SPSO Individual Decisions

Mrs C complained on behalf of her late husband (Mr A) that the Royal Infirmary of Edinburgh Hospital failed to call Mr A to a follow-up review appointment with the cardiology department. Mr A had been diagnosed with heart disease. He attended an out-patient appointment and saw a consultant cardiologist. During that appointment, it was agreed that Mr A should be reviewed two years from then. Some years later, Mr A collapsed. An ambulance took Mr A to hospital, but he died on arrival. On becoming aware that Mr A had not attended his follow-up appointment with cardiology, Mrs C wrote to the board to ask why he had not been called back to the follow-up appointment as agreed. The board said that Mr A had been asked to make a follow-up appointment but nothing was noted in the system, and they were unable to explain this conclusively. Mrs C complained about the board's failure to call Mr A in for his review appointment. She said that the appointment system seemed flawed and there needed to be a backup system in place so no one else missed an important appointment. We found that at the time when Mr A was advised to make a review appointment, all patients were advised during their consultation if and when a follow-up appointment was required. The patient would be asked to book an appointment accordingly at the reception desk. Once the appointment was booked, a letter was sent out confirming the date and time of the appointment. No further letters or reminders were sent. It was the patient's responsibility to remember to attend the appointment. The board told us that having reflected on Mr A's case, they acknowledged that there were failings in the appointment process. They told us that going forward, when staff typed the clinic outcome letter, they would now check that any requested follow-up appointments had been made. If an appointment had not been made, staff would contact the out-patient department requesting that the appointment be made and confirmation se

Mr C attended the Western General Hospital after he experienced seizures. They carried out scans, which showed a lesion (an abnormal growth) in his brain. Mr C complained that there was a delay in diagnosing that it was brain cancer, as medical staff initially thought that the lesion was an abscess (a collection of infected fluid). We took independent advice from a consultant oncologist (cancer specialist). We found it was reasonable that Mr C's lesion was thought to be an abscess, given the results of the scans and his medical history. We found that it was good practice that they also tested the lesion for cancer. We did not uphold this aspect of the complaint. Mr C also complained that when cancer treatment options were discussed with him, he was not given appropriate support. In addition, he complained that there was a delay in telling him about fertility options before he started his cancer treatment. We found that Mr C had appropriate support from the multidisciplinary team and his family when treatment options were discussed with him. We also found that he was given appropriate written information about fertility options. Therefore, we did not uphold these aspects of the complaint. Related reading View Decision Report 201803683 as a PDF (23.88 KB) Updated: August 21, 2019

Mrs C complained about the treatment provided to her husband (Mr A). Mrs C said that the board unreasonably removed Mr A's right kidney and ureter (the duct by which urine passes from the kidney to the bladder) on the basis of a diagnosis of cancer. We took independent advice from consultants in urology (the medical specialism that deals with the male and female urinary tract, and the male reproductive organs) and pathology (the study of disease). We found that there were failings in relation to record-keeping which we drew to the board's attention. We also found that there had been a delay in the surgery being carried out which the board had apologised for. However, we found the investigations carried out which led to the diagnosis of cancer were reasonable. We also found that the biopsies (tissue samples) taken in this case were appropriately interpreted at the time and that a mistake had not been made. Therefore, we did not uphold the complaint. Mrs C also raised concerns about the Significant Adverse Event Review (SAER) which had been carried out. We found that the SAER carried out was reasonable. We found that a comprehensive review of the case was carried out, and failings in the consenting process were recognised. We also found that there had been a thorough external review of the pathology slides and recommendations made for improvements. We did not uphold the complaint. Related reading View Decision Report 201801028 as a PDF (24.01 KB) Updated: August 21, 2019

