SPSO Individual Decisions

Mr C complained that he was unreasonably removed from the boards waiting list when he did not attend an appointment. We took independent advice from a dental adviser. We found that it was reasonable to remove Mr C from the waiting list without offering him another appointment in the clinical circumstances. We did not uphold this aspect of Mr C's complaint. Mr C also complained that the board did not communicate reasonably with him. We found that the board's letter to Mr C did not inform him that, if he contacted the service within four weeks, he may be offered another appointment. This was contrary to the NHS Lothian Standard Operating Procedures for Waiting Times Management. We also found that there was no written record of Mr C's call to the board. We upheld this aspect of Mr C's complaint. Lastly, Mr C complained about the way the board handled his complaint. We did not find evidence that the board had handled Mr C's complaint unreasonably. Therefore, we did not uphold this aspect of Mr C's complaint.

Mrs C complained about the care she received at St John's Hospital. In particular, Mrs C was unhappy with delays in the identification, monitoring and diagnosis of an abnormality in her pancreas. Mrs C had a number of hospital admissions and underwent four scans. The scans showed that the abnormality had increased in size. By the time of the final scan, it was identified that the abnormality was likely to be cancer. Mrs C was subsequently diagnosed with cancer and had surgery to have part of her pancreas removed as well as chemotherapy. We took independent advice from a radiologist (a specialist in the analysis of images of the body) and a general surgeon. We found that the management of the abnormality was reasonable until the point of the third scan. The report of this scan identified a definite increase in size of the abnormality, although inconsistently referred to it as unchanged. We considered that a referral should have been made to the surgical team to follow up the abnormality and concluded that the failure to do this was unreasonable. We upheld the complaint. However, we concluded that if follow-up had been appropriately planned, it was unlikely that the course of events would have been different in this case. This is because Mrs C received a scan to investigate abdominal pain around the same time that a scan would have been planned in line with the recommended timescales for follow-up of abnormalities. Mrs C also had concerns about the way the board handled her complaint. We noted that the board had acknowledged and apologised to Mrs C that there had been a significant delay in responding to the complaint. We were critical that the board did not seem to have identified the cause of the delay. We also found that the board had failed to provide updates to Mrs C about the delay. We upheld this complaint.

C, a support and advocacy worker, complained on behalf of their client (B) whose adult child (A) had developed deep vein thrombosis (a blood clot in a vein) and pulmonary embolism (a blocked blood vessel in the lungs) requiring treatment in hospital. Despite receiving blood thinning medication, A developed further pulmonary embolism. A's medication was revised and arrangements were made for A to be seen as an out-patient. A died after returning home following a later review appointment. B questioned the quality of care A had received from the board. We took independent advice from a consultant respiratory physician (a doctor who specialises in treating and managing patients with conditions affecting their lungs). We found that A received a good standard of care both as an in-patient and as an out-patient in line with the relevant guidance and good practice. There was no evidence that A's outcome could have been changed had the board acted differently. We did not, therefore, uphold C's complaint Related reading View Decision Report 201900525 as a PDF (24.28 KB) Updated: September 23, 2020

C complained that the board failed to provide them with reasonable care and treatment regarding their Lyme disease (LD – a disease caused by bacteria). We took independent advice from a consultant in general internal medicine. C raised concerns that they were refused intravenous antibiotics when they understood this was an available treatment option. The evidence in C's medical records suggested a treatment approach was discussed and agreed about this. We took account of the advice we received that it did not appear from the evidence that any of the relevant medical complications of LD, which applied for starting a patient on intravenous antibiotics, had been established in C's case. We, therefore, did not find evidence that the clinical judgement of C's doctor was exercised in an unreasonable manner. Furthermore, the board's actions were consistent with the relevant guidelines when applicable. C also raised concerns about the manner and approach of a doctor. Our investigation did not identify the supporting evidence needed to conclude that unreasonable communication had occurred. However, we found that the time C waited for diagnosis of LD was unreasonable. We also found that there was an unreasonable delay before a referral for a second clinical opinion was actioned and a significant delay before nerve conduction studies were carried out, in particular, given that in C's case, the test results may have altered their clinical management. C also reported difficulties contacting the medical team to obtain the results of their investigations. We noted that the board had acknowledged this and apologised to C. For the reasons outlined above, we found there were elements of C's care and treatment that were unreasonable and we upheld C's complaint.

