SPSO Individual Decisions

Mr C complained on behalf of his late wife (Mrs A) about the care and treatment she received at Forth Valley Royal Hospital. Mrs A had been experiencing tingling in her fingers, which continued to worsen. Mr C complained there was an unreasonable delay in carrying out a scan to investigate Mrs A's condition. He also considered that there was an unreasonable delay in giving Mrs A the results of the scan. After Mrs A was referred for surgery, her mobility declined. Mr C felt that, with earlier surgery, she may have been walking normally. We took independent medical advice from a consultant orthopaedic surgeon (a doctor who specialises in conditions involving the musculoskeletal system). We found that Mrs A was appropriately referred for an urgent scan and that it was carried out within a reasonable timescale. However, we considered that there was a delay in reporting the results and in giving Mrs A the results, which was unreasonable as there were significant clinical findings that required urgent surgical intervention. The adviser considered that earlier surgery was likely to have improved Mrs A's outcome and mobility. However, they explained that a good outcome was not guaranteed, as her condition was degenerate and it was unlikely she could have been walking normally. In light of these delays identified, we upheld Mr C's complaint.

Mr C complained to us about the decision making of his GP practice. Mr C had received annual checks for prostate cancer for several years. However, the practice decided to change this to every two years. When Mr C's PSA levels were next checked, they had risen considerably and Mr C was found to have developed prostate cancer. Mr C complained that the practice unreasonably changed the frequency of his prostate checks. In addition to this, he complained about a number of administrative and communication issues relating to his prescriptions and treatment following his diagnosis. We took independent advice from a GP. We found that there is currently no national guidance relating to prostate screening but noted that it was important to discuss the pros and cons with the patient so they could make an informed decision. The practice told us that a discussion had taken place but Mr C recalled that it was more a case of the practice stating a firm position and taking the decision. We were unable to confirm that a discussion had taken place. However, the records did state that Mr C should be monitored based on symptoms rather than testing and that he should be seen as required. In addition to this, an International Prostatic Symptoms Score (IPSS, a tool used to screen for, rapidly diagnose and track the symptoms of prostate enlargement) taken after the consultation showed a lower score. In light of the known information at the time of the consultation, and the fact that there is no national policy regarding screening for prostate cancer, we considered that the practice's decision was reasonable. Therefore, we did not uphold this aspect of Mr C's complaint. In respect of the administration and communication issues, there appeared to have been some minor failings which were partly acknowledged in the practice's response to Mr C's complaint. However, we considered that the administration of prescriptions and paperwork had been largely adequate. Therefore, we did no

Mr C complained about the care and treatment provided to his mother (Miss A) during two admissions to the mental health unit at Forth Valley Royal Hospital. In relation to Miss A's first admission, Mr C had concerns about the monitoring and treatment of blood pressure and the treatment provided to Miss A by a psychiatrist. In relation to her second admission, Mr C had concerns about medical care, nursing care and issues around communication. Mr C also complained about the gap in community psychiatric care in the period between the two admissions. We took independent advice from a nurse and a consultant psychiatrist. We found that there were failings by nursing staff in the monitoring of Miss A's blood pressure and upheld this aspect of Mr C's complaint. However, we noted that the board had acknowledged this failing and had introduced a new system for recording observations. Overall, we found that the medical treatment provided to Miss A during her admission was reasonable and did not uphold these complaints. However, we noted that one letter sent to Mr C contained unhelpful language and we made a recommendation in light of this. In relation to the gap in community psychiatric care in the period between the two admissions, we found that the board had not followed the clinical management plan in place once Miss A's psychiatrist left the community mental health team. Therefore, we upheld this aspect of Mr C's complaint. We did note, however, that the board had apologised for this failing and had put a new appointment system in place to address this issue. In relation to Miss A's second admission, neither adviser identified any failings in medical care, nursing care or communication. Therefore, we did not uphold these aspects of Mr C's complaint.