Mr C complained that the board failed to provide reasonable care and treatment for his foot, and that the board did not respond to his complaint appropriately. Mr C underwent surgery to address a bunion (a type of bony lump that forms on the side of the foot) at St John's Hospital. Mr C experienced problems after his operation, and had further surgery on the same area approximately four years later. At this time, Mr C was noted to have septic arthritis (inflammation of a joint caused by a bacterial infection) and a procedure was performed to wash out the joint and remove infected tissue. Mr C's problems continued to persist, and he required further surgery the following year. We took independent advice from a consultant podiatric surgeon (a clinician who diagnoses and treats abnormalities of the foot). We noted that Mr C had presented with a foot that was difficult to correct surgically. While there was a lack of correction after the initial surgery, we did not conclude that this was an unreasonable failing by the board. Mr C also had concerns about the second procedure. We concluded that this had been performed reasonably. However, we noted that Mr C's foot wound had been slow to heal following the procedure and he had received extensive antibiotic treatment. In these circumstances, a post-operative x-ray should have been performed to determine whether there was evidence of spreading infection. An x-ray was not performed and we concluded that this was unreasonable. On balance, we upheld this aspect of the complaint. Finally, Mr C raised concerns about the board's handling of his complaint, stating he had anticipated a more compassionate response. We found that the board's complaint response acknowledged the problems Mr C experienced appropriately. We also noted the board had not complied with the timescale under their Complaints Handling Procedure. Therefore, we upheld this aspect of the complaint. We noted that the board had acknowledged this failin

Mr C complained on behalf of his partner (Ms A) who had been diagnosed with lung cancer. She also suffered from other illnesses. Ms A had experienced shortness of breath and fatigue. It was established that she had anaemia and was referred to St John's Hospital for a blood transfusion by the oncology team at another hospital. When Ms A arrived at St John's Hospital there were no beds and before being transferred to the Medical Assessment Unit (MAU) she spent seven hours on a temporary bed in the corridor. She was eventually transferred to MAU and was given a blood transfusion later that night. Later, she was moved to an observation ward and the next day she was discharged home. A few days later, Ms A was unwell again and she was admitted to St John's Hospital once more. Again, she spent a number of hours in a corridor before being admitted to the MAU. Mr C complained that these events were unacceptable given Ms A's serious illness. The board recognised that the situation had not been ideal but said that on both occasions the hospital had been extremely busy. They apologised but said that they could not give assurances that the same situation would not occur again. They confirmed that Ms A had been treated in accordance with the cancer treatment helpline advice. They added that St John's Hospital had asked the referring hospital whether the transfusion could be deferred the first time Ms A attended hospital but were told that it could not. We took independent advice from consultants in general medicine and oncology (cancer). We found that although the board had no control over the number of patients arriving at the same time, it was, nevertheless, unreasonable that a cancer patient like Ms A should have had to wait so long (seven hours each time) before being transferred to MAU. We also found that there was no clinical reason why Ms A should have been given a blood transfusion late at night. For these reasons we upheld the complaint. Although Mr C had

Mr C complained that the board had failed to provide a reasonable standard of psychiatric (the branch of medicine that deals with mental illness) care and treatment to his wife (Mrs A) before her death. Mrs A had been diagnosed with a brain tumour. The psychiatrist responsible for her care considered that she had a depressive illness, but Mrs A's family disagreed with this. Mr C also complained about the comments the psychiatrist made at a consultation. We took independent advice from a consultant psychiatrist. We found that the psychiatric care and treatment provided to Mrs A had been reasonable. However, we considered that some of the language the psychiatrist used was unhelpful and left the family feeling criticised. We considered this had been unreasonable and upheld this aspect of Mr C's complaint. Mr C also complained that the board failed to handle his complaint reasonably. We found that although Mr C had clearly expressed dissatisfaction in an email, the board had failed to record this as a complaint or to contact Mr C for clarification. When Mr C subsequently made a further complaint, the board then delayed in responding to this. Therefore, we also upheld this aspect of Mr C's complaint.

Mr C complained about the care and treatment he received at the Royal Infirmary of Edinburgh. He attended A&E after experiencing pain in his back and leg. Mr C was assessed by the on-call orthopaedic (conditions involving the muscoskeletal system) doctor and an x-ray was performed. Following this, Mr C was admitted to an orthopaedic ward. He was then discharged four days following admission. Weeks later, Mr C returned to hospital and a hip x-ray was performed. Investigations over the following days identified that Mr C had a pathological hip fracture and advanced prostate cancer. Mr C underwent a hip replacement procedure and was referred to the uro-oncology (the diagnosis and treatments of tumors of urinary systems) service. Mr C complained about the delay in accurately diagnosing his condition and that he was unreasonably discharged from hospital during the first admission. We took independent advice from a consultant orthopaedic surgeon. We were critical that the board were unable to provide the in-patient orthopaedic notes for Mr C's first admission, other than the summary of ward rounds. We found that the investigations performed following Mr C's initial presentation to the board were inadequate. We found that a hip examination and hip x-ray should have been performed given the examination findings. We considered it was likely that the failings in this case led to a delay for hip replacement surgery, during which time Mr C continued to suffer pain from the condition. We upheld this aspect of Mr C's complaint. In the absence of the orthopaedic records for the first in-patient admission, we noted that the board were unable to demonstrate that Mr C had been safely discharged. We concluded that the decision to discharge Mr C was unreasonable and we upheld this complaint.

