SPSO Individual Decisions

Mrs C, an advice worker, complained on behalf of her client (Mrs A) who had concerns about the treatment which she received from a consultant rheumatologist (specialism of the medical treatment of the musculoskeletal and its disorders) at Raigmore Hospital. Mrs A had a leg ulcer and was being considered for treatment for her arthritis (a disease causing painful inflammation and stiffness of the joints). She requested that the board provide her with a certain medication that she had identified when researching the internet. However, the board refused as the requested medication could not be used as first line treatment until alternative medication had been considered in the first instance. We took independent advice from a consultant rheumatologist. We found that the decision not to provide the requested medication until alternative first line medication had been attempted was reasonable and in line with accepted medical practice. We did not uphold the complaint. Related reading View Decision Report 201810676 as a PDF (23.78 KB) Updated: September 18, 2019

Mrs C's complaint concerned the care and treatment given to her late husband (Mr A) by his GP practice. Mr A first attended the practice with lower back pain but later attended with testicular pain. After an examination he was informed that there was suspicion of prostate cancer. An urgent referral was subsequently made by his GP and he was advised that there was a high risk that he had prostate cancer which had spread. Mr A later died. Mrs C complained that the practice had failed to properly investigate Mr A's testicular and back pain, and that their referral letter misrepresented the situation. Mrs C also complained that Mr A had been prescribed morphine which caused hallucinations and that no palliative care plan had been made for him. We took independent advice from a GP. We found that Mr A was treated reasonably and appropriately; there had been no delay in his diagnosis and an urgent referral had been made in a timely way. There was no evidence of misleading information in the referral letter and it was in line with General Medical Council Good Medical Practice. We also found that morphine could cause side-effects, particularly towards the end of life and that Mr A had been referred to the community palliative care team. We did not uphold the complaint. Related reading View Decision Report 201806794 as a PDF (23.95 KB) Updated: August 21, 2019

Mr C complained about the care and treatment his mother (Mrs A) received at Lorn and Islands Hospital. Mrs A initially presented to the emergency department experiencing vomiting. Following assessment, Mrs A received antibiotics and was discharged home. Mrs A returned to the emergency department two days later again with vomiting symptoms. After further assessment was carried out, Mrs A was discharged home. Mrs A attended the hospital again approximately five days later and was admitted to a ward. During the admission, investigations were carried out which indicated that Mrs A had metastatic cancer (cancer that has spread to other parts of the body). Mrs A's condition deteriorated during the admission and she died from her illness. Mr C complained about the care and treatment his mother received as well as the way hospital staff communicated with the family. We took independent advice from a consultant in general medicine and a registered nurse. We found that Mrs A was unreasonably discharged from the emergency department on two occasions without her symptoms being effectively managed. We also found that an incorrect diagnosis had been reached during the first presentation to the emergency department, whilst the second presentation was poorly documented. We noted that once Mrs A was admitted to the ward, there was an unreasonable delay in obtaining a CT scan (a scan that uses x-rays to create detailed images of the inside of the body) of Mrs A's chest/ abdomen. We upheld this aspect of Mr C's complaint. In response to Mr C's complaint, the board apologised that inaccurate information was given to family members regarding the length of time to obtain test results. We also found that there was a lack of discussion between nurses, doctors and the family around the possibility of discharging Mrs A home and a lack of clarity with the family about this. We upheld this aspect of Mr C's complaint. Finally, Mr C was also unhappy with the time that the board too

