GP acted differently, Mr A would have been offered earlier treatment. We took independent medical advice from a GP. We found that the practice had not been told that the diagnosis of cancer was definitive, but rather that it had been communicated as a 'suspicion of diagnosis'. We found that there was no obligation for the practice to record this if it was not definitive. Additionally, we found that it was not the practice's responsibility to ensure that further tests and reviews were being carried out as this was the responsibility of secondary care. Therefore we did not uphold Mrs C's complaint. Related reading View Decision Report 201604204 as a PDF (10.99 KB) Updated: March 13, 2018

Mrs C complained that staff at University Hospital Crosshouse failed to provide her father (Mr A) with appropriate clinical treatment following his admission with abdominal pain. Mr A was diagnosed with cholangitis (an infection of the tube connecting the liver to the duodenum, the first part of the small intestine immediately beyond the stomach) and an ERCP (endoscopic retrograde cholangiopancreatography, a procedure where a flexible tube is passed into the small intestine) was performed on Mr A four days later. Mr A suffered a retroperitoneal perforation (a small tear in the upper bowel) during the ERCP. Mr A's condition deteriorated and he died. We obtained independent advice from a consultant gastroenterologist and a consultant general surgeon. The consultant gastroenterologist explained that an ERCP was the appropriate procedure in Mr A's case, as verified by the British Society of Gastroenterology and National Institute for Health and Care Excellence guidelines. They explained that the procedure was carried out appropriately, was documented as being relatively straightforward and was well tolerated by Mr A. However, they said Mr A suffered a recognised complication of an ERCP. Both advisers said that although Mr A's perforation was not detected as soon as it could have been, the management of Mr A's condition would not have changed with an earlier diagnosis. The consultant general surgeon confirmed that the time taken to diagnose the perforation was not due to poor practice. We therefore did not uphold Mrs C's complaint. Related reading View Decision Report 201508840 as a PDF (11.39 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment provided to her father (Mr A) by staff at Ayr Hospital. She complained that full diagnostic tests had not been carried out when Mr A was in hospital on two occasions, and that signs of heart failure had been missed by staff. Mrs C also complained that Mr A had been prescribed with medication for his previously diagnosed Parkinson's disease (a progressive neurological condition in which part of the brain becomes more damaged over many years) without a full examination and consultation, and that the medication he was given caused adverse side effects. Mr A was discharged with a full care package and died shortly afterwards. During our investigation we took independent medical advice from a consultant physician and a specialist Parkinson's disease nurse. We found that whilst the clinical treatment provided to Mr A had generally been reasonable, the board failed to consider a diagnosis of pulmonary embolism (blood clot in the lungs) and carry out the diagnostic test for this. Therefore we upheld this aspect of Mrs C's complaint. We also found that when Mr A was prescribed with medication for Parkinson's disease, he was not appropriately assessed by the Parkinson's nurse and that there was no documented justification for the prescription. We also found that side effects were not appropriately discussed with Mr A or his family, and that prescribing guidelines were not appropriately followed. Given this, we upheld this aspect of Mrs C's complaint.

Mrs C complained on behalf of her son (Mr A). Mr A was admitted to A&E at University Hospital Crosshouse with a three-day history of stomach cramps, diarrhoea and vomiting. It was suspected that he had gastroenteritis and after his symptoms settled he was to be discharged. However, Mrs C said she spoke with the consultant gastroenterologist responsible for Mr A's care and told them that this had been an ongoing problem. Mr A was kept in hospital for a further six days and then discharged with plans to follow up. Prior to the follow-up, Mr A was admitted to hospital as an emergency and diagnosed with Crohn's disease (a long-term condition that causes inflammation of the lining of the digestive system). Mrs C complained that during his initial admission, Mr A was not given appropriate care and treatment. We took independent advice from a consultant in gastroenterology. We found that on Mr A's admission to hospital, a clear history was documented in the emergency department notes of several weeks of recurrent episodes of abdominal pain associated with significant and unintentional weight loss. This history was later repeated by Mrs C. We found that in the circumstances, this should have raised suspicion of a diagnosis other than that of food poisoning, such as Crohn's disease. The adviser said they would have expected a scan of the abdomen or of the small bowel to have been undertaken during the admission or shortly afterwards. Had this happened, Mr A would have been diagnosed sooner. We therefore upheld Mrs C's complaint.

