SPSO Individual Decisions

C held power of attorney for their parent (A) and complained about the management of A's medication during a hospital admission for treatment of a chest infection. A's medication Furosemide and Ramipril (both used to treat heart failure) were stopped for eight days. A was readmitted to hospital again having suffered a heart attack and died. The board acknowledged it was not recorded who stopped A's medication and why they did so, and that there were failings in how A's medication was reviewed and managed prior to discharge. We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly). After review of relevant medical records and statements, we found that while it may have been reasonable to stop A's medication at the time, there was a failure to record who made the decision and their rationale for the decision. We also found the board did not give adequate consideration as to whether the cessation of A's medication may have had an impact on A's readmission, further heart problems and subsequent death. We also found that A's discharge letter was not appropriately updated prior to discharge. We upheld three of C's complaints, however we concluded that the board's communication with C about the changes to A's medication was not unreasonable in the circumstances and this complaint was not upheld.

C complained on behalf of their spouse (A). A was admitted to University Hospital Wishaw (the hospital) with severe pancreatitis (inflammation of the pancreas). At that time, this was attributed to recent alcohol intake. They developed multi-organ dysfunction (respiratory, cardiovascular and renal) over the ensuing 24 hours, but subsequently made a slow but full recovery. Three years later, A developed abdominal pain whilst on holiday abroad. They were again diagnosed with severe necrotic pancreatitis, which was attributed to raised triglycerides (a fatty substance similar to bad cholesterol), rather than alcohol. It was subsequently documented that they had not drunk alcohol since the earlier episode of pancreatitis. They were admitted to an intensive care unit, intubated and ventilated and managed with conservative supportive therapy. An ultrasound scan during this admission did not show that they had any gallstones. Once A was sufficiently well to travel, they were transferred to the hospital, where they remained until discharge. A subsequently had an ultrasound and this demonstrated a thickened gallbladder containing sludge. They then underwent cholecystectomy (gallbladder removal). C complained on behalf of A that the board unreasonably delayed in performing a test to establish the cause of A's pancreatitis. We found that the board failed to follow national guidelines by not performing ultrasound scanning at the time of A's first admission to hospital with acute pancreatitis. Ultrasound scanning might have resulted in the identification of biliary sludge within the gallbladder at that time and prompted gallbladder removal, thus potentially avoiding the more severe episode of recurrent acute pancreatitis. It should also be stressed, however, that a negative scan at that time would have been unlikely to change A's subsequent clinical course. There was little documentation of discussions with A and their family. In view of these failings, we upheld t

C, an advice worker, complained on behalf of their client (B) about the treatment B's spouse (A) received from the board. A had a rare form of dementia and their condition deteriorated to the point where they become a potential risk to themselves. A was admitted to hospital so their medication could be monitored and altered more effectively but they died a few days after being admitted. B was concerned about the pain relief medication A was given in the final days of their life. In B's view, the pain medication was not administered consistently and A did not receive sufficient medication to alleviate their pain. B felt that a syringe driver should have been used to administer morphine, as they did not feel nursing staff provided pain relief medication as required. We took independent advice on this complaint from a nursing specialist. We found evidence of good nursing care being provided and confirmed that it was reasonable for a syringe driver not to be used in this instance. However, we also noted a significant gap in the nursing records where there was no evidence of A's level of comfort being monitored. While acknowledging that there was evidence of good care being provide to A, the significant gap in some of the records and the inconsistency in the record-keeping meant we could not conclusively say what happened during this period and what condition A was in. This led us to conclude that the board failed to adequately evidence that A was monitored appropriately and provided with appropriate pain relief during this period. In light of this, we upheld C's complaint.