Mr C complained about a delay in the board diagnosing hereditary haemochromatosis (a medical condition caused by an overload of iron in the body). Mr C experienced various symptoms that he said increased in number and severity over six years until his diagnosis. Mr C raised concerns that the doctors should have investigated further rather than repeating the same tests, and that they missed a condition that would have been easily diagnosed by a simple blood test. We took independent advice from a consultant in general medicine with a clinical interest in haemochromatosis. We noted that it is quite rare and diagnosis can be delayed in many cases for over five years. Mr C was seen by different clinicians in various different specialities before the diagnosis emerged following a random blood test for ferritin (iron storage protein). There was no family history of the condition and we considered that the symptoms Mr C experienced prior to the diagnosis were non-specific rather than being classical symptoms of haemochromatosis. We also considered that a blood test done a year before the diagnosis would not prompt consideration of hereditary haemochromatosis as a likely explanation. We concluded that staff did not unreasonably delay in considering the diagnosis at an earlier stage. We did not uphold Mr C's complaint. Related reading View Decision Report 201800066 as a PDF (23.97 KB) Updated: May 22, 2019

Mrs C complained about the care and treatment her late mother (Mrs A) had received in Raigmore Hospital before her death. Mrs A had been referred to the hospital by her GP. The referral letter said she had fallen at home and referred to acute kidney injury. Mrs A fell on two occasions after being admitted to hospital. It was then identified nearly three weeks later that she had fractured her hip. Mrs A later died in the hospital. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nursing adviser. We found that the care and treatment provided to Mrs A in relation to her kidney function was reasonable and appropriate. In addition, she had not displayed sufficient pain or deformity that meant a hip fracture should have been considered. However, the nursing records indicated that Mrs A was at risk of falling, but there was inadequate information about what action would be taken to prevent any falls. We found that it was reasonable for staff to try to reduce Mrs A's agitation after her first fall by allowing her to walk with a member of staff, but it would have been more appropriate to have had two members of staff with her. Staff should also have told the family about the first fall when they contacted them about the second fall. In view of these failings, we upheld Mrs C's complaint, although we noted that the board had already apologised to Mrs C and had taken a number of actions to try to prevent similar failings in the future.

Miss C complained on behalf of her brother (Mr A) about the care and treatment he received while he was a day patient at a psychiatric hospital. Miss C complained that the hospital wrongly decided to not detain Mr A under the Mental Health (Care and Treatment) Act (Scotland) 2003 (MHA) and that they failed to appropriately supervise him. Miss C also complained that the board unreasonably delayed in responding to her complaint. As part of their investigation of Miss C's complaint, the board carried out a Significant Adverse Event Review (SAER). The SAER concluded that Mr A did not meet the legal criteria for detention under the MHA as he was capable of making decisions, he consented to treatment, and they were satisfied that Mr A was under the usual levels of supervision. The board acknowledged there was a delay in completing the SAER and subsequently in providing the final response to the complaint. Miss C was unhappy with this response and brought her complaint to us. We took independent psychiatric advice. We found that it was appropriate that Mr A was not detained under the MHA as he did not meet the legal criteria. We also found that appropriate assessments were carried out on Mr A's mental health and that he received an appropriate level of supervision. We did not uphold this aspect of Miss C's complaint. In relation to complaint handling, we concluded that the board unreasonably delayed in responding to Miss C's complaint due to the delay in completing the SAER. Therefore we upheld this aspect of Miss C's complaint. The board have acknowledged this failing and have taken action to address this. Related reading View Decision Report 201805658 as a PDF (24.04 KB) Updated: May 22, 2019

Miss C complained about the care and treatment provided to her by the GP practice. Ms C has complex medical conditions and was concerned about a medication being stopped, a decision to refer her to a specialist and the way in which a blood sample was taken. We took independent advice from a GP. In relation to the medication being stopped, we found that it was reasonable and safe for the practice to do this whilst waiting for a referral to a specialist. The GP had also asked Miss C to arrange an appointment with them if she wanted to discuss this. In relation to the referral to a specialist, Miss C felt that this was unnecessary. We considered the referral to be reasonable in order to establish the medical reason for Miss C's symptoms. Miss C was concerned about her vein being 'blown' when blood was taken, however, she did not raise this with the practice at the time. The GP subsequently apologised and said they were unaware of this as they were able to continue to draw blood. Miss C also raised concerns about communication from the practice regarding her medication being stopped. The practice accepted that this was the case, apologised and altered the way in which this would be communicated in future. We considered that the care and treatment Miss C received was reasonable and we did not uphold this complaint. Related reading View Decision Report 201709163 as a PDF (23.93 KB) Updated: May 22, 2019