Mr C complained about the medical practice on behalf of his mother (Mrs A). Mrs A was discharged from hospital and given three new medications. On learning of these new medications, the practice decided to carry out a review of Mrs A's prescriptions, as this would result in her being prescribed 18 different medications a day. Mrs A's GP phoned Mrs A's daughter (Mrs B) to discuss the medications as they considered that these new medications were not necessary and may cause side effects that would exacerbate Mrs A's existing conditions. Mrs B felt that the GP's manner was callous and uncaring and that the content of the call was inappropriate. Following the call, the practice decided to prescribe the medications in line with the request from Mrs A's respiratory consultant. However, this call led Mrs A's family to decide that they would change GP practices. Mrs A died before the new practice was able to arrange Mrs A's medications. On investigation we found that there was some discrepancy in the information available to the practice, caused by a delay in the hospital sending them Mrs A's full discharge letter. This meant that they were not in possession of the consultant's rationale for providing the new medication and had to carry out the review based on the medical history they were aware of. Our adviser considered the relevant medical records and concluded that it was reasonable for the practice to carry out a review of Mrs A's medications in the circumstances. They also considered the conclusions reached in the review to be reasonable, based on the information available to them at that time. On reviewing the records we were unable to see any evidence that the content or manner of the call in question was unreasonable. For these reasons, we did not uphold Mr C's complaint. Related reading View Decision Report 201603200 as a PDF (11.44 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment received by her husband (Mr A) at Ayr Hospital for a rare type of bladder cancer. Specifically, Mrs C was dissatisfied with surgery performed, the communication with her and Mr A, and the board's response to her complaint. We took independent advice from a consultant urological surgeon and a consultant radiologist. We found that the surgical treatment and follow-up review were both of a reasonable standard. Whilst we did not uphold the complaint about Mr A's treatment, we identified unreasonable failings in the reporting of a scan which had shown Mr A's cancer had worsened. We found that even had the scan had been reported accurately, it would not have changed Mr A's treatment or outcome. However, Mrs C and Mr A would have known about this much sooner. We also noted that although there was no specific indication for it at the time, it would have been preferable for Mr A's particular case to have been reviewed by the urology multi-disciplinary team and we made a recommendation in relation to this. In addition, we were critical that the board had not identified the error in the reporting of the scan after Mrs C complained about the matter. We also considered that the communication with Mr A and Mrs C fell below a reasonable standard.

Mrs C complained to us that the medical practice failed to provide her mother (Mrs A) with appropriate clinical treatment for her reported symptoms. Mrs C said that by the time Mrs A had been referred to hospital, she was found to have severe sepsis (blood infection). Mrs C said the GPs did not examine Mrs A fully and failed to admit her to hospital sooner. We obtained independent GP advice. We found that the GPs who visited Mrs A had on a number of occasions said to Mrs A that her blood tests and presentation were concerning and that hospital admission or further investigation was advised. However, we found that Mrs A declined the offer of a hospital admission on three occasions. Related reading View Decision Report 201605172 as a PDF (10.93 KB) Updated: March 13, 2018

Miss C complained about the care and treatment received by her partner (Mr A) at University Hospital Ayr. Mr A attended the hospital for a urology review as he had been experiencing problems involving his testicles, perineum and groin area. Miss C complained that no cause could be found for his pain and that although he had previously undergone a procedure involving his scrotum, this would not cause the sharp pain about which he was complaining. Mr A was subsequently admitted to hospital as an emergency. A scan showed that there was no blood flow to his left testicle, and it had to be removed. Miss C complained that Mr A had been discharged too soon and without being seen by the consultant. She also said that the consultant concerned had refused to do further tests to establish the cause of Mr A's problems. We took independent advice from consultants in emergency medicine and urology. We found that Mr A's treatment in A&E was of a reasonable standard and in line with his presenting symptoms, and that he was admitted and referred to the appropriate specialist in a timely way. We also found that the surgery Mr A had was reasonable. However, the level of documentation justifying the consultant urologist's decision-making and the information given to Mr A to allow him to make informed consent was not in accordance with General Medical Council (GMC) guidance. Furthermore, Mr A received little in the way of explanatory information and he was not examined when he attended for review. We upheld this aspect of Miss C's complaint. In response to Miss C's complaint to the board, Mr A was referred to a urologist in another area, which we found to be good practice. However, Miss C's complaint to the board was not handled within the relevant timeframe and we upheld this aspect of Miss C's complaint.