Mr C's child, (child A), was born with a cleft palate (an opening or split in the roof of the mouth that occurs when the tissue doesn't fuse together during development in the womb) which led to difficulties in breathing and feeding. After treatment at one hospital, child A was transferred to Forth Valley Royal Hospital. They were discharged 11 days later, however, Mr C had to return child A to Forth Valley Royal Hospital that night because they had been struggling to breathe since their discharge. Child A was admitted and within a few days they were referred to another hospital. Mr C complained that child A should not have been discharged from Forth Valley Royal Hospital given their medical condition at the time. Mr C also complained that the board failed to address his complaint in a reasonable way. We took independent advice from a paediatrician. We found that the decision to discharge child A was reasonable given his medical condition at the time. There were no medical concerns noted in the days prior to their discharge and we considered that the board's actions were appropriate. Therefore, we did not uphold this aspect of Mr C's complaint. In relation to complaints handling, we found that the board fully addressed Mr C's concerns. However, we found that there was an unreasonable delay in arranging a meeting and that there had been a lack of communication with Mr C regarding this. Therefore, we upheld this aspect of Mr C's complaint.

Mrs C complained about the care and treatment given to her late father (Mr A) after his GP referred him to the board for neurology treatment. Mr A had his first neurology appointment and the following month was diagnosed with a rare type of cancer. He was told that he would require no treatment. However, three months later he attended the emergency department at Forth Valley Royal Hospital with chest and abdominal pain and was admitted to the hospital. Mrs C complained about Mr A's care and treatment by both nursing and clinical staff, and about the lack of information she and her family were given. Mr A died some weeks later, and Mrs C said that the family had been unaware of the seriousness of Mr A's illness and its prognosis and, as such, they were shocked and unprepared for his death. We took independent advice from consultants in emergency medicine and haematology (medicine of the blood) and from a registered nurse. We found that Mr A's emergency treatment had been reasonable and appropriate and that he was assessed and managed properly. Afterwards, when Mr A was admitted to the ward, the approach to his illness was watchful waiting. We found that his death could not have been anticipated. For these reasons we did not uphold the complaints about the care and treatment given to Mr A by clinical staff. We did find that there had been some failures in his nursing care and that there were gaps and inconsistencies in his medical notes, and so we upheld Mrs C's complaint about nursing care. However, we noted that the board had already apologised and taken action with regards to these failings, and therefore we made no further recommendations in this regard. While Mrs C was unhappy about the level of information given to her family, we were satisfied that they had been kept informed of Mr A's deteriorating condition, but that his imminent death could not have been foretold. On balance, we did not uphold this part of the complaint. Related reading View Decis

Miss C underwent cataract surgery at Falkirk Community Hospital and, during this operation, she suffered a leak of the fluid in her eye and her eye was stitched following surgery. A few years later, Miss C suffered a detached retina and underwent surgery for this. Following the surgery, Miss C's vision deteriorated significantly, and she subsequently had to have further surgery. Miss C was concerned that the stitching of her eye following her first surgery may have contributed to the detached retina, and she said that staff had commented at the time that they did not have the correct equipment on hand (but went ahead anyway). Miss C was also concerned that she had high pressure in her eye following the second surgery, and required to be readmitted a couple of days later. She felt that she should have been kept in hospital for longer for observation and queried whether this had impacted on the poor outcome of the surgery. In response to Miss C's complaint, the board explained that the first surgery was complicated by zonule dehiscence (the breaking of the structures that hold the lens in place, which can cause fluid within the eye to come forward). The board said that this may have contributed to Miss C's subsequent detached retina, but that it was unlikely since the detached retina occurred a long time after the surgery. We took independent advice from a consultant ophthalmologist (a doctor who deals with diseases and injuries to the eye). We found that Miss C suffered a recognised complication during her first surgery, which was appropriately managed, and that the decision to stitch her eye was reasonable. We also found no evidence that staff did not have the correct equipment for stitching the eye and, therefore, we did not uphold Miss C's complaint. However, we noted that there was no record of any discussion with Miss C to explain the complication that had occurred. Therefore, we made a recommendation to the board regarding this. In relation to Miss C'