C, an advice and support worker, complained to the board on behalf of their client (A) who had attended A&E at University Hospital Wishaw. A had sustained severe pain and swelling behind their right eye and was concerned that they may have suffered a stroke. A was seen by the stroke team who confirmed that A had not suffered a stroke and A was discharged home with a diagnosis of severe migraine. A began to have the same problems with their left eye two weeks later and by that time still had not regained sight in the right eye. A reattended the hospital. After initially being told it was another migraine incident, which they did not accept, A was referred to another hospital and then to ophthalmology (the branch of medicine that deals with the anatomy, physiology and diseases of the eye) for further treatment including eye drops and laser surgery. A has regained sight in the left eye but will not regain sight in the right eye. A had concerns about the lack of treatment provided at their first attendance at A&E. We took independent advice from a consultant in emergency medicine. We found that the A&E doctor, although reaching a reasonable diagnosis based on some of A's reported symptoms, failed to conduct appropriate investigations on A's specific eye symptoms which had been recorded by a nurse and a paramedic at the time. This should have resulted in a referral to ophthalmology. We upheld the complaint.

C complained about the care and treatment provided to their late parent (A) at University Hospital Monklands. During their admission, there was an incident involving A in the early hours of the morning. The board said that A was mobilised to a commode and, at A's request, given privacy to use it. The board said that A fell during this time and sustained injuries. C was sceptical of the account given by the board of how A sustained their injuries. A remained in hospital until their death a little over a week later. C complained to the board that A was injured, about medical treatment and nursing care after A was injured, and about the attitude of a specific doctor. In response, the board advised C of their view of what had happened, apologised that A had fallen and assured C that work was ongoing in relation to reducing the number of patient falls at the hospital. C was dissatisfied with the board's response and raised their complaints with this office. We found that the board had not reasonably assessed A's falls risk, had not reasonably undertaken staff handovers in respect of A, unreasonably mobilised A to the commode without their hip brace and unreasonably allowed A to use the commode alone and unsupervised. We upheld C's complaint about the care provided to A in respect of their falls risk. There was disagreement between C and the board about the circumstances of particular parts of A's care and treatment following their injury but, notwithstanding this, we found A's care and treatment following their injury was reasonable. We did not uphold C's complaints about the care and treatment of A following their injury. In relation to C's complaint about the attitude of a specific doctor, the recollections of C and the doctor about a specific discussion are contradictory but the evidence available of board staff's communication with C shows these were reasonable. We did not uphold C's complaint about the attitude of the doctor.

C underwent an emergency caesarean section (an operation to deliver a baby. It involves cutting the front of the abdomen and womb). Following this, the stitches holding C's wound together failed. C believed they had not been properly cared for after their surgery. They said they had experienced abnormal levels of pain and discomfort. These had been incorrectly attributed to other causes such as constipation, but C believed they were a sign their wound closure was failing. C also noted significant amounts of fluid had leaked from the wound. C felt this was excessive, but that it had not been properly considered by nursing or medical staff. C said the experience had been very traumatic for them and for their spouse. The board had conducted an internal review into the failure of the stitches. C felt they had not been properly involved in this and that it had not recognised properly the seriousness of the incident, or the implications of its conclusion that incorrect suture material was used. We took independent medical advice which stated the complication suffered by C was rare. C's condition was monitored appropriately postoperatively, including escalation for medical review due to the concerns about wound leakage and pain levels. Although the documentation was poor, there was no evidence of operator error, or that the specific suture material used had contributed to the failure of the wound. We found C's care and treatment had been of a reasonable standard. Therefore, we did not uphold the complaint. The board had acknowledged there had been confusion between the complaints process and the serious adverse event review process and that this had led to delays and poor communication with C. We found that the board's handling of the complaint had been unreasonable, but they were able to demonstrate that they were taking steps to address this issue. Related reading View Decision Report 201905755 as a PDF (24.67 KB) Updated: May 19, 2021

