SPSO Individual Decisions

C complained that they had been unreasonably removed from the practice list without prior warning due to alleged verbal abuse. We reviewed the guidance provided by the General Medical Council (GMC), British Medical Association (BMA) and the National Health Service (General Medical Services Contracts) (Scotland) Regulations 2018. We took independent advice from a GP. While we appreciated that C disagreed that their behaviour was inappropriate, this is how the staff at the practice perceived the behaviour. This was also supported by extracts from the contemporaneous records detailing that the practice found C's behaviour to be abusive and upsetting. The Regulations and the guidance from the GMC and the BMA indicate that a warning should be given to the patient, giving the reasons for the possibility of removal from the practice list. The only exceptions to the requirement to give a warning appear to be on the grounds of violence where the police and/or the procurator fiscal are involved, or where the practice believes that issuing the warning would put the safety of members of the practice or those on the premises at risk or it is, in the GP's opinion, not otherwise reasonable or practical for a warning to be given. The practice decided that a warning letter did not apply due to how upset a staff member was. We found that the practice appeared to have taken the view that issuing a warning to C would not be appropriate due to the impact of this incident on the member of staff. We found that the practice acted reasonably (by requesting C's immediate removal from the practice list) and within established rules for removing a patient from the list. We did not uphold C's complaint. Related reading View Decision Report 202005987 as a PDF (24.62 KB) Updated: April 20, 2022

C complained about the care provided by the board to their parent (A) whilst admitted at Glasgow Royal Infirmary. A had been admitted with low blood iron levels and a two-week history of back pain, queried to be a spinal fracture of osteoporotic (weakened bones) or pathological (caused by a disease) origin. Following A's admission, they suffered a “controlled fall”. Twelve days later, A complained of being unable to move their legs. An MRI scan of the spine was carried out, which confirmed that A had suffered a fractured vertebra causing spinal cord compression affecting A's ability to move their lower limbs and control bowel and bladder functions. A was subsequently treated conservatively due to their age and comorbidities. C complained about the circumstances surrounding the fall A suffered and that staff had not recorded details of the incident under the Datix reporting system as required. C considered that A had sustained the spinal injury during this incident and that the lack of Datix report meant that there had been a delay in identifying the injury. The board accepted that a Datix report had not been completed as required at the time of A's fall but that this had not prevented A from being assessed. The board also stated that a Datix report had been completed retrospectively and that the incident had been reviewed by the hospital falls team. The board stated that it was not believed that A's fall had caused the spinal fracture, which may have been present in advance of A's admission. We took independent advice from consultants in emergency and general medicine. We found that despite A presenting to the A&E with a queried spinal fracture, no neurological examination was carried out nor was any consideration given to performing an X-ray of A's spine. This was unreasonable practice. In addition, the board's failure to complete a Datix record of the fall A suffered was also unreasonable although it was impossible to say with any certainty that this in

C was concerned about the care and treatment that their late spouse (A) received at Inverclyde Royal Hospital following a surgery for a hip fracture. C complained that A did not receive appropriate post-operative rehabilitation and physiotherapy (the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery). We took independent advice from a physiotherapy adviser. We found that the physiotherapy assessments and treatment were appropriate. Therefore, we did not uphold this aspect of C's complaint. C also complained about the nursing care that A received. In particular, C was concerned that proactive steps were not taken to prevent A falling and that A was not supervised to take their medication. We took independent advice from a nursing adviser. We found that the board acted reasonably by implementing appropriate and proportionate actions to mitigate the risk of A falling. However, there was no record that A was supervised to take their medication and this was unreasonable given A's cognitive impairment and physical frailty. In light of the above, we upheld this aspect of C's complaint.