C complained to the board about the decision to move them to another ward and the manner in which they were discharged while they were a patient at Royal Edinburgh Hospital. The board explained that beds are allocated according to clinical need and, due to extreme pressures on hospitals at that particular time, it was felt appropriate to move C to another ward as they were clinically stable. The board said appropriate referrals were made following C's discharge, however, as C did not return to the ward following an overnight pass, they were unable to complete their assessment for home treatment. We took independent advice from a mental health nurse. We found that it was unavoidable that a patient had to be transferred to another ward due to the pressures on the wards at the time, and that the board followed a reasonable process in selecting C as a suitable candidate. We did not uphold this aspect of the complaint. However, we found that while appropriate assessment was carried out, the board failed to appropriately manage C's discharge as they did not ensure that Intensive Home Treatment Team supports commenced when C left the hospital. We upheld this aspect of C's complaint.

Following open surgery, Miss C’s abdomen was closed. Miss C was unhappy with the stitching of her abdomen as it had a ‘dog eared’ appearance at one end. Miss C considered that the stitching was inadequate and she should have been given corrective surgery. As the board did not consider that this was necessary at the time, Miss C proceeded to have private surgery to change the appearance of the scar. We took independent advice form a plastic surgeon. We found that the closure of the surgical wound was achieved by an acceptable technique using appropriate materials. We found the stitching was of a reasonable standard. After several months, there was a small ‘dog ear’ at the end of the scar. We found that the scar was immature at this stage and that it was reasonable to state that it should be allowed to heal, rather than performing corrective surgery at that time. We did not uphold the complaint. Related reading View Decision Report 201903853 as a PDF (24.15 KB) Updated: August 19, 2020

C complained about the care and treatment they received from A&E of St John's Hospital. C has a history of painful skin conditions requiring hospitalisation. C presented at A&E and was triaged by a nurse. The nurse carried out an assessment of C’s condition and discussed it with the a doctor. C was referred to the out-of-hours GP service. C said that they should have been examined by a doctor in light of their symptoms and previous history. We took independent advice from a senior emergency nurse practitioner. We found that C’s medical history was considered and observations of their temperature, heart rate and blood oxygen were recorded. The notes did not contain details of the physical examination nor the discussion with the doctor. The out-of-hours GP that C was referred to did not refer them back to the doctor, as they could have done, if they thought the referral was not appropriate. We concluded that C had received a reasonable standard of care and treatment and did not uphold the complaint. Related reading View Decision Report 201906037 as a PDF (24.23 KB) Updated: August 19, 2020

C, an advocate, complained on behalf of their client (A) about the care and treatment A received at St John's Hospital when they attended after becoming unwell with vomiting. A had also been suffering from migraines over the previous few days. C complained that there was inaccurate reporting of the CT angiogram (a specialised scan using x-rays to look at the heart) which resulted in a delay in diagnosing a stroke; there was a delay in performing a lumbar puncture; and there had been a lack of consistent communication with the family. C also complained that A was not treated fairly due to comments made by staff about their previous medical history and that they did not receive assistance with personal care. The board accepted that there was a failing in relation to the provisional report of the CT scan and this would have initiated treatment for A's stroke at that time. The board apologised and said that they would highlight the case at their local learning meeting. The board accepted that there was no documented evidence to support that A was receiving help with personal care, for which they apologised. However, they noted that there were regular attempts to keep A and their family updated on care. 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), from a consultant in general medicine and from a registered nurse. We found that, while many aspects of the medical care provided were reasonable (including the timing of the lumbar puncture), there was an unreasonable error regarding the provisional CT scan. This meant that there was a delay between the scan being performed and it being correctly reported. We upheld this aspect of the complaint. We considered that A would have received medication, such as aspirin, to thin their blood earlier, but the effect of this is to prevent future strokes rather than im

Ms C complained about the care and treatment she received at the Royal Infirmary of Edinburgh. Ms C complained that she was unreasonably prescribed a drug, uniphyllin, in order to treat her asthma. We took independent advice from a consultant in respiratory and general internal medicine. We found that it was reasonable to prescribe uniphyllin for Ms C's asthma and long-term breathing difficulties. Therefore, we did not uphold this aspect of the complaint. Ms C experienced a tonic-clonic seizure (type of seizure that involves both stiffening and twitching or jerking of a person's muscles) whilst taking the drug and said that she was not advised that this was a possible side effect. We considered that it would have been reasonable for Ms C to have been provided with information so that she could be involved in decisions made about her care and the possible side effects of medication. We upheld this aspect of Ms C's complaint. Ms C also complained that she was given an increased dose of the drug without the effect of this being monitored. We found that the symptoms Ms C was experiencing were not necessarily a sign that the dose she was given was too high. An increase was also reasonable for maximum therapeutic effect. We did not uphold this aspect of Ms C's complaint. Finally, Ms C complained that there was an unreasonable delay in advising her to stop taking the drug after she had a seizure. We considered that it would have been reasonable for Ms C to have been advised in A&E to stop taking the drug when she was admitted after her seizure. We upheld this aspect of Ms C's complaint.