C complained about the care and treatment provided to their late relative (A). A had surgery for a fractured hip and wrist at Hairmyres Hospital. At a clinic appointment a few weeks later, A was advised that there was an issue with a screw being close to the joint in their hip. A was not keen on further surgery and there was an agreement to review them again in six weeks. Subsequently, A's pain increased and their mobility decreased. An x-ray showed that the screw had failed; therefore, surgical correction was considered and further surgery was subsequently performed. A's clinical condition deteriorated and they died a number of weeks later. C complained to the board about A's care and treatment. The board responded to the complaint and carried out a review of A's care. The board identified some evidence of poor care. C remained unhappy and complained to us about A's care and treatment and the board's handling of their complaint. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and from a trauma and orthopaedic (a specialist in the treatment of diseases and injuries of the musculoskeletal system) consultant. We found that A was appropriately reviewed by medical staff and that there was no evidence of a delay in A's pain being identified following their first operation. However, we identified that medication errors in relation to the prescription of vitamin D had occurred which were significant. Whilst we did not find evidence that the errors caused harm to A, the errors had not been appropriately documented in the medical records when they were identified; nor were they reported on the second occasion as they should have been. A and their family were also not informed about the medication errors at the time, contrary to General Medical Council (GMC) guidance. We were critical that the board's review of A's care did not take sufficient action to adequately address these errors. We also found

C complained about the care and treatment a family member (A) received in Monklands Hospital prior to their death. C raised particular concerns that nursing care was not delivered proactively and that the family had to continually ask for care to be provided, including catheter care, oral care, nutrition and pain management. A suffered a fall while in hospital and C also raised concerns about the adequacy of the medical assessment which was carried out following this. We took independent advice from a nursing adviser. We found that the nursing care was reasonable overall, with appropriate care rounding evidenced in the records. This covered catheter care, pain management and general care. However, we identified an unreasonable two-hour delay in commencing appropriate medication for pain and agitation due to medical staff being unavailable to prescribe. We also identified that prescribed oral care was not administered as prescribed, and that person-centred care planning did not reflect A's needs with regards to oral hygiene and end of life needs. We considered that this contributed to A's noted discomfort in the final days of their life and, on balance, we upheld this complaint. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) regarding the medical assessment which followed A's fall. We noted that a thorough and well-documented assessment was carried out which concluded that A had sustained minor injuries only and that no scans or further investigations were required. We did not consider there was a clear connection between the fall and its follow-up and A's subsequent deterioration. We did not uphold this complaint.

C are asthmatic and suffer from chronic obstructive pulmonary disease (COPD). C was referred to the board by their GP due to a flare up of COPD. C was reviewed by a locum consultant respiratory (relating to or affecting the action of breathing or the organs associated) physician at Monklands Hospital. C was concerned that the decision was made to change their inhalers from Relvar and Incruse to a Trelegy inhaler. C said that this caused their condition to flare up and resulted in their breathing becoming laboured. We took independent advice from a consultant in respiratory and general internal medicine. We found that a clinic letter from a few years earlier did not make it clear that a diagnosis of asthma (in addition to the confirmed diagnosis of COPD) was suspected nor list the medication with doses that C was receiving. We noted that the lack of clarity regarding C's suspected diagnosis and treatment resulted in C's GP and subsequent hospital consultants not being aware that C had a possible diagnosis of asthma and was on the higher steroid dose of Relvar. Based on the information known to the consultant at the time, it was reasonable to consider combining the Relvar and Incruse inhalers in to a Trelegy inhaler. However, there was no evidence in the records that the change in medication was explained to C in a reasonable way. In particular, we noted that the possible risks and benefits of this change were not explained to C so that they could make an informed choice about whether to make the change. In these circumstances, we considered it was unreasonable for the board to substitute the medication C was taking for their respiratory condition (Relvar and Incruse) with a Trelegy inhaler. We upheld C's complaint.

C, an advocacy and support worker, complained on behalf of their client (A) who was admitted to University Hopsital Hairmyres with delirium which was found to be caused by a urine infection. A was seen by a doctor who firstly detained them for 72 hours under the Mental Health Act. When the time period ended the detention period was extended to 28 days. A was then transferred to another hospital where the staff did not feel that there was a requirement for the detention and it was rescinded. A felt that the decision to detain them was not clinically required and that the hospital failed to carry out an appropriate mental health assessment on their admission to hospital. We took independent advice from a consultant psychiatrist. We found that an appropriate mental health assessement was carried out based on A's symptoms. We found that although A did have a urine infection which would have caused their delirium, there was sufficient clinical indication that A was suffering from a mental health problem and that there were grounds to detain them under the Mental Health Act. We did not uphold the complaint. Related reading View Decision Report 202003555 as a PDF (24.24 KB) Updated: March 24, 2021