Mrs C complained about the standard of aftercare she received at Raigmore Hospital following hip surgery, both in terms of the orthopaedic care (treatment of diseases and injuries of the musculoskeletal system) and physiotherapy care (treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise). Mrs C said that her thigh should have been physically examined by the surgeon as she found out later that she had weakness in her thigh muscle and that physiotherapy staff did not provide treatment at two appointments she attended. We took independent advice from a consultant orthopaedic surgeon and a physiotherapist. In terms of the orthopaedic care, we found that an x-ray was appropriately carried out which confirmed Mrs C's fracture was healing. We considered that there was no requirement to perform a physical examination of Mrs C's thigh and it would be accepted that she would have weakness with this type of injury and associated surgery. We noted that Mrs C also received support by way of a referral to the hip fracture service. In terms of the physiotherapy care, we established that no specific referral had been made to the service in relation to Mrs C's hip. We considered that appropriate treatment was provided in response to the GP referral for carpal tunnel (a medical condition where there is pressure on a nerve in the wrist). Furthermore, reasonable action was taken by physiotherapy staff to refer Mrs C to the orthotic clinic (the branch of medicine that deals with the provision and use of artificial devices such as splints and braces) regarding her leg length discrepancy following hip surgery. We concluded that the aftercare was of a reasonable standard and did not uphold Mrs C's complaint. Related reading View Decision Report 201707681 as a PDF (24.2 KB) Updated: May 22, 2019

Ms C, an advice and support worker, complained on behalf of her client (Mr A) regarding the treatment which he had received from the practice, prior to him being diagnosed with prostate cancer. Mr A had attended frequent consultations with right hip pain and had been referred to physiotherapy (treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) on a number of occasions. He was also sent for an orthopaedic (treatment of diseases and injuries of the musculoskeletal system) referral which had not helped. Mr A stopped attending physiotherapy as he received no benefit from the exercises or the painkillers which the practice had prescribed. We took independent medical advice from a GP. We found that initially it was felt that Mr A had a musculoskeletal problem (injuries or pain in the joints, ligaments, muscles, nerves, tendons, and structures that support limbs, neck and back) which was reasonable in view of the presenting symptoms. The practice provided appropriate pain relief and made appropriate referrals for specialist opinions in orthopaedics and physiotherapy. It was only when Mr A presented with pain in his upper spine, which triggered a red flag sign, that blood tests were arranged which indicated possible prostatic cancer. This resulted in an urgent referral to the cancer specialists. We had no concerns about the way the GPs at the practice managed Mr A's reported symptoms over the period and there was no delay in making a specialist referral when he reported a new symptom of spine pain. We did not uphold the complaint. Related reading View Decision Report 201808175 as a PDF (24.2 KB) Updated: May 22, 2019

Mr C complained about the care he received from the practice prior to his diagnosis of hereditary haemochromatosis (a medical condition caused by an overload of iron in the body). Mr C experienced various symptoms that he said increased in number and severity over six years until his diagnosis. Mr C raised concerns that the practice should have carried out relevant tests, referred him to relevant specialists and reviewed his ongoing symptoms. We took independent advice from a GP. We found that appropriate tests were arranged and appropriate and timely referrals were made to various specialities. We considered that a slightly raised blood test result was not diagnostic of haemochromatosis and relates to different conditions. We concluded that the care provided by the practice was of a reasonable standard. We did not uphold Mr C's complaint. Related reading View Decision Report 201800379 as a PDF (23.76 KB) Updated: May 22, 2019