C, a support and advocacy worker, complained on behalf of their client (A). A presented to the practice with symptoms of stomach pain and upper and lower backpain. Following several consultations, a GP referred A for an abdominal and renal ultrasound on a routine basis. A was contacted by the hospital with an appointment and was advised that their GP could expedite this if they considered it appropriate. A was referred on an urgent basis by the practice to gastroenterology (specialism of the treatment of conditions affecting the liver, intestine and pancreas) which later confirmed A's diagnosis of cancer. A complained to the practice that they had failed to expedite the referral despite their worsening symptoms. A believes that if they had been referred to secondary hospital services punctually and had obtained a timely diagnosis, their medical treatment would not have been as invasive and that the risk of cancer spreading to other organs would have been reduced. In response to the complaint the practice said that an urgent referral was sent to gastroenterology when it was clear that A's symptoms had progressed. A was dissatisfied with the practice's response and C brought the complaint to our office on A's behalf. During our investigation we requested independent advice on the practice's consultations with A and the arrangements for referring A for further investigations. We found that the decision to refer A initially on a routine basis for an ultrasound was reasonable, given A's symptoms. We found that the medical records indicated consultations with A were reasonable and on the basis of the progression of A's symptoms, there was no unreasonable delay in the urgent referral to gastroenterology being made. We found that the referrals were reasonable and there was no unreasonable delay in making them, as such we did not uphold the complaint. We provided some feedback to the practice on the management of A's pain. Related reading View Decision Report 202103

C underwent a bowel operation. They were told that scarring from the surgery would affect their ability to start a family in the future. C attended the board's fertility clinic and asked for fertility preservation treatment. This was denied on the basis that this treatment was only being offered to cancer patients at that time. C complained that they were denied access to this treatment, despite it being approved for other patients who had had the same surgery. Following their surgery, C experienced complications that ultimately led to them developing sepsis and requiring further surgery. C attended their local A&E, but was discharged home after an examination. C complained that they were discharged despite showing clear signs of postoperative complications and infection. We found that, although C had been advised that fertility preservation treatment was only being considered for cancer patients, this was not the reason that they had been denied access to this treatment. Rather, a National Complex Case group had reviewed C's case and concluded that they would have alternative options for starting a family in the future and that fertility preservation was, therefore, unnecessary. We found that the reasons for the board's decision in this respect was reasonable and did not uphold this aspect of the complaint. With regard to C's attendance at the A&E, we found that reasonable investigations were carried out to check for infection. There was no obvious sign of infection at that stage. However, we were critical of the board for failing to identify that C was displaying signs of postoperative complications. Staff failed to carry out an abdominal examination. We noted that C should have been urgently referred for follow-up investigations with their surgeon and the board failed to do this. We upheld this aspect of the complaint.

C complained about the care and treatment their family member (A) received from the board. A had a complex medical history and received treatment in hospital on a number of occasions. C became aware that a wound that A had on their leg had deteriorated. C was very concerned about the condition of the wound. C complained that, although A had been in and out of hospital on a number of occasions, the board had failed to take reasonable steps to treat A's leg wound. They complained that A was discharged from hospital on multiple occasions following treatment for infections, but that follow-up arrangements were inadequate and, as a result, the leg wound was left to deteriorate. C said that A had suffered both physically and mentally and that family members had been extremely distressed seeing A suffer. We found that A's complex medical history meant that they had multiple hospital admissions and that they were seen regularly by community based district nurses and tissue viability nurses. A's wounds were quite severe and were complicated by the fact that their condition caused their leg muscles to contract, keeping the two skin surfaces together and difficult to access for pressure-relieving treatment. There was no suggestion that the wound on A's leg was caused, or made worse, by any shortfall in the care and treatment provided by the board. We were satisfied that staff caring for A were aware of their wounds and made efforts to relieve the discomfort that they caused as well as working towards helping them to heal. Upon each admission to hospital, A's wounds were assessed and a referral was made to the tissue viability service for review. Whilst on some occasions A was discharged home before the review could occur, they continued to receive care at home from the community tissue viability nurses. Whilst overall we were satisfied that A's wounds were taken seriously and a management plan was in place, we found that some discharge documentation was incomplete and

