SPSO Individual Decisions

Mrs C's father (Mr A) had suffered from a painful degenerative condition that caused his spinal cord to become compressed. An operation was carried out and, after a difficult recovery, Mr A was pain free for a number of months. He then began to have new pain in his shoulder and went to his GP as he was worried that this could have been a recurrence of the condition. Mr A's GP considered that he did not have any new symptoms that indicated his spinal cord was compressed. Mr A had a number of consultations over the following months where the GP adjusted his pain relief medication. He also attended hospital appointments which clinicians reported to the GP; none of them considered that he was suffering from spinal cord compression. Mr A was subsequently seen at home by the GP as he was in too much pain to visit the surgery. The GP made a referral for a scan which was carried out a few days later. The scan showed a narrowing of the spinal canal and an urgent referral was made. Mrs C complained that the GP repeatedly failed to diagnose her father's condition, delayed referring him for a scan and had not assisted him in obtaining medical equipment to help him manage at home. The practice responded saying that the GP had acted appropriately. After taking independent advice from one of our medical advisers, we found that the GP had provided Mr A with reasonable care and treatment. Our adviser explained that there was no evidence that Mr A was suffering from new spinal cord compression and so there was nothing to suggest that a scan should have been carried out earlier. In relation to obtaining medical equipment for use at home, our adviser said that the occupational therapy department would deal with this rather than the GP. As the GP had advised Mrs C's family to contact the occupational therapy department, we considered that this had been handled reasonably. Related reading View Decision Report 201305012 as a PDF (11.52 KB) Updated: March 13, 2018

Mr C complained that when he attended his medical practice the GP who saw him did not tell him that he could stop his diabetic medication. As a result, he had continued to take it for a year, and he wondered whether this was detrimental to his health. The practice apologised and explained that the GP recalled discussing the matter with Mr C at the time but forgot to amend the repeat prescription list. They said that by continuing with the medication, Mr C did not come to any harm. After taking independent advice from one of our medical advisers we found that, although we could not establish exactly what the GP and Mr C discussed, it was the GP's intention to stop the medication at that time. However, human error prevented the medication from being removed from the repeat prescription list. Because of this, we upheld Mr C's complaint. However, as the practice had already apologised to Mr C and reminded staff about properly documenting conversations with patients, we did not make any recommendations. Related reading View Decision Report 201402836 as a PDF (11.1 KB) Updated: March 13, 2018

Mr C complained that the board had failed to investigate his concerns about a number of issues affecting his daughter (Miss A)'s clinical treatment. These included whether appropriate clinicians were involved, the method of transfer used to another facility, information about hospital equipment and that staff had said that he had been verbally abusive. Our investigation found that the board treated Mr C's complaints seriously and had devoted a large amount of staff resources in an effort to address his concerns. They had agreed to appoint new clinical staff, provided explanations about the accuracy of hospital equipment and explained why staff had felt uncomfortable about Mr C's behaviour. Related reading View Decision Report 201401984 as a PDF (10.96 KB) Updated: March 13, 2018

Mr C complained about the NHS health centre at his prison. He said that the health centre doctors did not provide adequate care and treatment when he sought medical attention for stomach, testicular and rectal (bowel) concerns. We took independent advice from one of our medical advisers, who is a GP. We found that Mr C had been appropriately examined and assessed in respect of the rectal issues. However, we upheld that part of his complaint because, although Mr C had not been presenting with a clinical picture that suggested bowel cancer, he had visited the health centre several times on the same matter. National guidelines on the diagnosis and management of bowel cancer recommend that a specific blood sample is taken for all patients with persistent or recurring rectal bleeding (bleeding from the anus). That was not done in Mr C's case. Doing this would have better equipped the doctor to decide on the urgency of the referral that he made to the hospital. We also found that the referral letter to the hospital was not sent until two months after the doctor decided on a hospital referral. Although the clinical picture was not suggestive of bowel cancer, the part that rectal bleeding can play in bowel cancer makes that delay worrying. In due course, Mr C attended hospital and was discovered not to have cancer. We did not uphold Mr C's complaints about the other issues as his medical records showed that the health centre had appropriately examined and assessed him in relation to these and we had no further concerns.