Mr C complained that his request for orthodontic treatment was unreasonably refused by the board. Following contact from our office, the board repeated their offer to provide Mr C with a further referral to an orthodontic consultant to assess suitability for treatment. As a result of this further action by the board, we determined that it would not be appropriate to take forward Mr C’s case at this time when he was still undergoing assessments. Related reading View Decision Report 201701227 as a PDF (10.79 KB) Updated: December 2, 2018

Mrs C complained about the care and treatment her husband (Mr A) received at Forth Valley Royal Hospital. Mr A was admitted to hospital after sustaining a fracture to his thigh bone. An operation was carried out to insert a pin into the thigh bone to secure the fracture. During the operation, the wrong size of screw was used to fix the pin to the bone. Medical staff discussed this situation with Mr A following the operation, and it was agreed that a further operation would be carried out to replace the screws with those of a correct size. This operation was completed successfully and, after a period of recovery, Mr A was discharged home. Mr A was then re-admitted to hospital after he became unwell. The board carried out blood tests which showed signs of infection, yet it was not clear where the source of the infection was. Mr A's condition deteriorated and he died from a bowel condition related to the infection. Mrs C complained that the wrong screw was used in the first operation and she felt that the second operation had caused the infection that led to Mr C's death. The board apologised to Mrs C about the use of the wrong screw and informed us that this issue had been discussed at a number of clinical meetings in order to prevent the issue from happening again. We took independent advice from a consultant orthopaedic and trauma surgeon. They considered that the care and treatment provided to Mr A was reasonable, with the exception of the use of the incorrect screws. The adviser said that, in their opinion, the infection related to Mr A's re-admission was not linked to the orthopaedic treatment he received. Although we were unable to conclude that the orthopaedic treatment received led to Mr A's death, we upheld this complaint and asked that the board send us evidence of the steps they said they had already taken to prevent this from happening again. Related reading View Decision Report 201607162 as a PDF (11.46 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment that the board provided to her late brother (Mr A). Mr A attended the emergency department at Forth Valley Royal Hospital. After performing an examination and taking blood tests, staff considered that he had gastroenteritis (inflammation of the stomach and intestines). Mr A returned the next day, and staff continued to feel he was suffering from a viral illness. Mr A was seen the following day by an out-of-hours GP. He was then admitted to the board's acute assessment unit, who performed a range of further tests. The tests were normal, and Mr A returned home. He was seen the next day by a further out-of-hours GP. Mr A returned to the board's emergency department the following day, and was again admitted to the acute assessment unit. Over the subsequent days, Mr A's condition deteriorated and he was diagnosed with carcinomatous meningitis (a type of cancer). Mr A died a number of days after his second admission to the acute assessment unit. Mrs C complained that the board unreasonably delayed in diagnosing Mr A with carcinomatous meningitis. She also said that staff unreasonably discharged Mr A from the hospital on several occasions. Finally, she said that staff unreasonably failed to provide effective pain relief. We took independent advice from a consultant in emergency medicine, an out-of-hours GP, and a consultant in acute medicine. We found that carcinomatous meningitis is a rare form of cancer that is aggressive and that it presented atypically in this case. We found that staff carried out appropriate investigations, and that it was not unreasonable for them not to identify the cancer at an earlier stage. We identified one delay in reporting an x-ray, although this did not appear to impact on the timescale for diagnosis. As such, we did not uphold Mrs C's complaint about an unreasonable delay in diagnosing Mr A. Regarding Mrs C's complaint about the discharges, we found that staff had a reasonable bas