Mr C complained to us that his GP had not provided him with appropriate medication in view of his symptoms and medical history. Mr C had on-going high blood pressure and this was complicated by low sodium levels. He felt that the medications his GP had prescribed him were the cause of him being hospitalised due to low sodium and dehydration. We took independent medical advice and found that whilst it had been difficult to balance Mr C's blood pressure and sodium levels, his GP had prescribed him appropriate mediation. We found that when he was hospitalised, he was suffering from a very rare side effect of one of his medications. The adviser said that they would not have expected Mr C's GP to have been alert to the possibility of this side effect. We found that there was one occasion on which Mr C's GP could have given Mr C a blood test and failed to. However, we noted that the practice had already apologised for this. Therefore, we did not uphold Mr C's complaint. Related reading View Decision Report 201602674 as a PDF (11.08 KB) Updated: March 13, 2018

Ms C complained about the dental care and treatment she received during a course of treatment for a root canal. She complained that at one appointment, the local anaesthetic injection had resulted in her lower lip becoming tingly for several months, and that it then went completely numb. She also complained that she had not been told of the potential risks of local anaesthetic injections. During our investigation, we took independent advice from a dental practitioner. We found that whilst altered sensation is a rare complication of a local anaesthetic injection, it does not suggest any failing on the part of the dentist. We also found that there is no requirement for dental practitioners to discuss potential risks of local anaesthetic injections with patients. Therefore, we did not uphold Ms C's complaints. Related reading View Decision Report 201603804 as a PDF (10.97 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment given to her husband (Mr A), who suffered from dementia and was wheelchair-bound. Mr A was admitted to University Hospital Ayr with a urinary tract infection, was kept in hospital for about a week, then discharged on a Friday. Mrs C required a lot of assistance to manage Mr A over the weekend, and following a GP visit the following Monday, he was readmitted to hospital. It was agreed that Mr A would be transferred to a nursing home for his future care. However, while in hospital he suffered ischaemia (lack of blood supply) to his left leg and died. Mrs C complained about a number of aspects of care, including that nursing staff did not seem to have a good understanding of dementia and did not understand Mr A's needs. The board met with Mrs C and apologised for some aspects of care. They developed an improvement plan in response to Mrs C's complaint, which included changes to improve continuity of care and staff communication with families. The board also introduced a 'dementia champion' on the ward to raise awareness of dementia. However, they did not tell Mrs C about the action that had been taken in response to her complaint until prompted by this investigation. After taking independent medical and nursing advice, we upheld Mrs C's complaints about the first discharge and about nursing care. While we found most aspects of nursing care were reasonable, we were critical that the board used a standard chart for monitoring Mr A's pain, whereas they should have used a chart designed for people with cognitive impairment (such as dementia), who are not always able to express their pain verbally. We did not uphold Mrs C's complaint about communication, as we found there was evidence that staff had regular conversations with Mr A's family about his condition. While Mrs C said she always had to initiate conversations, it was not possible to tell this from the clinical records, and we found no evidence that staff did n

Ms C complained about care she received from her medical practice. When Ms C received a copy of her medical notes she found that during a previous consultation two years earlier, the GP had noted a mild vaginal prolapse and had not told her about this. Ms C complained that she should have been told about the prolapse and treated for it, and that the practice had not reasonably responded to her complaint. We sought independent medical advice and found that while the failure to inform Ms C of this incidental finding had not caused significant harm to her, the GP should reflect on this decision further. We upheld this complaint. However, the adviser's view was that the decision not to provide treatment at the time was reasonable, as was the response to Ms C's complaint. We therefore did not uphold this aspect of Ms C's complaint.

Mr C complained about the care and treatment he received from his medical practice. He was concerned that the GP inappropriately prescribed him steroid medication for asthma which caused his heart rate to increase, requiring hospital treatment. Mr C felt that his GP dismissed his ongoing concerns about his heart rate and breathlessness. We took independent advice from a GP adviser and considered that it was appropriate that Mr C's GP diagnosed worsening asthma and prescribed steroid medication in accordance with national guidance. In addition, whilst Mr C had been diagnosed previously with atrial fibrillation (where the heart beats irregularly and faster than normal), the type of steroid prescribed was not specifically associated with this condition. Therefore we considered that it was reasonable practice to prescribe this treatment and did not uphold Mr C's complaint. Related reading View Decision Report 201508103 as a PDF (11.03 KB) Updated: March 13, 2018