Mr C complained about the care and treatment provided to his late daughter (Miss A) by unscheduled care practitioners (UCPs) at A&E at Campbeltown Hospital. Miss A had attended the hospital on a number of occasions within a short period of time and reported symptoms of severe pain and sickness. Miss A then attended another hospital outwith the board area and a diagnosis of pancreatic cancer was made. Mr C said that Miss A felt that the UCPs had not listened to her and that had led to a delay in the diagnosis. We took independent medical advice from a GP. We found that there was no evidence that the UCPs had failed to provide Miss A with a reasonable standard of treatment. She had been attending hospital specialists who were treating her for other medical conditions and that her reported symptoms could reasonably have been connected with the other medical conditions or side effects of the medication she was taking. There was nothing to suggest that Miss A was suffering from the effects of pancreatic cancer when she saw the UCPs. There are usually no symptoms in the early stages of the disease and those symptoms which do develop do so when the disease has reached an advanced stage; by the time of diagnosis, pancreatic cancer has often spread to other parts of the body. We did not uphold the complaint. Related reading View Decision Report 201806300 as a PDF (23.96 KB) Updated: May 22, 2019

Ms C, an advocate, complained on behalf of her client (Mrs A) about a delay in diagnosing gastric diverticulum (a pouch protruding from the gastric wall) and subsequent treatment. Ms C raised concerns that Mrs A underwent unnecessary repeat tests because the initial investigations had not been interpreted properly. We took independent advice from a consultant general and colorectal surgeon (a physician who specialises in the medical and surgical treatment of conditions that affect the lower digestive tract). We found it was reasonable that the gastric diverticulum had not been picked up on the initial tests, given it is a rare condition, and that there had been other reasonable explanations for Mrs A's abdominal pain and weight loss. We considered it was appropriate to repeat Mrs A's tests, at which time the gastric diverticulum was identified. We concluded that the delay in diagnosis was not unreasonable and treatment was carried out thereafter within a timely manner. We, therefore, did not uphold the complaint. Related reading View Decision Report 201708601 as a PDF (23.84 KB) Updated: May 22, 2019

Mr C complained on behalf of his mother-in-law (Mrs B) about the care and treatment provided to her husband (Mr A) at Raigmore Hospital. Mr C complained that the board failed to manage Mr A's falls risk appropriately and failed to provide a reasonable standard of oral and nutritional care to Mr A. We took independent advice from a nursing adviser. We found that Mr A sustained seven falls during his admission, with the last fall resulting in him suffering a serious injury. The board had apologised for this and the lack of communication by their nursing team on some occasions, and we acknowledged the action that the board said they had taken to address this. However, we found that there were additional failings and an unreasonable level of care provided to Mr A not identified by the board. We noted that there appeared to have been a lack of action and a failure in record-keeping in relation to the management of Mr  A's falls risk. We considered that the supervision provided was unreasonable and highlighted that there was no person-centred care plan provided to record the management of Mr A's falls risk and interventions in place to reduce the risk of falls, or the level of observation he required. In addition, communication with Mr A's family was unreasonable. Therefore, we upheld this aspect of Mr C's complaint. In relation to Mr A's oral and nutritional care, the board accepted that this was not of an acceptable standard and apologised. We found that there were shortcomings in the assessment and management of Mr A's nutritional needs and in record-keeping. Although staff made urgent referrals to the dietician, Mr A did not appear to have been treated as a priority. We also found no evidence that Mr A's oral care needs were met. Therefore, we upheld this aspect of Mr C's complaint.