Ms C complained about the decision of staff at the Royal Hospital for Sick Children to assess that two referral letters from her child's (Child A) GP should be graded as routine rather than urgent. Child A had ankyloglossia (tongue-tie); this occurs where the strip of skin connecting the baby's tongue to the bottom of their mouth is shorter than usual which affected their ability to feed. As the board had added Child A to the routine waiting list, Ms C paid for the procedure to be completed on a private basis, and Child A immediately improved their feeding ability. Ms C believed that the GP referral letters should have been graded as urgent which would have allowed the procedure to be carried out sooner. We took independent advice from a consultant paediatrician (consultant specialising in the medical care of children). We found that as Child A was able to feed using a bottle and was gaining weight, there was no need to classify the referral letters as urgent; this was in line with board policy. We did not uphold the complaint. Related reading View Decision Report 201908741 as a PDF (24.25 KB) Updated: July 22, 2020

Mrs C complained about the care and treatment her late brother (Mr A) received from the practice. Mr A attended two consultations at the practice as he had experienced shortness of breath on exertion for the previous few weeks. The GP arranged for a chest x-ray and blood tests to be carried out. These tests did not highlight any concerns but Mr A confirmed that his breathing difficulties were ongoing. The GP felt his breathing difficulties could have been caused by angina (chest pain caused by reduced blood flow to the heart muscles) and increased his medication for this with the intention to refer Mr A for more specialist assessment if his symptoms persisted. Mr A died suddenly one week after his second consultation. Following a post-mortem, it was confirmed that the primary cause of death was a pulmonary embolism (a blockage in one of the pulmonary arteries in the lungs, caused by a blood clot). Mrs C complained to the practice and queried why the GP did not look at Mr A's medical history, as this included details of a previous blood clot. In addition to this, Mrs C queried why no further investigation was carried out after the second consultation when Mr A's x-ray results were confirmed as clear. In their response to Mrs C's complaint, the practice concluded that the GP's clinical assessment and decision-making, based on the information at the time, was considered and reasonable. Mrs C was unhappy with this response and brought her complaint to us. We took independent advice from a GP. We found that the care and treatment the practice provided to Mr A was reasonable. We were satisfied that appropriate consideration was given to Mr A's medical history in respect of blood clots when assessing his breathing difficulties. We also concluded that the practice's actions, after Mr A's x-ray results were known, were reasonable and appropriate. We were satisfied that the records indicated the practice had a firm treatment plan in place for Mr A and had clearl

Mr C complained that the board had not made reasonable decisions around whether to provide plasma exchanges (a procedure which separates your blood into its different parts: red cells, white cells, platelets and plasma. The plasma is removed from the blood and replaced by a plasma substitute) to his wife (Mrs A) and whether to further explore the possibility of thrombectomy (procedure of removing a blood clot from a blood vessel), or reasonably monitor her levels of consciousness during an admission to hospital following a stroke. We found that the board's decisions around plasma exchanges and the possibility of thrombectomy had been reasonable, but that the board had not reasonably monitored Mrs A's levels of consciousness for a period. This meant that there was a delay to the board providing her with specific treatment. Although this treatment had only a small chance of success, we decided that the board's actions had been unreasonable. Therefore, we upheld this aspect of Mr C's complaint. Mr C also complained about how the board had responded to his complaint. We found that the board's responses had been reasonable and did not uphold this aspect of the complaint.