C complained about the care and treatment provided to their child (A) by the dermatology service at University Hospital Hairmyres regarding skin lesions. In particular, C was concerned about the length of time taken to refer their child to paediatric dermatology at a children's hospital, that this referral was not marked as urgent and antibiotics or a steroid cream were not prescribed earlier. We took independent advice from a consultant dermatologist. We found that the length of time taken to refer A to paediatric dermatology was not unreasonable in the circumstances. It was reasonable that the referral to paediatric dermatology was routine rather than urgent given A's clinical presentation, that antibiotics were not prescribed earlier as there was no indication of increased swelling, pain and increasing size or progression of the lesions, and that topical steroids were not prescribed in the absence of a definite clinical diagnosis. We did not uphold C's complaint about the care and treatment provided to A. C also complained about the way the board handled their complaint. We found that one of the board's complaint responses did not address all the points raised by C. We upheld C's complaint in this regard.

C, a member of the Scottish Parliament, complained on behalf of one of their constituents (A) about the care and treatment they received from the board. Initial investigations carried out diagnosed A with atrial fibrillation (AF, a problem of the heart characterised by irregular and often faster heartbeat). While waiting for a cardiology (the branch of medicine that deals with diseases and abnormalities of the heart) appointment, A suffered a heart attack and was admitted to Hairmyres Hospital. C raised concerns that the hospital’s cardiology department knew A had a problem with their heart two weeks before they suffered the heart attack and that aspects of A’s care and treatment during their admission were unreasonable. In particular, they complained that A was placed in a bed next to a disruptive patient who was suicidal while in the Acute Assessment Unit (AAU), that there was a delay in carrying out a coronary angiogram procedure (a type of x-ray used to examine blood vessels), and that communication by hospital staff was poor. C also complained that A’s follow-up rehabilitation treatment after discharge was unreasonable. We took independent advice from a cardiology adviser. We found that while there were issues identified initially with A’s heart, there were no concerning features associated with their AF that would raise suspicion that A might have a heart attack. While we acknowledged that being in a bed next to a disruptive patient in AAU, must have been very distressing for A at a particularly difficult and anxious time, we found that this reflected the status of AAU as a communal assessment ward and was consistent with standard practice. Regarding C’s concerns about the delay in the carrying out of the coronary angiogram, we found that it was reasonable for staff to delay this procedure in the context of staff being required for other urgent and emergency procedures. We acknowledged C’s concerns about staff communication and how this made A feel, in particu

The complainants (B & C) raised concerns about the practice following the suicide of their child (A). A and B had attended the practice two weeks prior to A’s death and B & C told us that they held concerns regarding the manner of the GP they saw, which A and B had found to be dismissive and unsupportive. While they did not consider that the doctor could have predicted the extent of A’s distress, they considered that the doctor’s demeanour may have contributed towards A feeling unsupported. B & C also held concerns regarding the way in which the practice had cared for them following A’s death, as they had concerns about a prescription for Diazepam (a drug which belongs to a group of medicines called benzodiazepines and usually used to treat anxiety) they both received, the lack of other support offered, and the way in which the practice carried out a Significant Adverse Event Review (SAER) into what had occurred. On investigation, we found that the doctor in question had already accepted that their body language had been inappropriate and apologised for this, when responding to B & C’s original complaint. We took independent advice from a GP on the care and treatment offered and we considered that the support provided by the doctor at the appointment was otherwise reasonable. Therefore, we did not uphold that element of the complaint. We considered that the handling of the prescription of Diazepam and the bereavement support otherwise offered to B & C had been inappropriate. We also found that the SAER had been unreasonably delayed. Therefore, we upheld these complaints.