Mr C was referred to Dumfries and Galloway Royal Infirmary. After tests and surgery, it was confirmed that he had prostate cancer, and he was started on hormone therapy. Mr C later had a scan of his abdomen and pelvis, and it was thought that the cancer was spreading and that he might also have Crohn's disease (a long-term condition that causes inflammation of the lining of the digestive system). In the meantime, Mr C was required to have a bone scan. Mr C complained that in carrying out his surgery, the board did not follow his wishes about the use of anaesthetic, and did not tell him about the use of hormone therapy, that he might have Crohn's disease or that he needed a bone scan. He also complained about the delay in arranging a colonoscopy (examination of the bowel with a camera on a flexible tube) and in receiving radiotherapy. We obtained independent advice on the complaint from one of our medical advisers, who is a consultant urological surgeon (a specialist in problems of the urinary and male reproductive systems). We took all relevant information into account, including the complaints correspondence and Mr C's medical records. Our investigation found that, in accordance with his wishes, Mr C had a spinal anaesthetic when he had surgery. However, in association with this, he had been given some sedation to relieve anxiety. Although Mr C said that he had been explicit about the use of sedation, there was nothing in his notes to confirm this and we did not uphold this complaint. Mr C also said that there was a delay in providing him with a colonoscopy and the evidence showed that after a scan (made as a result of an urgent referral and which suggested possible Crohn's disease) it was ten weeks before a request for a colonoscopy was made. It took a further month for this to be carried out and it was only then, when a diagnosis was confirmed, that radiotherapy could be considered. Mr C's complaint about delay was, therefore, upheld. Furthermore, we f

Mr and Mrs C complained to the board about how a bone marrow sampling procedure was carried out on Mrs C. Some weeks after making the complaint Mrs C died. Mr C felt the board's response to their complaint was inadequate, and so he complained to us. We looked at information from Mr C and from the board. We found that Mr and Mrs C did not make a written complaint to the board, but spoke to a member of staff who made a note of the complaint. The board investigated it, and wrote to Mrs C. Their letter to Mrs C mainly contained apologies rather than explanations, particularly apologising that staff did not acknowledge sooner the level of pain and discomfort she experienced during the procedure. As there was no written complaint, we could not say with certainty exactly what answers Mr and Mrs C told the board they wanted about the procedure. We found, however, that much of the detail the board gave us when we contacted them was considered during their investigation of the complaint, but was not in their letter. Given this, we decided it would have been reasonable for the board to have included some of this in their letter, to reassure Mrs C that the procedure was carried out in line with normal standards. Their letter did not achieve an appropriate balance between apology and explanation. We upheld Mr C's complaint.

Mrs C complained about the care and treatment she received from her medical practice when she attended with clearly visible changes in her left breast. The GP told Mrs C that there was nothing wrong other than a blockage and suggested that she buy starflower oil. Mrs C's health deteriorated over the next few months and nine months later, she was diagnosed with breast cancer. After taking independent advice from our GP medical adviser and considering the records and Mrs C's comments, we found that the GP had failed to adequately examine her breast. In view of the visible changes, Mrs C's age and the fact that she had a family history of breast cancer, we also found it unreasonable that the GP did not immediately refer her to the breast clinic. Our adviser said that the delay in referring Mrs C there was likely to have had a significant impact on the extent of the tumour and the level of treatment Mrs C required. However, the practice had carried out a significant event review, had demonstrated that they had learned lessons from the complaint and had apologised to Mrs C. In view of this, we did not need to make any recommendations. Related reading View Decision Report 201305253 as a PDF (11.17 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment she received at Galloway Community Hospital for her injured wrist. She said that the locum consultant orthopaedic surgeon who dealt with her did not provide a proper diagnosis, treatment and advice when he saw her at the hospital trauma clinic. She said he only looked at one of four x-rays taken in A&E before telling her that her wrist was not fractured. She said that it was fractured and that the consultant's actions compromised her recovery. We took independent medical advice on this case from a consultant in trauma and orthopaedics. Our adviser said that the x-rays indicated that Mrs C had fractured her wrist and that the consultant failed to identify this when he saw her at the trauma clinic. His notes and his comments on Mrs C's complaint indicated, however, that he reviewed Mrs C's x-rays. Without independent evidence, it was not possible for us to say whether he failed to examine all four x-rays and this was why he did not correctly identify the fracture. Our adviser explained, however, that in spite of the incorrect diagnosis, Mrs C received the correct treatment for her condition and her recovery was not compromised. We concluded that, on balance, the care and treatment she received was reasonable, although we made recommendations about the incorrect diagnosis.