C complained to us on behalf of their parent (A) who has dementia. A was admitted to Glasgow Royal Infirmary (GRI), after falling at home. A's condition improved and they were discharged home. After a few days, A was readmitted to GRI and treated for pneumonia (inflammation in the tissue of the lungs). Although A responded well to the treatment, their family was concerned about their mobility and pain when moving. A was referred for imaging of their pelvis and hip, which did not find a skeletal injury. Later that month, A was transferred to Stobhill Ambulatory Care Hospital. Around a week later, A was given a lumbar x-ray, which found a vertebral wedge fracture (a fracture of the bones commonly called the lower back). C raised concerns about A's medical care and their nursing care at both hospitals. We took independent advice from a consultant physician in geriatric medicine (a specialist in medicine of the elderly). We did not consider that there was an unreasonable delay in carrying out A's lumbar x-ray. In particular, we found that it was appropriate that the medical staff had focused on ruling out A having fractures that might be treatable with surgery. We did not uphold this aspect of C's complaint. We also took independent advice from an acute nursing specialist. We found that A's pain was not assessed appropriately, as nursing staff did not use the correct tool for someone with cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember). We also found that A fell at a time that they should have been under enhanced supervision by nursing staff due to their high risk of falls. We upheld this aspect of C's complaint.

C complained to the board about the care and treatment which their late parent (A) received at the A&E at Glasgow Royal Infirmary. A had presented as an emergency following them taking too much medication. A was not admitted to hospital but was discharged home and advised to take Codeine (a sleep-inducing and analgesic drug derived from morphine). A died shortly after their discharge from hospital. We sought independent clinical advice from a professional adviser. We found that apart from a failure to complete some initial observations, staff in A&E performed appropriate investigations and that it was clinically appropriate to discharge A from hospital. There was no indication from the clinical records that staff had prescribed A Codeine on discharge or that this was said to them. We did not uphold the complaint. Related reading View Decision Report 202100985 as a PDF (24.14 KB) Updated: January 19, 2022

C made a complaint on behalf of their partner (A), who had a cancer diagnosis. C complained that there was a failure to keep A reasonably informed about appointments for treatment. C considered that the board had failed to ensure that they had A's address correctly recorded on the patient database. C also raised concerns about a delay in responding to the complaint, and a failure to provide a consistent explanation about why A was not reasonably informed of appointments for treatment. We found that the board were able to provide copies of letters with the correct address, and whilst these had not been received by A, it was not possible to say that they had not been sent. In addition, whilst A turned up for an appointment that A did not know had been cancelled, the consultant did see A to carry out a full consultation. We did not uphold this aspect of C's complaint. We found that the board provided conflicting accounts of what address information was held on the databases for C and for SPSO and whether or not this required to be corrected/had been corrected. We also found that there was a delay in responding to C's complaint. We noted that the complaints department had moved, but we considered that it was reasonable to expect that the board would have in place a mechanism to forward the mail addressed to the complaints department to the new location within a reasonable period of time. We upheld these aspects of C's complaint.

C complained about the care and treatment of their late parent (A) who died in Glasgow Royal Infirmary (GRI) from respiratory failure and an undiagnosed progressive neurological condition. Potential Motor Neurone Disease (MND, a rare condition that progressively damages parts of the nervous system) had been noted by a neurology registrar five months earlier but this diagnosis was never confirmed. A was admitted to GRI four times over the following months, and C complained that their rapidly deteriorating condition was not acted upon and that palliative care was not initiated. We took independent advice from a consultant neurologist (a specialist in nerves and the nervous system, especially of the diseases affecting them), who noted that investigations planned by the neurology registrar were not followed up, and that a referral to a specialist neuropathy clinic was not fulfilled, within national waiting time targets. We found that the medical teams caring for A during their hospital admissions failed to consider a neurological disorder as the cause of their deterioration and failed to seek specialist neurological input. We considered that neurological clinical standards should have been applied regardless of the absence of a confirmed diagnosis, and this would have included a timely assessment of communication, nutritional and respiratory needs. Notwithstanding this, we found that the palliative symptom treatment offered to A in the last months of their life was of a reasonable standard and, despite the absence of a diagnosis, we saw no evidence that A suffered from a lack of care or treatment. On balance, however, we upheld this complaint. C also complained that the family were not informed that A's condition was terminal. We did not consider that staff were in a position to predict A would die when they did, given the lack of clear neurological diagnosis, and we were satisfied that there was communication with the family when death was appreciated to be immi