C underwent specialist reconstructive surgery. After the surgery, C experienced urinary incontinence. C said that they had believed the surgery would be of a routine nature and complained that they had not been not provided with adequate information about it; in particular, that a possible side effect was incontinence. We took independent advice from a urology adviser (a doctor who specialises in the male and female urinary tract, and the male reproductive organs). We found that the board failed to provide adequate information to C about the planned procedure prior to obtaining their consent and, therefore, we upheld this complaint. C also complained about the delay in the surgery being carried out. The board accepted that there was a delay in C accessing treatment and explained that the delay reflected the waiting list issues the department had at the time. We found that there was an unreasonable delay in C's planned procedure being carried out. We upheld this complaint. C complained that the board failed to provide them with reasonable care and treatment. C had concerns about how the board managed their place on the waiting list for the planned procedure and about the aftercare provided. The board acknowledged that there was a breakdown in communication which resulted in C having to arrange aftercare themselves. However, they said that their waiting list was managed appropriately. We found that there was nothing to suggest that C's place on the board's waiting list was managed inappropriately. However, we upheld the complaint on the basis of the breakdown in communication which resulted in C arranging aftercare treatment themselves. Finally, C complained that the board failed to handle their complaint reasonably. The board acknowledged that there had been a delay in responding to C's complaint and that they had not communicated about the delay with C. We found that the board did not respond to C's complaint within expected timescales or communicate wi

Mr C has autistic spectrum disorder (a developmental disability that affects how a person communicates with, and relates to, other people). After attending an advice clinic, Mr C was assessed by a psychologist. He was then referred to a community mental health service to see if they could help him with social skills and managing anxiety. The community mental health service did not consider they could meet Mr C's specific needs; and they explained that he might be able to access support from a charity instead. Mr C complained that after his psychology assessment, he was not referred for care and treatment suitable to his needs. We took independent advice from a psychologist. We found that Mr C was appropriately assessed and referred for help with social skills. We found that the community mental health service gave the referral careful consideration. We also found it was reasonable that they refused it, as the charity was better equipped to meet Mr C's needs. We did not uphold this aspect of the complaint. Mr C also complained that the board failed to handle his complaint in a reasonable manner. We found that the board did not communicate clearly with Mr C about his complaint, in particular in relation to the scope of their investigation. We upheld this aspect of the complaint.

Ms C complained about the medical care and treatment provided to her father (Mr A) when he was an in-patient at the Royal Infirmary of Edinburgh. Ms C had concerns about the medical reviews, the decision to withdraw treatment/fluids, the monitoring of Mr A's condition, whether Mr A had an infection, the decision to reinstate active treatment, and communication with Mr A's family. We took independent advice from a consultant in geriatrics (a doctor who specialises in medicine of the elderly) and general medicine. We found that the care and treatment provided to Mr A was reasonable and decisions were made sensitively to balance the wishes of Mr A's family and to reduce distress for Mr A. We did not uphold this complaint. Related reading View Decision Report 201904336 as a PDF (24.06 KB) Updated: July 22, 2020

Ms C complained about the dental assessment she received from a consultant in restorative dentistry at the board and the consultant's report of their findings. Ms C said that the consultant failed to consider her health/dental health issues and the views of her own dentist appropriately. She complained that the consultant unreasonably concluded that she did not qualify for specialist treatment at the board. Ms C felt that the consultant should have agreed for her to have dental implants. We took independent advice from a dentist. We found that Ms C's dentist felt that her natural dentition should be removed to make way for dentures and that they referred Ms C to the board for a second opinion. We found that dental implants were not available on the NHS, other than in exceptional circumstances, which Ms C did not meet those criteria. We noted that the two alternative treatment options identified for Ms C by the board consultant would most appropriately be carried out by her own dentist rather than a specialist at the board. We also found that Ms C's health and dental phobia issues would usually be managed by a patient's dentist and would not be the remit of a restorative consultant. However, we noted that if these proved to be too complex, then a patient should be referred to the Public Dental Service, where dentists are better versed in treating patients with medical, behavioural or phobia issues We concluded that the board provided Ms C with appropriate care and treatment and, therefore, did not uphold the complaint. Related reading View Decision Report 201810727 as a PDF (24.43 KB) Updated: July 22, 2020

Miss C attended the Royal Infirmary of Edinburgh A&E having cut her lower right leg. The wound was treated with wound closure strips and a dry dressing. Miss C complained that it was not appropriate to treat her wound with strips and that they should have been sutured as she developed an infection and required further treatment. The board explained that wounds on the lower leg take longer to heal, are more prone to infection and it is unlikely suturing would have resulted in a different outcome. We took independent advice from a medical adviser. We found that the use of wound closure strips can be as effective as sutures in cuts. There was no evidence to suggest that the treatment provided was unreasonable and it would not be possible to determine whether the wound would not have become infected if it had been stitched. Therefore, we did not uphold the complaint. Related reading View Decision Report 201904131 as a PDF (24.15 KB) Updated: June 17, 2020