Mrs C complained about the care and treatment provided to her late mother (Mrs A) at Forth Valley Royal Hospital. Mrs A was admitted to the hospital following a collapse at home. During her admission, she fell and sustained serious injuries. Mrs C believed that the fall in hospital contributed to Mrs A's death a few days later, and that healthcare professionals failed to take appropriate action to minimise the risk of Mrs A falling, particularly in light of her complex medical history. Mrs C also raised concerns about complaints handling issues, including a failure to respond thoroughly and a delay. We took independent advice from a nursing adviser who specialises in falls prevention and a medical adviser who specialises in acute medicine. We found that, while there was evidence that nursing staff had highlighted Mrs A's risk of falling and had put in place a number of interventions to address it, there were shortcomings in this. Mrs A's condition deteriorated shortly before her fall and we found that a further review of her needs should have been carried out then. We also found that, in the lead up to the fall, the amount of time that Mrs A was left on a commode with little supervision was excessive. Having said that, the advice we accepted was that the fall did not directly lead to her death. On balance, we upheld this aspect of Mrs C's complaint. With regards to Mrs C's concerns about complaints handling, we found that the board's investigation was thorough and their position that they could not give Mrs C a definitive account of how Mrs A fell because nobody saw it was reasonable in the circumstances. However, we upheld the complaint because the time it took the board to respond to Mrs C was unreasonable.

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs A) about the care provided by the practice following a phone consultation. The day following her discharge from hospital for heart bypass surgery, Mrs A called the practice for advice. A GP called her back a short time later and discussed medication with her. At this time, Mrs A reported a clicking sensation in her chest. The GP reassured her about this sensation and advised her to contact the practice again if she became more unwell. Mrs A's condition deteriorated later that day and she was admitted to hospital, where she was treated for an infection. Ms C raised concern that the GP did not identify that Mrs A had an infection and felt that a home visit should have been carried out. We took independent advice from a GP adviser. Whilst they noted that the GP's clinical record of the consultation was brief, on balance, the adviser considered that the assessment and care provided was reasonable. We accepted this advice and we did not uphold this complaint. Related reading View Decision Report 201701293 as a PDF (11.14 KB) Updated: March 13, 2018

Miss C complained about the dental care and treatment provided to her after she was diagnosed with gum disease. She complained that the dentist did not offer to refer her to a specialist for treatment, and instead recommended that she have her teeth professionally cleaned every three months. Miss C also complained that the dentist had not taken x-rays to assess for bone loss in the four years since she was diagnosed with gum disease. Miss C felt that as a result of the dentist's ineffective treatment of her gum disease, her condition had become worse. We took independent dental advice. We found that whilst the treatment provided by the dentist to Miss C was reasonable in some respects, we found that they had not offered Miss C the opportunity to see a specialist for her gum disease when she was first diagnosed. We also found that the dentist had failed to follow guidelines with regards to charting the progression of the gum disease. We further found that the dentist had failed to record basic periodontal examination (BPE) scores, which according to the relevant guidance should be recorded at every appointment. We also found that the dentist failed to follow good practice and take radiographs when Miss C's BPE score was four (any score of four or above is considered to require monitoring and/or treatment). On this basis, we upheld Miss C's complaint. Miss C also complained that the dentist did not reasonably respond to her complaint. We found that the complaint response did not tell Miss C that she could bring her complaint to us if she remained dissatisfied. Therefore, we upheld this aspect of Miss C's complaint.