C complained about the care and treatment they received from the board for their hearing problems, and for their problems of dizziness/loss of balance. We took independent advice from an ear nose and throat (ENT) specialist. We found that C's hearing problems were investigated appropriately and they were given multiple repeated investigations. We also found that appropriate steps were taken to investigate C's problems of dizziness/loss of balance. Therefore, we did not uphold C's complaints. Related reading View Decision Report 202000612 as a PDF (23.93 KB) Updated: December 22, 2021

C complained about the standard of medical care and treatment provided to their late parent (A) during an admission to Queen Elizabeth University Hospital (QEUH). A was admitted to QEUH with worsening symptoms of a chest infection and a leg ulcer. When A’s condition deteriorated, medical staff decided to transfuse three units of blood. During the transfusion, A went into cardiac arrest and died. C complained that the decision to transfuse A with blood was unreasonable given their condition and symptoms, and that this led directly to their death. We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that A should have had a thorough clinical review prior to the transfusion being prescribed. The transfusion monitoring protocol was not followed, and the board acknowledged that this may have led to a delay in recognising A’s deterioration. We also noted that when A’s observations and condition indicated a serious concern, nursing staff should have contacted a senior doctor but instead contacted the most junior doctor on duty. We considered all of this unreasonable. We saw no evidence that the severity of A’s condition, and likely poor prognosis, was actively considered or discussed with them or their family. This would have been good practice. We noted that after A's death the team appropriately discussed the case with the Procurator Fiscal and the death certificate review team, who stated that they would be content for a death certificate to be issued without the need for a post mortem examination. However, when this was then discussed with A’s family, they remained concerned and said they would like things investigated further. With reference to the relevant guidance, we found that the case should have been referred back to the Procurator Fiscal for further consideration. If the Procurator Fiscal had still considered there was no need to investigate, the medical team should have offered the family the option of a

C complained on behalf of their spouse (A) about the treatment A received in hospital after they fell at home and injured their back. A had previously suffered a stroke and, as a result, a computerised tomography (CT) scan of their brain was carried out. This showed no change from the previous CT scan that was carried out. Following an assessment in A&E, it was concluded that A’s back pain was muscular and that they were also suffering from an infection. A remained in hospital for treatment and observation. Twelve days after being admitted to hospital, MRI scans of A’s brain and lumbar spine were arranged. These scans showed that A had suffered a new stroke and had spinal compression fractures. C felt that A should have had an MRI scan when they were admitted to hospital or soon after. In C’s view, this would have confirmed the issues earlier and resulted in more appropriate care being delivered. We took independent advice from an appropriately qualified adviser. In respect of whether the board unreasonably delayed in diagnosing and treating A’s stroke, we found that there was not sufficient evidence of a fresh stroke to justify an MRI scan at the time of admission. Based on A’s presentation at the time and the need to prioritise their treatment, there was not an unreasonable delay in the board diagnosing and treating A’s fresh stroke. As such, we did not uphold this complaint. In respect of whether the board unreasonably delayed in diagnosing and treating A’s spinal compression fractures, we found that, given A’s symptoms, an earlier MRI scan of the spine was not indicated. However, we highlighted one clinician’s entry in the medical records that indicated a need for further investigation of A’s back injury that was identified on the date of admission. This entry also suggested that an x-ray was to be arranged. However, this specific entry in the medical records did not appear to have been followed up or acted on, with no narrative in the records to explain why. Fo

C complained about the care and treatment provided to one of their twins (A) at delivery and in the neonatal unit after delivery at Queen Elizabeth University Hospital. C was concerned, in particular, about blood loss at birth, the delay in a blood transfusion being carried out, a delay in blood pressure being taken, record-keeping and communication. We took independent advice from a consultant obstetrician (a doctor who specialises in pregnancy and childbirth) and a consultant neonatologist (a doctor who specialises in the medical care of newborn infants, especially ill or premature newborns). We found generally that the evidence in the records showed a safe and appropriate delivery. We found that the blood loss at birth was within the standard parameters for twins delivered by caesarean section, although it is accepted that it was not possible to establish the total blood loss for A. We also found a blood transfusion was carried out within an appropriate timescale. However, A did not have their blood pressure taken until three hours after being admitted to the neonatal unit. We found it would be standard practice for a ventilated and unstable baby on a neonatal unit to take a non-invasive blood pressure reading. The board did not have a policy requiring this. Therefore, we upheld this complaint. In addition the board accepted their record-keeping during delivery was not of an appropriate standard. They also recognised that communication required to be improved, and they have taken steps to address both of these issues. We identified concerns about record-keeping in the neonatal unit and this has been brought to the board’s attention.