Mrs C complained about the medical and nursing care and treatment her late mother (Mrs A) received when she was admitted to Lorn and Islands Hospital. She also complained about the communication with her family and that the board had failed to handle her complaint in a reasonable way. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nursing adviser. We found that it was difficult to provide an overall view about the medical care and treatment given to Mrs A due to the length and complexity of her admission. However, we found there had been a delay in diagnosing Mrs A's delirium and that she had a urine infection. We also found that the death certificate process was handled insensitively. Therefore, we upheld this aspect of Mrs C's complaint. In relation to the nursing care given to Mrs A, we found no failings on the part of nursing staff regarding Mrs A's dehydration, dietary intake and her personal care. Therefore, we did not uphold this aspect of Mrs C's complaint. In relation to communication, we found that the nursing communication was reasonable. However, we found that there was a delay in medical staff communicating the results of a CT scan and the overall assessment of Mrs A's health to Mrs C. Therefore, we upheld this aspect of Mrs C's complaint. Finally, in relation to complaint handling, we found that the board had failed to comply with their complaints handling procedure and we upheld this aspect of Mrs C's complaint.

Ms C, an advocacy worker, submitted a complaint on behalf of her client (Ms A). Ms A was diagnosed with polycystic ovaries (a condition that affects a woman's hormone levels) after undergoing a laparoscopic (minimally invasive) surgery to untwist a torted right ovary. Further investigations were carried out, including two ultrasound scans. After experiencing severe lower abdominal pain, an emergency salping-oophorectomy (removal of the fallopian tube and ovary) was carried out. This took place two days after Ms A's second ultrasound. Ms C complained that the second ultrasound scan was not carried out appropriately and that an ultrasound scan should have taken place when she was admitted to hospital inbetween her two other scans. We took independent advice from an obstetrics and gynaecology consultant (a  doctor who specialises in pregnancy, childbirth and the female reproductive system). We found that it was reasonable for the board to not carry out an ultrasound scan during Ms A's admission. We noted that Ms A's condition appeared to have been managed appropriately and conservatively, based on the information known at the time. We also found that an ovarian torsion can happen over a few hours and, therefore, it is possible that it had not occurred when the second ultrasound took place. We acknowledged that it was not possible to know for certain whether anything of concern was overlooked during this ultrasound, however, we considered that the board's management of Ms A's condition was reasonable and appropriate. We did not uphold either of Ms C's complaints. Related reading View Decision Report 201802815 as a PDF (24.16 KB) Updated: February 20, 2019

Ms C complained about a delay in the results of a magnetic resonance imaging (MRI) scan being reported which showed that a small pancreatic tumour, which was being monitored, had grown in size. Ms C also complained that when a computerised tomography scan (CT - a scan which uses x-rays and a computer to create detailed images of the inside of the body) was carried out around four months later, there was a failure to identify a breast lump. We took independent advice from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant in acute medicine. We considered that there was an unreasonable delay in the MRI scan being reported which would have impacted on the time taken to carry out further investigation of the pancreatic tumour. We upheld this aspect of Ms C's complaint and noted that the board were taking steps to address the delays in the service. We also recommended further action to be taken. In relation to the CT scan, we found the actions of the board to be reasonable. The scan was intended to concentrate on Ms C's pancreas and liver rather than a general look for cancer anywhere. We found that it was reasonable that every organ was not examined in great detail given Ms C did not have concerning symptoms. Therefore, we did not uphold this aspect of Ms C's complaint.

Mrs C complained about a delay in diagnosing her child's (Child A) kidney condition. Mrs C was concerned that despite several years of symptoms, appropriate investigations to diagnose Child A's condition had not been carried out and that this had resulted in loss of kidney function. Mrs C also considered that the issue could have been identified on an antenatal scan. Mrs C complained to the board but was unhappy with their response to her complaint. We took independent advice from a consultant paediatrician (a doctor who specialises in child medicine). We found that Child A's condition would now likely be identified during antenatal anomaly scanning but that at the time of Mrs C's pregnancy, there was no requirement for this type of scan to be carried out. We did not find that the diagnosis had been unreasonably missed. We noted that the board had already reflected on this case and now have a lower threshold for referring children for scans where they report pain moving towards the back. We did not uphold this aspect of Mrs C's complaint. In relation the board's handling of Mrs C's complaint, we found that the board had not addressed her comments about the potential for diagnosing Child A's kidney condition during an antenatal scan. Therefore, we upheld this aspect of Mrs C's complaint.