Mr C complained about the care and treatment he received for a diabetic foot ulcer. Mr C had been receiving treatment for diabetes-related foot problems for an extended period. Due to difficulties with recurrent infection and Mr C's difficulty in complying with his treatment programme, he was fitted with a special cast to protect the ulcer on his foot. Mr C complained that the cast had been too tight and had damaged his foot, resulting in the possible amputation of his toe. The board said no injury had been noted to Mr C's toe prior to the removal of the cast. They suggested that the injury had taken place between the removal of the cast and a subsequent medical review. The board said that the cast had been appropriately applied and reviewed and that the care and treatment had been of a reasonable standard. We sought independent medical advice and found that Mr C's cast had been an appropriate course of treatment. There was no evidence that it had been incorrectly applied, or that it had damaged Mr C's foot. There was no record of a wound to Mr C's toe when the cast was removed. Mr C's medical review following removal of the foot cast did not attribute the injury to the cast. We also found that Mr C's ulcer had reduced whilst the cast was on his foot, demonstrating that the treatment had worked as planned. We found that Mr C's care and treatment had been of a reasonable standard. The cast to his foot had been applied and removed by an appropriate specialist and there was no evidence to link the injury to his toe to the cast. Related reading View Decision Report 201600175 as a PDF (11.25 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment given to her mother (Mrs A) at University Hospital Crosshouse prior to Mrs A's death. At the time of her admission, Mrs A had been very unwell with pneumonia and sepsis. Mrs C said that she and her family were not alerted to the seriousness of Mrs A's condition and were not prepared for her death. Mrs C said that Mrs A was not cared for appropriately, specifically that she was left in soiled clothes and bedding, not given medication in a timely manner, that there was a delay in moving Mrs A to the high dependency unit and that fluid was removed from Mrs A's lung in an incorrect way. Mrs C said that it was only after Mrs A's death that it was disclosed that she may have been suffering from leukaemia. Mrs C also complained that the board's response to her complaint was inadequate. We took independent advice from a nursing adviser and a consultant physician and geriatrician. We found that overall, Mrs A's care had been reasonable. Mrs A had wanted to be independent regarding personal hygiene, with help from family members rather than from staff. Mrs A's medication was administered appropriately and in a timely manner. The procedure to remove fluid from Mrs A's lung was reasonable, as was the timing of moving her to a high dependency unit. We found evidence that Mrs C and her family had been kept updated about Mrs A's condition. We also found that it was only after Mrs A's death that it was determined that she had leukaemia. We did not uphold these aspects of Mrs C's complaint. However, our investigation did raise concerns about the facilities on the ward and we made a recommendation to address this. We found that the board's response to Mrs C's complaint had been poor in that it failed to provide sufficient detail in a timely manner. We therefore upheld this aspect of Mrs C's complaint.

Miss C had been experiencing poor health over a number of months and made a suicide attempt by medication overdose. She contacted NHS 24 and was taken to University Hospital Ayr. Miss C's symptoms included slurred speech and problems with walking. Miss C was assessed by nursing, medical and psychiatric staff and was later discharged. The following day, she attended with the same symptoms and was again discharged home. The next day, Miss C's GP arranged for her to attend University Hospital Crosshouse. A scan confirmed Miss C had a brain tumour, which was subsequently operated on. Miss C complained that, despite her presenting symptoms, she was not properly assessed or treated when she attended at University Hospital Ayr. We took independent advice from a specialist in emergency medicine. We found that at the initial admission, the focus of attention had been on the immediate presenting problems of Miss C's mental health and the effects of the overdose and that the assessment and treatment provided that day were appropriate and reasonable. The adviser said that in normal circumstances, the symptoms Miss C presented with on her second attendance at the hospital should have resulted in further investigation. In this case, however, the adviser noted that the doctors involved had felt it was likely that Miss C's presenting symptoms were related to the overdose the previous day and that it was reasonable that they reached this conclusion. Therefore, we concluded that the assessment was reasonable. We also reviewed Miss C's records and were satisfied that the treatment she received was appropriate. Therefore we did not uphold Miss C's complaint. Related reading View Decision Report 201601919 as a PDF (11.41 KB) Updated: March 13, 2018

Mr C complained that staff at University Hospital Ayr failed to provide him with appropriate clinical treatment, based on the symptoms he reported. Mr C experienced pain in his back and dropped foot (a muscular weakness that makes it difficult to lift the front part of the foot and toes). Mr C's GP arranged for him to attend A&E and he was seen by members of the hospital's orthopaedic team. A diagnosis was made of a prolapsed intervertebral disc (ruptured disc in the spine) with associated motor weakness. The decision was made not to treat Mr C surgically at that time. An MRI scan was also considered to be unnecessary. Mr C was referred to his GP to arrange physiotherapy and he saw a physiotherapist some days later. Based on Mr C's symptoms, he was then referred to hospital and received an MRI scan and an emergency operation. After receiving independent advice from an orthopaedic surgeon, we did not uphold Mr C's complaint. We found that an examination of Mr C at A&E did not reveal red flag features (features which would have required urgent intervention). In this context, we found that the plan of management without surgery adopted at A&E was appropriate. We therefore did not uphold Mr C's complaint. Related reading View Decision Report 201508381 as a PDF (11.23 KB) Updated: March 13, 2018