C was suffering from swelling and pain in their right knee. C attended an appointment with a consultant vascular surgeon (a specialist in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels). The consultant noted that C had varicose veins (swollen and enlarged veins that usually occur on the legs and feet) but believed them to be uncomplicated. The consultant felt the swelling in the right leg was not caused by a problem with the veins and that there were no other symptoms of venous disease. C was not referred for vascular surgery. C had an ultrasound scan which confirmed the lump on the leg and the symptoms were likely caused by a trapped nerve. C complained that the care and treatment provided were not reasonable and that it was unreasonable not to refer them for varicose vein surgery. We took independent advice from a consultant adviser. We found that the examination and conclusions of the board were reasonable on the basis of C’s condition at the time. We noted that there were no indications that further vascular investigations/treatments needed to be offered. Additionally, we were satisfied the board had appropriately applied the National Policy NHS Protocol for access to Varicose Vein surgery. We did not uphold the complaints. Related reading View Decision Report 202001741 as a PDF (24.39 KB) Updated: October 20, 2021

C’s parent (A) had a history of heart problems and suffered a cardiac arrest. Investigations at that time led to a diagnosis of deep vein thrombosis (DVT, a blood clot in a vein). Four years later, A’s heart condition had deteriorated and they were assessed for a possible heart transplant. These investigations indicated severe pulmonary oedema (a condition caused by excess fluid in the lungs) and significant emphysematous changes (emphysema is a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness) which meant A was not a suitable candidate for a transplant. The presence of emphysema was previously unknown to A. A died the following year due to heart failure with emphysema listed as a secondary cause. The doctor completing A’s death certificate found mention of mild emphysematous changes in the discharge letter around the time of the diagnosis of DVT. This was the first time A’s family had been made aware of these early findings. C complained about A’s care and treatment. The board responded that mild emphysema is a very common incidental finding in CT scans of patients, such as A, who are cigarette smokers. The board said the degree of emphysema found was mild and would not have contributed to A’s symptoms or altered the plan for investigation at the time or the care provided to A subsequently. The board gave their view that there was no treatment that could have been offered that would have prevented the progression of the emphysema. The board apologised that they did not provide more information to A about the results of the CT scan at the time and advised that the case had been shared with the cardiology team and the importance of scan results being discussed with patients and recorded in their notes had been reinforced. C was unhappy with this response and brought their complaint to this office. We took independent medical advice from a consultant in respiratory and general medicine. We found that, although the discharge

C complained that the board unreasonably carried out a biopsy after a mass was identified in C’s chest. C said due to the type of tumour it shouldn’t have been biopsied. We took independent advice from a consultant physician and rheumatologist (a specialist in rheumatism, arthritis, and other disorders of the joints, muscles, and ligaments) and a consultant radiologist (a specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that while the type of tumour should not have been biopsied, it was not identified as that type of tumour until after the biopsy and that was reasonable. We found that the decision to perform a biopsy was reasonable based on the information available at the time. As such, we did not uphold this complaint. Related reading View Decision Report 201910303 as a PDF (24.12 KB) Updated: October 20, 2021

C complained in relation to their late sibling (A) who was admitted to Glasgow Royal Infirmary following a fall. During their time in hospital, they contracted various infections (latterly pneumonia) and was diagnosed with dementia. A's health deteriorated during their time in hospital and they died. C said that medical staff failed to take adequate steps to ensure that A received sufficient nutrients to fight the infections they acquired whilst in hospital and this was a contributory factor in their death. We took independent advice from an appropriately qualified adviser on the care and treatment, specifically the feeding aspect, and found that the care and treatment provided to A was reasonable. We did not uphold the complaint. Related reading View Decision Report 202001026 as a PDF (24.1 KB) Updated: October 20, 2021