Miss C, who is an independent advocate, complained to us on behalf of her client (Miss A). Miss A had previously had input from the board's speech and language therapy (SaLT) and learning disabilities teams, and was looking for further input from them. The board, however, did not provide this. They said that the SaLT team could not identify a clinical risk to Miss A that would benefit from further intervention, and that the learning disabilities team had identified behavioural family therapy as being appropriate, which was begun. Miss C complained about these decisions. The board investigated the complaints but remained of the view that their decisions had been reasonable. Miss C then raised her complaints with us. We obtained independent advice from one of our medical advisers, who is an experienced mental health professional. He read Miss A's relevant records and considered the situation carefully. He explained that the use of both services has a particular purpose, and that the board had to take this into account. He agreed that the way the decisions were taken was correct, and that the board's decision not to offer further direct engagement was reasonable. We accepted his advice and did not uphold Miss C's complaints. Related reading View Decision Report 201305371 as a PDF (11.21 KB) Updated: March 13, 2018

Miss B and Miss C complained that the nursing and physiotherapy care and treatment given to their mother (Mrs A) in hospital was inadequate. They said that although their mother had advanced dementia she had been living an active life. Although not independent, she had been fully mobile unaided, eating by herself, interested in her surroundings and reading and talking. However, after she was discharged from hospital she had a urine infection and pressure ulcers on her heels. She was immobile, and no longer able to swallow tablets or eat solid food. She also took little notice of her surroundings and did not talk. Her daughters believed that this was a result of what happened in hospital. Our investigation considered all the relevant documentation, including the complaints correspondence and Mrs A's medical records. We also obtained independent advice from two of our advisers (a nursing adviser and a physiotherapist). We upheld the complaint, as our investigation found that there were aspects of Mrs A's care and treatment that were unsatisfactory. A care plan should have been put in place when Mrs A's heels became discoloured. Although we found no evidence that Mrs A developed a urine infection while in hospital, we found that her medical records lacked detail. The content of the physiotherapy treatment provided was appropriate, but the frequency of treatment was not. It was not in accordance with Scottish Intercollegiate Guidelines Network (SIGN) guidelines and was inadequate, although our adviser noted that the outcome was unlikely to have been different even with more sessions. We also found that Mrs A's overall management and treatment lacked documented evidence of planning and what was done. There was also no documented evidence of discharge planning or contact with community physiotherapy about follow-up treatment.

Mr C, who is a prisoner, wanted his prescription increased due to extreme pain in his knee, and lower back pain. After the consultation, he complained about the medical treatment he received, and was unhappy with the way he had been treated and spoken to by the GP. We took all the available information into account, including Mr C's relevant clinical records and the complaints correspondence. We also obtained independent advice on Mr C's care and treatment from one of our medical advisers. We did not uphold the complaint, as our investigation found no specific shortcomings in the way that the GP dealt with Mr C. We were also satisfied that, based on his medical records, Mr C had access to different GPs and was referred for further investigation as well as for a specialist physiotherapy review. Our adviser said that the examination and medication dosage were reasonable, and that the GP had taken Mr C's individual needs into account. However, we were concerned that there was no evidence that the GP spoke to Mr C to exclude any potentially serious cause for his back pain, and we made a recommendation about this.

Mr C, who had previously surrendered his driving licence for medical reasons, complained that a consultant at Dumfries and Galloway Royal Infirmary delayed in writing a report for the Driver and Vehicle Licensing Authority to confirm that he was medically fit to drive. Mr C also complained about the board's response to his complaint. We found there was an unacceptable delay in writing the report in support of Mr C's licence application, and upheld this part of his complaint. The board explained that there was an administrative backlog, and that the report had to be written by a doctor (as opposed to an administrator). Mr C did not believe this because he was not told about the backlog when he spoke to his consultant's secretary. Our investigation established that there was a backlog, and that the report was something that only a doctor could deal with. The consultant had explained in an internal email that they could not easily delegate completion of the report, due to lack of medically qualified support. While we took the view that it might have been helpful if the board had given Mr C some of this additional information, we did not uphold his complaint about their response, as we found that it was acceptable. The board also told us they would have expected Mr C to have been kept informed when there was a delay in replying. This did not happen, and the board did not tell us what they have done to stop this happening again. So, although we did not uphold that part of Mr C's complaint, we made a recommendation about this.