C has an adopted child who has a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). A's behaviour is so challenging that both parents fear A will cause serious harm to themselves or to them. C wished A to be prescribed medication for their ADHD, but Child and Adolescent Mental Health Services (CAMHS) said that they required to carry out a face-to-face assessment before medication could be prescribed. They said they were unable to offer this at present because of COVID-19 restrictions. C considered that A needed urgent input, but the board said that A's need was not considered urgent. The board said that they would see A as soon as they were able to. C complained that the board had failed to assess A's need for CAMHS treatment as urgent. We took independent advice from a consultant child and adolescent psychologist. We considered that A's need for treatment had been appropriately assessed with reference to COVID-related criteria. We did not uphold C's complaint. We were, however, critical of the delays in assessment of A's condition and commented that, were it not for these delays, A should by now have had the opportunity of psychiatric review and clinical treatment. Related reading View Decision Report 202001237 as a PDF (24.33 KB) Updated: January 20, 2021

C complained on behalf of their partner (A) after A's leg was amputated above the knee without C’s consent. We did not uphold this complaint as there was evidence of discussion with A prior to the operation and a consent form had been signed by A. C also complained that the board unreasonably amputated A’s leg above the knee when a toe amputation would have been sufficient. A’s leg was vascularised down to their knee and there were significant problems with A’s foot. A toe amputation would not have been sufficient. It was reasonable to amputate A’s leg rather than conduct by-pass surgery. We did not uphold this aspect of the complaint. C also complained that a Do Not Attempt Cardia Pulmonary Resuscitation (DNACPR) was put in place while A was unable to consent to it and that A was later discharged with this. We noted that there were issues relating to retaining a copy of the DNACPR on file, it but as consent was obtained once A was able to consent, we did not uphold this aspect of the complaint. C also complained that the board changed their response to the complaint regarding consent to A’s amputation. The board had originally stated that A had been unable to consent to the amputation at the time and that it was performed out of medical necessity; however, later they located documentation to show that A had actually consented. We upheld this aspect of the complaint.

C, an advice and support service worker, complained on behalf of their client (A) regarding care and treatment A received from the board. A presented to University Hospital Monklands with abdominal pain, which had been treated as a urinary infection. It was thought that the symptoms were related to their kidneys. A had a scan days later and as a result was diagnosed as having a twisted right ovarian cyst which required surgery. C complained that there had been a misdiagnosis and delay in carrying out a scan. They questioned whether the ovary would not have needed to be removed had the correct diagnosis been made earlier. C also complained that A’s mobility and pain were not properly assessed, and compression stockings were not provided. In responding to the complaint, the board apologised that there had been a breakdown in communication regarding the scan and advised that this would be discussed with the doctor in further detail. In terms of the nursing care provided, the board did not identify any failings. We took independent advice from a consultant general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus) and from a registered nurse. In terms of the medical care, we found that A’s ongoing pain three days after being treated for urine infection was uncommon and that a diagnosis of kidney stones or another cause of pain should have been considered. We considered that a scan should have been carried out on the day it was originally planned and it was unreasonable care that this did not happen. However, we did not consider that A’s outcome of undergoing surgery and having an ovary removed would have been affected by the delay in the scan. Nevertheless, we found that the delay resulted in A being in pain for longer and acknowledged that this was distressing for them. We upheld this complaint. In terms of the nursing care, we found it was reasonable not to have provided A with compression stockings. However, we

C complained on behalf of their sibling (A) following A's contact with a health board’s mental health service when they were in crisis. C was concerned about the standard of care and treatment provided to A. C’s concerns were wide-ranging and covered numerous aspects of the provision of care and treatment. C said this included repeated, unreasonable, failures by staff to recognise and diagnose A with psychosis and paranoia, to prescribe appropriate medication, to communicate adequately with A or their family or both, adequately supervise A, to agree a care plan and put in place appropriate discharge care, and to admit A as an in-patient at each emergency department attendance. We took independent advice from a consultant psychiatrist and from a mental health nurse. We found that the diagnosis was appropriately assessed and reasonable conclusions reached on management and treatment of A. However, we also noted some concerns about aspects of communication with A and their family and found significant shortcomings in relation to record-keeping about a discharge from one hospital admission in particular. We upheld this aspect of the complaint.