Ms C complained that the total knee replacement surgery she had undergone had not been carried out appropriately. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). The board were unable to locate the operation note for the surgery. However, we found that the evidence that was available indicated that it was likely there had been a technical error in the operation in that too much bone was resected (removed). However, without the operation note, it was not possible to state this categorically. We also found that Ms C had been poorly consented for the operation. There was little evidence that she had been informed of the risks of surgery. The risks of ongoing pain, dissatisfaction and the fact that revision might be necessary were not specifically recorded. It was also unreasonable that the operation note was not available. Given this, we upheld this aspect of Ms C's complaint. Ms C also complained that the board's response to her complaint was unreasonable. We found that the board's response had been inaccurate about who carried out the operation. There was also a delay in responding to the complaint and no evidence that the board agreed revised time limits with Ms C for responding. Therefore, we also upheld this aspect of the complaint.

Mr C complained about the clinical care and treatment provided to his late mother (Mrs A). Mr C complained that Mrs A had been incorrectly diagnosed with dementia and that the care and treatment Mrs A received during her admission to the Western General Hospital (WGH) and by the community mental health team (CMHT) prior to her death was unreasonable. We took independent advice from a consultant psychiatrist and a consultant geriatrician (a specialist in medicine of the elderly). We were concerned that the board had failed to follow their retention and destruction policy and that some of Mrs A's medical records had not been retained in line with that policy and were therefore not available during the investigation of the complaint. However, from the available evidence, we found that the diagnosis of dementia was questionable and that there had been a failure to review this diagnosis as new information emerged. Therefore, we upheld this complaint. In relation to the clinical care and treatment given to Mrs A during her admissions to the WGH, while we found that aspects of the care and treatment given to Mrs A was reasonable, there had been a number of failings and we upheld the complaint. However, we noted that the board had carried out a significant adverse review event and had made a number of recommendations. In relation to the community mental health care given to Mrs A, we were unable to address all the issues raised by Mr C due to the absence of relevant medical records. However, based on the available evidence we found that there had been a lack of coordination and communication between the various mental health teams and as a result, we upheld the complaint.

Miss C complained about the care and treatment she received at A&E at Royal Infirmary of Edinburgh (RIE) and when she attended for an MRI scan. She also complained about the clinical and nursing care and treatment provided during a number of admissions to the RIE. We took independent advice from a consultant in emergency medicine in relation to Miss C's attendance at A&E. We found that the care and treatment was reasonable, in particular, that Miss C was seen by an emergency medicine doctor who obtained a thorough history and conducted a comprehensive examination; that the possibility of a pituitary (a small gland in the brain that makes hormones) tumour was considered and the most appropriate radiological imaging plan was discussed with a radiologist; that arrangements were made for an emergency out-patient MRI scan which was carried out within the timeframe for an urgent MRI scan. We took independent advice from a consultant radiologist in relation to the care and treatment given to Miss C when she attended for an MRI scan. We found no evidence that the care and treatment was unreasonable and, therefore, we did not uphold the complaint. In relation to the clinical care and treatment given to Miss C when she was admitted to the RIE on three occasions, we took independent advice from a consultant surgeon. We found that the clinical care and treatment given to Miss C during these admissions was reasonable and we did not uphold these complaints. Finally, we took independent advice from a nursing adviser in relation to the nursing aspects of the care given to Miss C during two of her admissions to the RIE. We found failings in relation to Miss C's discharge medication on one occasion and we upheld this aspect of her complaint. The board accepted these failings and had taken action which we considered was reasonable. Therefore, we made no further recommendations. We found no failings in relation to the nursing care and treatment given to Miss C during the second

Mrs C complained that the reporting of x-rays taken of her knees was unreasonable. Mrs C was referred by her GP for an x-ray as she had been suffering from pain in her knees for over a year and her GP thought that she might be experiencing the onset of arthritis (a disease causing painful inflammation and stiffness of the joints) . Knee x-rays were carried out and Mrs C's GP later advised her that the x-rays showed no signs of arthritis. However, Mrs C subsequently attended a private hospital and was advised that x-rays did show early onset arthritis and swelling in both knees. Mrs C stated that the x-rays from the board had not been looked at properly. We took independent advice from 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 no evidence that the reporting of Mrs C's knee x-rays had not been reasonable but the images taken allowed for different interpretations and did not give a clear enough picture to result in a definite arthritis diagnosis. Therefore, we did not uphold the complaint. Related reading View Decision Report 201810248 as a PDF (24.3 KB) Updated: June 17, 2020