Mrs A had Parkinson's disease (a progressive neurological condition in which part of the brain becomes more damaged over many years) and an Alzheimer's-type condition and needed help with a number of day to day tasks. Her son (Mr C) was her next of kin, carer and power of attorney. He complained that when Mrs A was admitted to hospital, staff failed to recognise his status and include him in discussions about her treatment. Mr C felt that he had to actively seek information from staff, rather than this being openly discussed with him. He also complained about the quality of the nursing care and the appropriateness of a decision to discharge Mrs A. We found that, although Mr C was eventually appropriately included in discussions about Mrs A's treatment, he was not adequately involved during the first days of her admission. As such, important background medical information was not gathered, as Mrs A could not provide this herself. We noted that the board have useful tools for staff to establish whether there is a carer available, but these were not used. We were satisfied that appropriate consideration was given to Mrs A's suitability for discharge and that there was clear evidence of Mr C being consulted and of his comments influencing the decision-making process. However, we were critical of the board's handling of Mr C's complaints, as their investigation into his concerns was substantially delayed.

Mr C complained about the prison healthcare team making changes to medication he had been prescribed for chronic leg pain and migraines. He also complained about not being given medication for high blood pressure. Mr C, however, withdrew his complaint before our investigation was completed. Related reading View Decision Report 201300252 as a PDF (10.69 KB) Updated: March 13, 2018

Mr C complained on behalf of his son (Mr A). Mr A had mental health problems but although he was twice on the waiting list for treatment for this, the board removed him from the list because he was either being investigated by the police or was awaiting trial. Mr C complained to the board, who confirmed that as there were outstanding charges against Mr A, his name had been removed. They said that this was in accordance with their usual protocol. As part of our investigation we obtained independent advice from one of our medical advisers, a consultant forensic psychiatrist. Our adviser said that the board's protocol was contrary to the NHS policy of individualised care according to need. Mr A had been removed from the waiting list without due consideration for his needs and circumstances. We upheld the complaint as Mr A had received no treatment, and had significant psychological needs that went unmet.

Mr C complained that when he made a request to the practice for a copy of his late mother's GP clinical records he was not provided with a full copy of her records for the previous ten years. He also had concerns that since 2005 his mother had visited the practice with recurrent ear infections, but it was not until late 2010 that she was referred to an ear nose and throat consultant, who diagnosed a tumour in her ear. We did not uphold Mr C's complaints. Our investigation found that the practice had provided a full copy of his late mother's records and had explained that they initially kept paper records before moving to electronic records. We also found that although Mr C's mother had reported ear infections intermittently since 2005, these had cleared with treatment. By 2010 the ear problem with which she presented to the practice was different. Related reading View Decision Report 201204261 as a PDF (11.08 KB) Updated: March 13, 2018

Mr C complained about the care and treatment that his brother (Mr A) received from the board in the month before his death. Mr A was admitted to hospital suffering from pains in his chest, upper abdomen and down his right arm, and an initial diagnosis of heart attack was made. While Mr A was in hospital it also became apparent that he had a pneumonic chest infection (lung infection). This became the leading diagnosis, with an underlying diagnosis of heart disease, with evidence that Mr C had suffered a previous heart attack. Treatment was based on this assessment, and once Mr A was considered to be well enough, he was discharged. He was not referred for an angiogram (an image of the blood flow through the heart) while in hospital, and Mr C complained specifically about this. Mr A was referred for a follow-up echo-cardiogram test (ECG - a test to measure heart activity) and was given medication to reduce the risk and possible complications of a further heart attack, but he died five days after being discharged. Shortly after Mr A died, Mr C complained to the hospital about his brother's care and treatment. He waited over two months for the board's response, and when he received it, Mr C was still unhappy about their decision. The board commissioned an independent review of the case, to determine whether there was any fault that they had not identified in Mr A's care and treatment. The report did not identify any failings, and was followed up by a further, final response from the board to Mr C. Mr C then complained to us about his brother's care and treatment and about the way the board handled his complaint. We obtained independent advice on this complaint from a medical adviser. Their advice indicated that Mr A's symptoms were hard to diagnose, particularly at the early stages, as his symptoms were not typical and related to the interaction of two conditions - chest infection and heart disease. However, the adviser said that Mr A's treatment was reasonab