Ms C, an advocacy and support worker, complained on behalf of her client (Mr  A) about the care and treatment for knee pain Mr A received at Raigmore Hospital. Mr A had been assessed by a physiotherapist (a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) but they did not arrange an x-ray or CT scan. Mr A's GP continued to prescribe pain relief, but as there was no improvement he sought a private opinion. The private opinion included a CT scan of the knee which identified that Mr A would require surgery for a torn cartilage. Mr A complained that there had been a delay in his treatment by the failure of the physiotherapist to arrange a CT scan of his knee. We took independent advice from a physiotherapist. We found that the physiotherapist had taken an appropriate medical history from Mr A and an appropriate examination which resulted in a reasonable diagnosis of degenerative damage to the knee cartilage with a treatment plan of rehabilitation. There was no clinical requirement to arrange a CT scan at that time. Although it was subsequently established that Mr A had suffered an acute cartilage injury rather than by normal wear and tear, the treatment by rehabilitation can be used for either. Therefore, did not uphold Ms C's complaint. Related reading View Decision Report 201803689 as a PDF (24 KB) Updated: January 23, 2019

Mr C complained on behalf of his son (Mr A) about the mental health care and treatment provided by the board. Mr C complained that there had been a failure to provide support from a community psychiatric nurse, a delay in referral, and a failure to provide the necessary crisis support. We took independent advice from a psychiatrist (a medical practitioner who specialises in the diagnosis and treatment of mental illness). We found that the mental health care and treatment provided to Mr A had been timely, supportive, and in line with Mr A's needs and wishes. We did not uphold this aspect of Mr  C's complaint. Mr C also complained about the board's complaint response. We found that whilst the board gave limited information in response to one of Mr C's questions, this was in relation to care provided by another organisation. Therefore, we did not consider this unreasonable and we did not uphold this aspect of Mr C's complaint. Related reading View Decision Report 201801804 as a PDF (23.72 KB) Updated: January 23, 2019

Mrs C complained about the care and treatment her late husband (Mr A) received at Raigmore Hospital. Mr A had a history of numerous medical conditions and was seen in the cardiology department (the branch of medicine that deals with diseases and abnormalities of the heart) due to a build up of fluid. It was decided that no cardiac intervention was needed and the plan was to see Mr A again in six months, however, six weeks later he developed an infection and required to be admitted to hospital. Mr A's kidney function also deteriorated and treatment was aimed at aiding his heart function and fluid balance. Mr A's condition continued to deteriorate and he later died. Mrs C complained that Mr A's renal and cardiology care was unreasonable. We took independent advice from consultants in cardiology and renal medicine. We found that Mr A's condition was a complex one and it was difficult to balance his heart function and fluid balance. Mr A's deteriorating kidneys meant that he retained more fluid which put a greater strain on his heart and there was a precarious balance to be achieved between his body having too much fluid and too little. This took a great deal of clinical skill and overall, his care and treatment had been reasonable. However, we also found that there had been inadequate cardiology follow-up after Mr A had been discharged from hospital, although this did not impact on his care. Furthermore, Mrs C and Mr A were unaware, until just before Mr A died, that he was most unlikely to survive. Therefore, we upheld this aspect of Mrs C's complaint. Mrs C also complained that staff failed unreasonably to respond to Mr A's attempts to complain about his care and treatment and appeared unaware of the board's complaints procedure. We found that Mrs C and Mr A experienced difficulties in pursuing a complaint and upheld this aspect of Mrs C's complaint.