C attended A&E at Wishaw General Hospital complaining of chest tightness, sweating, nausea and palpitations (a noticeably rapid, strong, or irregular heartbeat due to agitation, exertion, or illness). C felt that their concerns were not fully listened to and concerns about side effects of medication were not taken into account. We took independent advice from a consultant in emergency medicine. We found that the assessment C received was of a reasonable standard for a patient presenting with chest pain and appropriate investigations were carried out. We did not uphold this aspect of the complaint. C also complained about the response they received to their complaints. We found that while some of the board's actions were reasonable (a resolution was sought; C spoke with the consultant about their concerns; C was offered to add their account to the medical record), overall the board's complaint handling was unreasonable. We found that the board had not responded to all of the points that C raised as complaints, and the board acknowledged this failing in a later complaint response. We also found that the board should have been clearer when advising C of which stage of the complaints process they were at and should have managed C's expectations about the next steps if a resolution could not be reached. Therefore, we upheld this aspect of the complaint. C also complained about the board's application of their Unacceptable Actions Policy (UAP). We found that the board had acted in line with process. While they had warned C that they had a UAP and why they considered C's actions were unreasonable, they did not formally restrict C's contact with them through the UAP. We did not uphold this complaint.

C underwent knee surgery, following which the hospital provided them with a sick note. At the end of that sickness period, they were told that they required two more weeks of recovery before they could return to work. When C approached the practice, they were told they should be given a sick note by the hospital. C then went back and forth between the practice and the board. C said they were told by the board’s complaints team that it was the practice’s responsibility and that if the practice refused to provide a sick note, they would be in breach of their NHS contract. C said the process was very stressful and at one point they were without a sick note. While they were issued with one by the hospital, it was reiterated to C that this should have been the practice’s responsibility. The practice told us they had taken advice on whether it was their responsibility to provide a sick note for C. They said that the Lanarkshire Local Medical Committee (LLMC) had told them it was the responsibility of the hospital who had operated on C. They said that the LLMC was taking the matter up with the board more generally. The practice said that they would have provided C with a sick note, but by that time, the hospital had done this. We took independent advice from an appropriately qualified adviser. We found that records stated that C was the responsibility of the hospital until they were fully discharged. This meant that whilst C still had out-patient appointments to attend, the practice were correct to state that they were not responsible. We did not uphold C's complaint. Related reading View Decision Report 201906476 as a PDF (24.46 KB) Updated: November 18, 2020

C, a Patient Advice and Support Service adviser, brought the complaint on behalf of their client (B) with regard to the care and treatment provided to B’s late spouse (A). A had a compromised immune system and received regular immunoglobulin therapy (a blood-based treatment to increase the number of antibodies in the immune system). A was admitted to hospital with a high temperature and was found to have acute leukaemia. They deteriorated over several weeks and died a short time later. C complained about a number of aspects of A’s care and treatment including a change in their immunoglobulin brand; that A’s reason for admission to hospital was not clearly communicated; that A had cellulitis (a type of skin infection) in their hand; and that A being incorrectly administered a diuretic (a type of medication which increases the passing of urine) indirectly led to their death. We took independent advice from a consultant haematologist (a specialist in diseases of the blood and bone marrow). We found that the care and treatment provided to A was reasonable. Specifically, we found that there was no indication the change in immunoglobulin brand caused A’s deterioration; there were several terms that could have been used to describe the reason for A’s admission to hospital and the board’s actions in this regard were not unreasonable; it did not appear that A had cellulitis in their hand; and the incorrect administration of a diuretic was not a cause or contributor to A’s death. Therefore, we did not uphold C’s complaint. However, we noted some feedback for the board with regard to communication about A’s prognosis. Related reading View Decision Report 201907859 as a PDF (24.53 KB) Updated: November 18, 2020

C attended the practice to collect prescriptions and had a brief discussion with a member of staff. Subsequently, C received a letter from the practice informing them their registration with the practice had been terminated due to inappropriate behaviour. C considered the practice’s actions to be unreasonable. We found that the practice failed to follow the relevant process prior to removing C’s registration. The practice did not give a prior warning or keep reasonable records of the actions they took. We also found that the practice did not provide an accurate response to C’s complaint. As such, we upheld the complaint.