Mrs C complained about the care and treatment that staff at Forth Valley Royal Hospital provided to her over a number of years. Mrs C was seen by the board's consultant orthopaedic surgeon and elected to have knee replacement surgery. She experienced some pain and discomfort following the surgery, and was seen during this time by an orthopaedic nurse. Approximately three years later, Mrs C continued to experience pain and discomfort and was then seen by two additional consultant orthopaedic surgeons. Mrs C raised concerns that the knee replacement surgery was carried out inadequately as she felt that the board had provided her with a knee prosthesis that was too small. She also raised concerns about the monitoring that the board provided following her surgery. She also complained about the level of care and treatment that the board provided when she was seen by consultant orthopaedic surgeons over the following years. We took independent advice from a consultant orthopaedic surgeon. We found that there was no evidence from the records and x-rays that the prosthesis was the wrong size, or that there was any other error in the initial surgery. We noted that there is an inherent risk that surgery will result in a patient experiencing ongoing pain and difficulties, without this being caused by any failure in the surgery. We did not uphold this aspect of Mrs C's complaint. We upheld Mrs C's complaint about monitoring. We found that there was evidence of Mrs C expressing pain and discomfort during her reviews with an orthopaedic nurse that should have led to her being reviewed by a consultant orthopaedic surgeon, or should have led to some communication from a consultant. We did not uphold Mrs C's complaint about the subsequent care and treatment she received when she reported problems with her knee in the following years. We found that the documented views of the board's consultant orthopaedic surgeons were not unreasonable, and that the treatment provided was a

Mrs C complained about the care and treatment provided to her adult daughter (Miss A) at Loch View House, which is a specialist facility for providing care to patients with learning disabilities. Mrs C raised concern that following her daughter's admission to Loch View House, staff did not take into account that her clinical problems could have been due to difficulties with Miss A's diabetes control. We noted that Miss A was under the care of a consultant psychiatrist during the admission and we sought independent advice from a psychiatric adviser. They considered that the medical records clearly showed that staff had reviewed Miss A's history of diabetes management in the community and had recognised that Miss A's behavioural change might be related to her diabetic control. We did not uphold this complaint. Mrs C also complained about the way that staff managed Miss A's diabetes throughout the admission. We found that the board had acknowledged issues in relation to the provision of needles, required for administering medication, and had apologised to Mrs C for this. We took independent advice from a nursing adviser on this aspect of the complaint. They were satisfied that the board had put reasonable steps in place to address this issue and that appropriate steps for learning and improvement had been identified. We upheld this complaint, but did not make any further recommendations as the board had already taken action. Finally, Mrs C expressed dissatisfaction that staff failed to communicate with her adequately about her daughter's treatment. The psychiatric adviser found that the medical records evidenced regular communication with Mrs C and other members of the family throughout the course of Miss A's admission. They added that the records showed a high level of contact, mostly by phone, with detailed discussion and timely responses to concerns raised. The adviser considered that this level of contact was appropriate given Miss A's needs and they note

Ms C complained on behalf of her daughter (Miss A) about the care provided to her at Forth Valley Royal Hospital following an ultrasound scan which confirmed that she had lost her baby. Ms C was concerned that a sonographer, rather than a midwife, had told Miss A that the baby had died, and that she then had to wait for 45 minutes to see the doctor and midwife. She was also concerned that her daughter was not given a full explanation of the medication she would receive and of the process which would lead to the birth of her baby. She felt that the level of support and information provided to her daughter was inadequate. Ms C was also unhappy with what happened when her daughter returned to the hospital two days later to give birth to her stillborn baby. She felt that the support provided by the midwife was poor and this meant that her daughter eventually gave birth without the midwife being present. She was also concerned about the level of pain relief provided, documentation which suggested the baby would be cremated when this was not the intention of the family, and that the time of the birth was misreported in the records. We took independent advice from a midwifery adviser. We found that it was appropriate for the sonographer to report the ultrasound findings to Miss A. We noted the subsequent delay in seeing a doctor or midwife, but we did not consider that this delay was unreasonable for the hospital at that time. We were satisfied that the records showed that Miss A was provided with a reasonable level of support and advice and that she was given the opportunity to ask any questions she had at that time about medication or the birth process. Following her attendance at hospital two days later, we were satisfied that the level of support provided to Miss A was reasonable. We noted the issues with the form suggesting cremation, but we also noted that the board had agreed to review this literature when they responded to Ms C's complaint. As we were s