C complained about the care and treatment their late parent (A) received at Queen Elizabeth University Hospital. A was admitted to hospital with a diagnosis of pancreatitis (inflammation of the pancreas). They were treated with fluids and antibiotics and their fluid balance was measured. They recovered and were discharged later that month. A was readmitted with various symptoms including abdominal pain, vomiting, loose stools and not eating or drinking on two further occasions and was discharged both times. A was later readmitted to the hospital in cardiac arrest and died shortly after arrival at the hospital. We took independent advice from an appropriately qualified adviser. We found that the board failed to provide A with a reasonable standard of care and treatment. During one admission, there was a lack of comment on A’s hernia, a lack of investigation of low blood pressure and no evidence of a cardiology (specialists in diseases and abnormalities of the heart) input. On another admission, we found that the care and the management plan concerning A’s hernia was below standard and that there appeared to be a delay in the involvement of other specialists. We also found issues relating to the planning of surgery for A. Therefore, we upheld this aspect of C's complaint. C also complained that A's final discharge from hospital was unreasonable. We found A's discharge to be reasonable and did not uphold this aspect of C's complaint.

C was referred urgently to the gynaecology department (medicine of the female genital tract and its disorders). During the vetting procedure the board requested the referral be downgraded to routine and the GP complied with this request. Following a consultation with the first consultant, C was scheduled for an operation. During the pre-operation examination by the second consultant, a cervical tumour was found and the operation cancelled. When informed of this, C made a verbal complaint about their treatment since being referred. Biopsy results confirmed the tumour as malignant. C lost faith in the clinicians involved and requested a second opinion. A consultant oncologist (cancer specialist) met with C to discuss this and took steps to arrange a second opinion. C also took steps to obtain the second opinion using personal contacts. The second opinions provided concurred with that of the board. C complained to the board in writing regarding their experiences. A significant clinical incident (SCI) investigation was undertaken and following this, the board responded to C’s complaints. C was dissatisfied with the board’s responses and brought their complaint to this office. We took independent advice from a consultant gynaecological oncologist. The SCI investigation had found that the board failed to give advice, contrary to relevant guidance, to C’s GP regarding the referral submitted as urgent. We upheld C’s complaint about this and accepted advice received that the board’s revised guidance had addressed the identified failings. However, the board had not apologised to C for these. The board concluded the time taken between C’s referral by their GP and a correct diagnosis being reached was unreasonable and also accepted the time taken to respond to C’s complaint was unreasonable. We upheld C’s complaints about these and found that the board had not reasonably apologised to C for the delay in diagnosis. We found that C’s verbal complaint had not resulted in reasonab

C complained that the board failed to carry out an endoscopic retrograde cholangiopancreatography (ERCP, an imaging test involving a combination of endoscopy and X-rays for examination of the bile ducts and pancreas) procedure reasonably which resulted in a retroperitoneal perforation (a tear in the lining of the abdomen) and post-ERCP pancreatitis (inflammation of the pancreas). We took independent advice from a consultant gastroenterologist and hepatologist (a physician who specialises in the diagnosis and treatment of disorders of the gastrointestinal tract, liver, pancreas and gall bladder). We found that the ERCP was a necessary procedure in C's case, that the perforation and post-ERCP pancreatitis are recognised complications and that appropriate measures were taken to reduce the risk of post-ERCP pancreatitis by administering diclofenac (a non-steroidal anti-inflammatory or NSAID). We did not identify any unreasonable failings regarding C's care and we did not uphold this complaint. C also complained that they were not informed of the risks of the ERCP (including pancreatitis or duodenal perforation) and that following the ERCP, the tear was not mentioned to C by the consultants and that they were given different stories by them. We took independent advice from a consultant general surgeon. We found that the communication with C regarding the findings of the CT scan (a tear in the lining of the abdomen) was reasonable. We also found that an information booklet was attached to the consent form when it was signed, and that C was appropriately made aware of the risks and complications associated with the procedure. However, we noted that it would be good practice to keep a copy of the information booklet in the medical records and we included this in our feedback for the board. We did not uphold C's complaint regarding the board's communication. Related reading View Decision Report 201911297 as a PDF (24.65 KB) Updated: August 18, 2021