C had been referred to the blood pressure clinic at the hospital by their previous GP practice, and when they did not hear from the clinic, they called their current practice to enquire about this. The practice told C that they had failed to attend an appointment at the clinic and that C was to contact the hospital in the first instance. C made enquiries with the clinic to be informed that they had indeed missed an appointment and that they should ask the GP for a further referral. C said they had not received the appointment letter. We took independent clinical advice. We found that the practice had received notification by letter from the clinic that C had failed to attend an appointment and that should the practice deem C still required to be seen at the clinic, then they should initiate a further GP referral. We found that the practice should not have told C to contact the clinic as they were already aware that a further referral was required or that the practice could have decided to undertake more investigations locally to monitor C’s blood pressure levels. We upheld the complaint.

C complained on behalf of their partner (A) following A's admission to University Hospital Hairmyres with drowsiness. There was an indication that A may have taken too much of their prescribed medication at home. C raised concerns that a period of deterioration during A's admission was due to poor care. We took independent advice from an appropriately qualified adviser. We considered that A's deterioration was related to infection, and were unable to identify anything to suggest that their deterioration was due to poor care. We did not uphold this aspect of the complaint. C complained that their concerns about A's deterioration were ignored, and that when they asked to speak to medical staff, this was not arranged. The board noted that C had been given the telephone number of the consultant's secretary, and that two doctors were on the ward during the day on weekdays and were available to speak to patients and relatives. We considered that nursing staff should have arranged for the ward doctors to speak to C, rather than providing a number to make an appointment with the consultant. We considered that this would have been simpler, quicker and more effective. We upheld this aspect of the complaint. C also expressed concern about the arrangements in place for A's medication on discharge, including that they were not given a dosette box to assist them in managing the medication at home. We noted that there was concern that A's medication may have caused the symptoms which led to their admission, and as such they considered that the discharge medication should have received more care and attention. Therefore, we upheld this aspect of the complaint.

C complained that there was an unreasonable delay in providing their parent (A) with a diagnosis of pancreatic cancer. 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 gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines). We found that radiology unreasonably failed to detect and report pancreatic cancer from a scan taken five months prior to diagnosis and that there was an unreasonable failure to hold a multi-disciplinary team meeting between radiology and gastroenterology with imaging. We also found that there was an unreasonable delay in investigating the cause of A's pancreatic insufficiency as it would have triggered further imaging. We considered that earlier detection may have improved A's quality of life because they would have had a management plan for palliative care sooner. We upheld this complaint.

C was admitted to University Hospital Monklands with abdominal pain, vomiting and an inability to pass urine. C was diagnosed with possible appendicitis (inflammation of the appendix) and was operated on the next day. C was discharged after surgery but was later readmitted and underwent further surgery. C complained they should have had their first operation sooner, given the pain they were in. We took independent advice from a consultant in general and colorectal surgery (a surgeon who specialises in conditions in the colon, rectum or anus). We found that C's first operation was carried out within an acceptable timeframe. We did not uphold this aspect of the complaint. C complained their first operation was not carried out in a reasonable manner, as they experienced problems afterwards. C had suffered a recognised complication of the operation and we did not find failings in how C's first operation was carried out. We did not uphold this aspect of the complaint. C also complained that they should not have been discharged home after their first operation, as they were still unwell. We found it was unreasonable that C was discharged home, as they had a raised temperature and inflammatory marker. We upheld this aspect of the complaint. When C was readmitted to hospital for a further operation, C said that there was an unreasonable delay in carrying it out. We found there was an unreasonable delay giving C a scan, which caused a delay in carrying out their second operation. We upheld this aspect of the complaint.