Mr C complained about the practice's management of his son (Mr A)'s medication. We took independent advice from a GP. We found that Mr A's medication was managed in a reasonable manner and did not uphold Mr C's complaint. Related reading View Decision Report 201801819 as a PDF (23.41 KB) Updated: January 23, 2019

Mrs C complained that the board unreasonably communicated with her about the care of her mother (Mrs A). Mrs C was named as Mrs A's next of kin and had been listed as Power of Attorney, although this was not invoked for the majority of the period complained about. We took independent advice from a social worker. We found that the records indicated Mrs C was involved regularly and kept up to date by the care home, which would be normal practice given the care home was responsible for the day- to-day care of Mrs A. We considered that the communication with Mrs C was reasonable and did not uphold the complaint. Related reading View Decision Report 201801574 as a PDF (23.62 KB) Updated: January 23, 2019

Mrs C complained about the nursing care that her late mother (Mrs A) received at Broadford Hospital. Mrs C had a number of concerns about the board's record-keeping and also complained about the communication from the nursing staff. Mrs A was admitted to the hospital where a provisional diagnosis of urinary sepsis (blood infection) was made. Mrs A also developed a pressure ulcer while at the hospital. We took independent advice from a nursing adviser. We found that: • daily checks on Mrs A's Peripheral Vascular Catheter were not recorded. • a “Getting to Know Me” document was not in place for Mrs A. • a Short Term Care Plan was in place for Mrs A for more than 48 hours. • Mrs A's urine output was not recorded on the Feed/Fluid Balance Chart when she was being treated for sepsis. • no Active Care or Care Rounding Charts were in place for Mrs A. • the board failed to provide reasonable pressure ulcer care to Mrs A and there was no evidence that the family were informed of Mrs A's pressure ulcer. The board also identified some record-keeping failures during their own investigation of Mrs C's complaint and said that they had taken steps to address these. We asked the board to provide evidence of the action they had already taken. In light of the above, we upheld Mrs C's complaints that the board failed to provide Mrs A with reasonable nursing care and that the board failed to communicate reasonably with Mrs A's family.

Mrs C made a complaint on behalf of Mrs B about the care and treatment her late husband (Mr A) received at his GP practice. Mr A had a number of health issues including epilepsy for which he had been prescribed medication for many years. Mr A had attended the surgery for worsening upper abdominal pain following a two day history of vomiting. Mr A was admitted to hospital where he died several days later. Pancreatitis (inflammation of the pancreas) was recorded as one of the causes of Mr A's death. Mrs C complained that the practice had failed to provide Mr A with reasonable care and treatment. In particular, that Mr A's GP had failed to recognise that Mr A's epilepsy medication could cause pancreatitis. We took independent advice from a GP. We found that the care and treatment provided to Mr A by the practice was reasonable. Mr A's health concerns were appropriately investigated and blood tests and referrals were made as appropriate and in a timely manner. We also noted that pancreatitis is a very rare side effect of the medication Mr A was taking for his epilepsy. We considered that the care provided to Mr A by the practice was of a reasonable standard and in line with good medical practice. Therefore, we did not uphold Mrs C's complaint. Related reading View Decision Report 201704771 as a PDF (23.96 KB) Updated: December 19, 2018

Miss C complained about the antenatal care she received from the community midwifery team when she was pregnant. Miss C was informed she was on the "red pathway care" for her pregnancy which meant her antenatal care would be led by a consultant obstetrician (a doctor who specialises in pregnancy and childbirth) and supported by the community midwifery team. Miss C complained that she was told by her midwife at her first appointment that she would not need to have future appointments with her midwife and would only see her consultant. Miss C also complained that she missed out on vital check ups and she did not receive her relevant maternity forms on time. The board apologised that the consultant did not provide Miss C with the appropriate forms. We took independent advice from a midwife. We found that when Miss C contacted the community midwifery team, the midwife acted appropriately and offered to meet with Miss C to provide her with the necessary forms and information, however, Miss C refused this offer and did not engage in the service. We found at this point, Miss C was still within the required timescale for submitting her forms, therefore, she did not suffer any significant injustice as a result. We did not find any evidence that Miss C was advised at her first appointment that she was not required to see her midwife again. We did not uphold Miss C's complaint. Related reading View Decision Report 201801666 as a PDF (23.98 KB) Updated: December 19, 2018