Mrs C complained that when she was admitted to hospital with a broken ankle, staff administered an unreasonable level of morphine, resulting in a severe reaction. She also complained that when she raised her concerns about this with the board, they failed to provide her with a sufficiently detailed response, and failed to respond within a reasonable timescale. We investigated Mrs C's concerns, and sought independent advice from one of our medical advisers. Our adviser noted that Mrs C was given a fairly high dose of morphine, both orally and by injection, and suffered a subsequent reaction (opiate toxicity). However, we did not uphold this complaint as the adviser said that the levels prescribed were not unreasonable, given Mrs C's condition and the fact that she was about to undergo a plaster replacement on her ankle which would have resulted in an increase in pain. We also reviewed the board's complaints correspondence and were satisfied that they provided a reasonable response to Mrs C's concerns. However, to the extent that there was at one stage a delay in responding to Mrs C's correspondence, we upheld this complaint, although we did not find it necessary to make any recommendation. Related reading View Decision Report 201204517 as a PDF (11.27 KB) Updated: March 13, 2018

Mr C complained that the board unreasonably delayed in diagnosing that his late wife (Mrs C) had mesenteric ischemia (reduced blood flow to the intestines). He also complained that they delayed in operating on Mrs C following her diagnosis and that this caused her death. We took independent advice from one of our medical advisers, who explained that mesenteric ischemia is a very difficult condition to diagnose. It is usually diagnosed by excluding other causes and this can take some time. We were satisfied that the board carried out appropriate assessment and investigations to exclude other causes to diagnose Mrs C's condition. However, we found that the diagnosis of mesenteric ischemia should have been considered sooner in view of the fact that Mrs C was known to have vascular disease. The board decided that operating on Mrs C would be very high-risk, and referred her to another board for advice. Although we found that this was in itself reasonable, there were delays in obtaining the advice. It was then decided that Mrs C required a major surgical operation, which would carry some significant risks to her health. The surgeon who had been managing Mrs C's care was due to leave the board at that time. He referred Mrs C to another board and asked that they take over her management. Again, given the circumstances, we found that this was reasonable. However, we found that the referral should have been more urgent and the board should have pursued this when no response was received from the other board. Mrs C's condition deteriorated further before she was seen by the other board. She underwent an emergency surgical procedure and was admitted to intensive care. A second procedure was carried out to review her bowel. It was decided that the surgical options were limited, and the surgeon could not carry out a bowel resection (partial surgical removal). Mrs C subsequently passed away. Our adviser said that Mrs C was a high-risk candidate for surgery and it was

Mr C's wife (Mrs C) visited a medical practice on a number of occasions complaining of stomach pain. Mr C complained that the practice unreasonably delayed in diagnosing his wife's illness. The practice initially gave Mrs C painkillers. When the pain did not go away the practice took blood tests to rule out cancer. Mrs C then started to complain of weight loss as well as pain. When these symptoms occurred together the doctor referred her to general surgeons at the local hospital, where Mrs C was diagnosed with mesenteric ischemia (a condition that reduces blood flow to the bowel). To investigate the complaint we took independent advice from one of our medical advisers. He explained that this diagnosis was difficult to make, and would need to be made at a hospital as it required detailed investigations to confirm it. The adviser was satisfied that the practice had referred Mrs C appropriately when she started to have increasing pain and weight loss. The adviser confirmed that there was no evidence of an unreasonable delay in diagnosis. Related reading View Decision Report 201203049 as a PDF (11.21 KB) Updated: March 13, 2018

Mr C complained about the care and treatment that his late wife (Mrs C) received at the medical practice over a three month period. Mr C was unhappy that the practice did not carry out relevant investigations of Mrs C's persistent and severe abdominal pain. He told us that he felt that doctors at the practice did not listen to their concerns, and that there was a lack of support. After Mrs C was admitted to hospital, further investigations showed that she had pancreatic cancer, and Mrs C died a few weeks later. We did not, however, uphold Mr C's complaint. Our investigation found clear evidence to show that the practice had carried out appropriate and reasonable investigations to try to diagnose the cause of Mrs C's ongoing pain. They had also referred Mrs C to a specialist for further investigation. We noted that a CT scan (a special scan using a computer to produce an image of the body) had been carried out two months before her diagnosis, but had not shown any abnormalities. Our independent medical adviser also explained that pancreatic cancer tends to present late, often with non-specific symptoms, and has some of the lowest survival rates of all cancers. Related reading View Decision Report 201201552 as a PDF (11.26 KB) Updated: March 13, 2018