Ms C, a prisoner, complained about how her complaints were being responded to by the board. The board had written to Ms C informing her that the volume of complaints, comments and feedback she was submitting was putting a disproportionate strain on their resources and impacting on their ability to assist other people. They asked Ms C to adjust her behaviour. They said they were taking action under their Unacceptable Actions Policy and would be limiting the responses they gave to her complaints, focusing only on those they deemed most significant and which had not been resolved at the time. Ms C continued to submit complaints. We found that the board's policies on restricting contact were confusing and that clearer information could have been given to Ms C regarding the board's expectations and what they would do to manage Ms C's behaviour if she continued to submit high volumes of complaints. For that reason we upheld the complaint and made a recommendation to address it. We did not recommend an apology for Ms C as, although there had been a lack of clarity on the board's part, Ms C was well aware of the impact her actions were having on the board and did not take the opportunity to modify her behaviour.

Mr C complained about the care and treatment provided to his late father (Mr A) at Forth Valley Royal Hospital. Mr A was referred to the board and diagnosed with prostate cancer. At a multi-disciplinary team (MDT) meeting, a decision was made to adopt a watchful waiting approach (an approach used in prostate cancer management in men with few symptoms). Mr A attended an appointment approximately six months later, then another twelve months after that. At that point, it was found that Mr A's prostate specific antigen (an indicator of prostate cancer or other prostate conditions) had risen. Following a further MDT meeting, he was seen by an oncologist who felt that he was suitable for radical radiotherapy. In the following months, Mr A's condition deteriorated and he died. Mr C complained that staff failed to provide Mr A with appropriate clinical treatment. He questioned the decision to place Mr A on watchful waiting programme, and the level of review he received. The board partially upheld Mr C's complaint on the basis that communication could have been better. In particular, they acknowledged that it would have been appropriate for Mr A to have been seen by a consultant at the time the decision was made to put him on watchful waiting. The board advised that they had taken action as a result of Mr C's complaint, and that patients would be seen by a consultant following a decision to place them on watchful waiting. We took independent advice from a consultant urological surgeon and an oncologist. We found that the board followed guidelines and reviewed Mr A at reasonable intervals once watchful waiting was decided on. However, we found that the watchful waiting decision should not have been made without clinical assessment by a consultant, which may have led to a decision to offer radiotherapy. We noted that Mr A's cancer followed a path that was significantly worse than could have been expected, and that a decision to offer radiotherapy would not necessar

Mr C complained about the care his late wife (Mrs A) received from nursing staff during two admissions to Forth Valley Royal Hospital. On the first occasion she was admitted with sepsis (a blood infection) and on the second occasion she was admitted with a hip fracture. In particular, Mr C complained that the board failed to carry out appropriate falls risk assessments, failed to appropriately manage Mrs A's medication and delayed in obtaining a review for Mrs A following a fall. Mr C also complained that it took an unreasonable amount of time for him to be able to speak to a senior staff member about his concerns. During our investigation we took independent advice from a nursing adviser. The adviser considered that the overall care in relation to falls assessments, monitoring, care and falls prevention was unreasonable. They also found significant failings in how Mrs A's medication was managed. The board accepted that it took an unreasonable amount of time for Mr C to speak to a senior staff member about his concerns. They also accepted that there was a delay in having Mrs A reviewed following her fall. The board also accepted that there were significant failings in how Mrs A's medication was managed. The board identified learning as a result of the complaint. In light of the independent medical advice we received, we upheld all of Mr C's complaints. Although the board had taken steps to address the complaint, we made recommendations in light of our findings.

Mr C complained that the practice had failed to act appropriately on his reported symptoms of imbalance. Mr C has diabetes and related diabetic neuropathy (nerve damage). He said that over a long period he had complained to the practice of imbalance and falls but that this had always been attributed to his diabetic neuropathy. Mr C was diagnosed with multiple sclerosis (MS - a disease that effects the nervous system) and told us that he felt GPs at the practice should have picked up on this diagnosis earlier. In investigating this complaint, we took independent GP advice. We found that Mr C had complained to the practice of imbalance on two occasions. On the first occasion, this was attributed to the existing diagnosis of diabetic neuropathy, and we found this to be reasonable. On the second occasion, six years later, Mr C was thoroughly examined and no features of concern were found. Mr C was told to return if his symptoms changed, but this was the last time he was assessed by the practice. We found that the symptoms which later led to his diagnosis of MS seven years after his initial examination were not present during the previous two appointments and that the practice had acted appropriately. Therefore, we did not uphold Mr C's complaint. Related reading View Decision Report 201604349 as a PDF (11.21 KB) Updated: March 13, 2018