C sustained severe and multiple injuries to their wrist and pelvis following a road accident. C underwent numerous surgical procedures on their wrist and complained that the care and treatment they received was unreasonable. C felt that due to the placement, the screws that were used caused greater damage. C also said that the board chose not to undertake any further surgery to treat the ongoing pain and limited range of movement that C experienced. We took independent advice from an appropriately qualified medical adviser. We found that the board provided reasonable emergency care to C immediately after their accident. The surgery carried out was reasonable, with the screws and plates appropriately placed, given the type of injury that C had. We also found that it was reasonable for the board to decide to end the first operation (due to operation length) and undertake further surgery to complete their treatment of C's wrist, and that C's discharge was appropriate. We did not uphold this complaint. However, we noted that earlier counselling around the significance of an injury like this and making sure that C did not have unrealistic expectations, may have been helpful in this case. We provided feedback to the board on this point. Related reading View Decision Report 201911144 as a PDF (24.36 KB) Updated: August 18, 2021

C complained about the care and treatment provided to their late parent (A) in A&E. We took independent advice from an accident and emergency adviser. We found that A waited an unreasonable amount of time for a clinical review on their attendance to A&E and this did not meet the triage category standards assigned to A. We also found that sepsis (blood infection) should have been considered at an earlier stage during one of A's attendances to A&E given their low blood pressure and increased respiratory rate. We upheld this aspect of C's complaint. C complained that the board failed to provide A with reasonable care and treatment regarding a chyle leak (an accumulation of lymphatic fluid in the abdominal cavity). We took independent advice from a surgical adviser. We found that A was provided with reasonable care and treatment for the chyle leak, that their pain and discomfort was appropriately investigated and responded to and that reasonable action was taken in relation to the prevention of blood clots. As such, we did not uphold this aspect of C's complaint. Finally, C complained that A's mobility was not fully investigated while they were in hospital. We took independent advice from a physiotherapy adviser (a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise). We found that A was provided with reasonable care by physiotherapists in the assessment and management of their mobility. We did not uphold this aspect of C's complaint.

C complained that there was an error in carrying out their child (A)'s dental surgery at the Royal Hospital for Children. A had been referred by an orthodontist (medical professional dealing with the prevention and correction of irregular teeth) to have two teeth removed. C raised concerns that they had removed the wrong tooth (A's front tooth) and left in the two teeth they were supposed to remove. The board said that their oral and maxillofacial surgery clinicians (OMFS, specialists in treating diseases and injuries of the mouth and face) had appropriately reviewed A's original treatment plan. The board explained that their OMFS clinicians had tried to contact the orthodontist to explain that A's original treatment plan was not clinically possible. We took independent advice from a consultant OMFS. We found that A's treatment plan should not have been changed without consulting the referring orthodontist and agreeing the changes with them. We found that the clinical rationale for changing A's treatment plan was not clearly recorded. We also found that the changes were not communicated clearly enough to C and A in a manner that they could understand. We upheld C's complaint.

C complained about the care and treatment that they received from the Beatson West of Scotland Cancer Centre. We took independent advice from an oncologist (a doctor who specialises in the diagnosis and treatment of cancer). We found that the symptoms C described were not 'red flags' and could have been explained by recovery from the chest infection C had experienced. The response to C's symptoms (including the length of time to request and perform a CT scan) was reasonable in the circumstances. We also found that the communication with C about the results of the CT scan was reasonable C was also concerned that bleeding at their Dalteparin (anticoagulant that helps prevent the formation of blood clots) injection sites was not appropriately escalated or responded to. The board did not provide us with a contemporaneous record of the advice that was given to C regarding bruising and bleeding at their Daltaparin injection site. We found that it would be good practice for all contact with clinicians to be recorded and we included this as feedback for the board. However, we noted that there was no dispute between the board and C that the advice given on this occasion was for C to contact their GP. We found that the advice given to C was reasonable in the circumstances. We did not uphold C's complaint. Related reading View Decision Report 202004484 as a PDF (24.4 KB) Updated: August 18, 2021