Mr C, who had a previous history of repeated sinus infections, attended the day surgery unit at St John's Hospital for planned septoplasty surgery (corrective nose surgery). He was prepared for surgery by a nurse but Mr C was then reviewed by a doctor who decided that surgery was not required at that time and that Mr C could be discharged home with nasal capsules and would be reviewed at a later date. Mr C said that it was unreasonable that the doctor had overruled a previous consultant, who deemed that surgery was required, and that he was prescribed capsules which had not been effective in the past. We took independent advice from an ear, nose and throat surgeon. We found that it is not unusual for planned surgery to be cancelled on the day of surgery. Clinicians who may have not seen the patient previously routinely review the symptoms reported and may determine that the surgery is cancelled or that alternative surgery should proceed instead. We did not uphold Mr C's complaint. Related reading View Decision Report 201904902 as a PDF (24.21 KB) Updated: June 17, 2020

C complained on behalf of their sibling (A) who is a Type 1 diabetic. A was admitted to hospital twice following hypoglycaemic (low blood sugar) episodes. The second admission took place via A&E. The discharge letter for A's second admission described A as being 'anorexic' (an eating disorder where individuals feel a need to keep their weight as low as possible) and having 'learning difficulties'. A, and A's family, complained about the decisions taken to discharge A, about the treatment A received at A&E, that the board did not perform tests or investigate A's condition during A's second admission and about the descriptions of A included in the discharge letter. We took independent advice from an appropriately qualified adviser. We found that that the decisions to discharge A had been reasonable, that A had been provided reasonable treatment within A&E, that A's management during the second admission had been reasonable and that the board's inclusion of the descriptions A took issue with in the second discharge letter were reasonable. We did not uphold the complaints. Related reading View Decision Report 201806843 as a PDF (24.22 KB) Updated: June 17, 2020

C complained about the care and treatment they received from the practice. C had a history of back pain and attended a consultation at the practice. During the consultation, the GP discussed a number of pain relief medications with C and a prescription was made. Approximately three weeks later, C presented to a hospital and received emergency treatment for cauda equina syndrome (a rare and serious neurological condition that affects the bundle of nerves (cauda equina) at the base of the spine). C raised concern that the practice missed signs of cauda equina syndrome when they attended the practice a number of weeks earlier. They were also unhappy with the treatment provided at the time. We received independent advice from an appropriately qualified adviser. We found that an appropriate assessment was performed during the GP consultation. Having considered the accounts of C and the practice, we concluded that the practice did not miss red flags for cauda equina syndrome. We also considered that the discussion regarding medication and prescription were reasonable. We did not uphold C's complaint. Related reading View Decision Report 201809210 as a PDF (24.26 KB) Updated: June 17, 2020

C complained on behalf of their late parent (A) regarding nursing and medical care and treatment provided to A during an admission to the Western General Hospital. We took independent advice from a nurse and from a consultant in general medicine and care of the elderly. With regard to the concerns about nursing care, we found that there were failures in relation to: risk assessment completion and accuracy personal care pressure sore prevention and management wound care continence management encouraging mobilisation person-centred care planning We upheld this aspect of C's complaint. With regard to medical treatment, we found that there was an unreasonable delay in providing antibiotics for A's urinary tract infection. However, we noted that the board had acknowledged and apologised for this failing previously. We also found that A was kept on the medical assessment unit for the entire admission of over a week, despite this unit being for maximum stays of 48 hours. Given these failings, we upheld this aspect of C's complaint. C further complained that A had a dental appointment at another hospital in the area whilst they were an in-patient, and no arrangements were made to assist A to attend this or to arrange for them to be seen by their dentist at the Western General Hospital. The board had previously acknowledged that they should have arranged for transport and for a member of staff to attend the appointment with A, apologised, and offered to compensate C for the cost of transport. We upheld this aspect of C's complaint. Finally, C complained that the board failed to identify that they were making a formal complaint. We found that C's complaints were not appropriately identified and responded to in line with the Model Complaint Handling Procedure and the board had accepted this. We therefore upheld this aspect of C's complaint.