Mr C's wife (Mrs C) became unwell and visited her GP who arranged for tests, which showed she had kidney stones. Mrs A continued to suffer abdominal pain but a CT scan (a special scan using a computer to produce an image of the body) and various other gastrointestinal investigations (investigations of the stomach and intestine) did not show any significant abnormality. Mrs C's GP referred her to a hospital accident and emergency unit (A&E) surgical team for further assessment. An urgent out-patient CT scan was requested and she was discharged the same day. Nine days later, Mrs C went to A&E again because she continued to suffer severe pain, and was reviewed by the medical and surgical teams. Further tests were carried out and although she could have been admitted at this time, Mrs C preferred to go home and prepare herself for being admitted in two days' time. However, as Mrs C could no longer tolerate the pain, she returned to A&E the next day and was admitted to hospital. A CT scan and biopsies (tissue samples) confirmed that Mrs C had cancer of the pancreas that had spread to her liver, and she died a few weeks later. Mr C complained that the consultant did not examine his wife and that she was only prescribed painkillers and advised to take laxatives. We took independent advice from one of our medical advisers, who said that Mrs C was appropriately assessed and examined by the junior A&E doctor and that although laxatives had been recommended, there was evidence that the staff were also considering other causes of the pain. We also noted that relevant tests were organised, including x-rays and blood tests and Mrs A was appropriately given morphine for pain relief. However, we upheld Mr C's complaint, as we identified that it would have been reasonable and appropriate for the consultant, as the senior A&E doctor in attendance, to have examined Mrs C to confirm the junior doctor's assessment and findings. In doing so, we noted our adviser's view that such an exami

Mr C, who is a prisoner, complained that the health board inappropriately failed to conduct an adequate occupational therapy assessment to inform his needs and requirements as a disabled prisoner. However, he was freed from prison whilst we were investigating his complaint and did not provide us with a contact address. We were unable to obtain a contact address for Mr C and we had no option but to close our file on his case. Related reading View Decision Report 201200608 as a PDF (10.84 KB) Updated: March 13, 2018

Mr C complained that the board failed to provide him with reasonable care and treatment for his mental health problems. He detailed a number of areas about which he was concerned, and he was also unhappy about the way in which the board handled his complaint. He said that the consultant concerned had lied in his response. During our investigation, we took independent advice from our medical adviser who is a consultant psychiatrist. We found that that the frequency of the board’s contact with Mr C was reasonable. We also found that the frequent use of hospital admissions and the fact that a large team were involved in his assessment and treatment were examples of good clinical practice. Although some of the clinics that Mr C was to attend were cancelled, we did not consider that this was excessive. We also found that it was reasonable to arrange clinics in locations that would benefit the greatest number of patients. However, we found that Mr C had been prescribed with large doses of medication that were not appropriate for the disorder he had been diagnosed with. This led to him being over-sedated. For this reason, we upheld his complaint about care and treatment, although we noted that the board had since carried out a review of his medication. We did not uphold the complaint about complaints handling, as we found that the board’s response was reasonable and we did not consider that the consultant had lied.

Mr C's wife (Mrs C) was treated at a hospital for a number of health problems over a period of 13 years. This included a hip replacement in 2001, following which Mrs C developed a bacterial infection - Methicillin-resistant Staphylococcus aureus (MRSA). This was treated at the time, but Mrs C complained of pain in the hip from that point on. In 1998, Mrs C was referred to haemotology for investigation of a blood abnormality. The subsequent investigations concluded that it was likely that she had a cancerous mass on her pancreas. A whipple's resection (an operation) was carried out to remove part of her stomach, duodenum, bile duct and head of pancreas. The mass was found to be benign. Mrs C, however, experienced complications of the surgery, which left her with gastrointestinal problems (problems with the stomach and large and small intestines). In 2005, these began causing her to collapse. One such collapse caused the dislocation of Mrs C's hip replacement. The hip was put back in place, but Mrs C was discharged without a clear diagnosis of the cause of her collapse. In 2008, the hip scar became inflamed and swollen, then burst, releasing a large amount of blood and pus and immediately resolving her pain. Tests found that the hip replacement was infected with MRSA. Revision surgery was carried out, but as the bone had degraded, it was decided not to provide Mrs C with another hip replacement. Mr C complained that the whipple's procedure had been unnecessary. He was also critical of the board's investigation of the cause of Mrs C's blackouts and the failure to resolve her MRSA infection. He believed that this had been present since 2001 and had caused the bone degradation which prevented a further hip replacement from being provided. We did not uphold Mr C's complaint. We took advice from one of our medical advisers, who said that the risks associated with the whipple's resection were significantly lower than that of carrying out a biopsy (which might lead to a fals