Mr C complained about the way his medication was handled by the prison health centre, in particular that his medication was changed and that his complaints about pain had been ignored. We took independent GP advice. We found that, when reviewing Mr C's medication, the prison health centre had acted in line with the General Medical Council guidelines on prescribing. We also found that the care provided to Mr C in terms of his pain management was reasonable. We therefore did not uphold the complaint. Mr C also complained that a doctor based at the health centre had inappropriately stated that he hated migrants. We found no evidence to support Mr C's allegation and were satisfied that the allegation had been investigated by the board, including speaking to the doctor involved. However, we noted that there was no written record of the discussions with the doctor as part of the investigation. We were also satisfied that the decisions made in relation to Mr C's clinical management were based on the advice available to clinicians. As such we did not uphold this aspect of Mr C's complaint. Mr C was also unhappy with the handling of his complaint. We were satisfied that the board had handled Mr C's complaint in line with the complaints process and therefore did not uphold this complaint.

Ms C, who works for an advocacy and support agency, complained on behalf of Mrs A regarding the care and treatment she received at Forth Valley Royal Hospital. A scan showed a large abscess on Mrs A's liver. She had undergone surgery to remove her gall bladder three years earlier and it was noted on the scan that one of the surgical clips had become dislodged. It was felt that this was the source of Mrs A's infection and abscess formation. The abscess was initially drained radiologically (a process in which, using radiological imaging, a thin needle is guided into the abscess and a drainage catheter placed). Following two further hospital admissions with recurrence of the abscess, surgical drainage was carried out and the clip was removed. A further admission took place following a small recurrence and the surgical incision was re-opened and the fluid drained again. Ms C complained that the board failed to appropriately manage the complication arising from Mrs A's earlier surgery. In particular, she considered that a delay in removing the surgical clip resulted in the abscess recurrence and need for multiple admissions . We took independent medical advice from a consultant surgeon who noted that the possibility of surgical clips becoming dislodged was well recognised but rarely caused problems. They considered that it was reasonable for the board to have considered less invasive treatment than surgery in the first instance. They noted that, when this was unsuccessful, it was appropriate to proceed to surgery and remove the clip, which they noted was done within seven weeks of the first admission. They considered this reasonable. However, the adviser did not consider that the recurrence of the abscess was due to the ongoing presence of the clip, but rather due to inadequate drainage. They noted that the drain was only left in place for four days the first time and five days the second. They considered that the drain should have been left in place for 10 to 14 days in

Mr C complained to us on behalf of his constituent, Ms A. He said that on being transferred from a mental health unit outside Scotland to Forth Valley Royal Hospital, Ms A was not provided with reasonable mental health care and treatment, in particular that the diagnosis of personality disorder she had been given did not fit her symptoms. Mr C also complained that Ms A was not provided with reasonable out-patient treatment when she was discharged from the hospital, and that the board did not take reasonable steps to change incorrect information on her discharge documents. We took independent psychiatric advice. We found that the in-patient care and treatment provided to Ms A was not reasonable. Whilst we found that the treatment strategies offered to her were appropriate, the diagnosis of personality disorder was not sufficiently evidenced and documented. We found that no valid diagnostic assessment tool was used to assess Ms A and that her diagnosis was given without sufficient consideration of her previous diagnoses. We also found that the way this diagnosis was communicated was inconsistent, sometimes being reported as a provisional diagnosis and sometimes as confirmed. We found that there was a lack of documentation surrounding decisions taken about Ms A's care, including the decision not to implement the recommendations of a clinician who gave a second opinion, not to trial certain medications and the decision to change Ms A's lead clinician. We therefore upheld this aspect of Mr C's complaint. In terms of Ms A's out-patient mental health care and treatment, we found that it was reasonable for the staff involved to provide care on the basis of Ms A's diagnosis of personality disorder, and that out-patient care and treatment had been planned in a collaborative way with Ms A in line with treatment for personality disorders. When considering whether the board had taken reasonable steps to remove incorrect information from Ms A's records, we saw evidence th

Mr C complained that the board delayed in determining that he had multiple sclerosis (MS - a disease that effects the nervous system). Mr C said that he has diabetes and had regularly attended a diabetic clinic with the board to review his diabetic peripheral neuropathy (nerve damage). However, Mr C said he had repeatedly complained of poor balance to the board but that they had failed to find that he had MS despite his symptoms. In investigating this complaint, we took independent medical advice. We found that Mr C had often reported pain to board staff and this was treated in line with diabetic neuropathy. We also found that when Mr C presented with dizziness it was reasonable for the board to rule out any cardiac causes. Our investigation found that when Mr C's condition was noticed to be deteriorating, he was appropriately and quickly referred to a consultant neurologist. Therefore, we did not uphold Mr C's complaint. Related reading View Decision Report 201601778 as a PDF (11.05 KB) Updated: March 13, 2018

Mr C complained that the board failed to clearly diagnose his late mother (Mrs A's) pulmonary fibrosis (a lung condition), and failed to communicate the diagnosis and manage the condition appropriately. Mrs A's pulmonary fibrosis was first identified in a scan carried out five years prior to her death. She regularly attended her GP and hospital over the intervening years with symptoms that included breathlessness. We obtained independent medical advice from a consultant respiratory physician, a consultant general physician and a consultant in emergency medicine. We identified that there were missed opportunities to appropriately refer Mrs A to respiratory medicine. In particular, an attendance at an ageing and health clinic did not result in an onward referral despite clear evidence of progression of Mrs A's condition. We were assured, however, that the limited available treatment options for pulmonary fibrosis meant an earlier referral was unlikely to have altered Mrs A's prognosis. Nonetheless, we recognised that earlier specialist intervention would have afforded Mrs A and her family the opportunity to better understand the nature of her condition and be assured that her symptoms were being appropriately managed. We upheld this aspect of the complaint. Mr C also complained that the board did not respond to his letters of complaint fully and within a reasonable timeframe. We noted that the board's response to Mr C's initial complaint was issued in good time and attempted to address the specific concerns raised. Mr C then wrote to the board on a further two occasions listing several additional questions and outstanding concerns. We noted that the NHS complaints procedure does not make provision for further stages of the process and complainants who remain dissatisfied should be referred to the SPSO. We, therefore, did not consider that the board were obliged to provide the additional level of detail requested by Mr C. However, having agreed to provide a further wri

Ms C complained about the care she received at Forth Valley Royal Hospital after she was admitted via A&E with abdominal pains. While appendicitis was initially suspected, further investigations led staff to believe that Ms C was suffering from problems with her gallbladder. On the second day following her attendance at the hospital, a scan was carried out that showed Ms C's appendix had burst causing an abscess. She was operated on that day but suffered from pleural effusion (excess fluid surrounding the lungs) that had to be treated with a chest drain. Ms C felt that an earlier diagnosis could have resulted in a better outcome. We took independent advice from a consultant in emergency care and a consultant surgeon. In terms of emergency care, we found that Ms C had received appropriate care and investigation in A&E. However, we found that whilst it was reasonable that staff had considered Ms C was suffering from a gallbladder issue due to her symptoms, junior staff should have escalated the case when her condition worsened and alternative diagnoses should have been considered at that point. We found that there had been a delay of around 12 hours in diagnosing the cause of Ms C's condition as a result of her care not being escalated to senior staff appropriately. We upheld Ms C's complaint.