Mrs C complained about the care and treatment provided to her late mother (Ms A) at the Royal Infirmary of Edinburgh. Ms A had undergone treatment for early stage lung cancer, and was followed up at six-monthly intervals. Mrs C complained that at a follow-up appointment, Ms A had been told there were no signs of cancer, but a few weeks later was found to have liver cancer. Mrs C said that there was a failure to identify the spread of lung cancer and that Ms A had been given false hope. We took independent advice from a 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 an oncologist (a doctor who specialises in the diagnosis and treatment of cancer). We found that there had been a failure to identify a mass near Ms A's spine on a scan, and that this was unreasonable. However, we noted that it was unlikely that earlier identification of this would have altered Ms A's outcome. We also found that at a follow-up appointment, the clinical examination done was incomplete as it did not include examination of the abdomen. We upheld this complaint.

Ms C complained that the board unreasonably failed to discover an object left in her nasal tissue after surgery at St. John's Hospital. Ms C said that on removal of stents (splints placed temporarily inside a duct, canal, or blood vessel to aid healing or relieve an obstruction), one stent came away in two pieces. Ms C was alerted at the time that a piece of silicone stent may have been retained. Ms C continued to attend the hospital for treatment of chronic rhinosinusitis (a condition where the cavities around nasal passages (sinuses) become inflamed and swollen for a prolonged period). Sixteen months after the surgery, a scan was carried out which identified that a titanium clip had been retained in the nasal tissue. The silicone stent and titanium clip were removed at the same time Ms C was undergoing another surgery, approximately 12 months after the retained titanium clip was discovered. We took independent medical advice from a consultant rhinologist (a specialist in conditions affecting the nose). We found that the board unreasonably failed to discover and report on all elements retained in Ms C's nasal tissue after surgery. No investigations were carried out until the scan 16 months after the stents were removed, where it was found that the titanium clip was still in place. After it was discovered, it was over a year before it was removed. We found that there was an unreasonable delay in identifying the retained titanium clip. Therefore, we upheld this part of Ms C's complaint. Ms C also complained that the board failed to provide a reasonable explanation as to how an object was left in her nasal tissue after surgery. The board accepted that they had not provided a reasonable explanation. The communication regarding this issue was poor. When it was found that a titanium clip had been retained as well as the silicone stent, it was over four months before Ms C was informed of this. No explanation was provided as to why the clip was retained or w

Mr C, an MSP, complained on behalf of his constituent (Mrs A) about the decision taken by the board not to offer Mrs A surgery to her wrist. Mr C said that the board had not reached the decision based on full information. We took independent advice from a consultant plastic and hand surgeon (a surgeon who repairs or reconstructs missing or damaged tissue and skin). We found that the decision not to offer surgery was reasonable and had been made by a number of experienced surgeons together in a mutlidisciplinary setting. Therefore, we did not uphold the complaint. Related reading View Decision Report 201707407 as a PDF (23.6 KB) Updated: April 17, 2019

Ms C complained that her father (Mr A) was inappropriately discharged from the Royal Infirmary of Edinburgh. Mr A had poor balance and mobility and had expressed his concerns about his ability to cope at home. Mr A fell shortly after discharge. After a number of hours, he managed to get help and was taken back to the hospital. Mr A was kept in hospital for another month due to a suspected infection. We took independent advice from a nurse and a clinical adviser. We found that there had been a lack of discharge planning as to whether or not Mr A could safely cope at home and whether he required the assistance of carers or someone to stay with him. We also found that there were signs in the medical records which may have indicated that Mr A may have had an infection prior to discharge and that the signs were not acted upon. We upheld Ms C's complaint.

Ms C complained that the board's response to her complaint was unreasonable and contained many errors. We found that the board's response was an accurate reflection of their records of Ms C's treatment. The board explained why they could not delete entries from Ms C's medical records, and added Ms C's handwritten note to the records to reflect her view of events. The board acknowledged that they could have provided Ms C with better information and support to make informed choices about ongoing treatment, and said they were sorry for this. Ms C chose to get private treatment as she was unhappy with the treatment she had received from the board and wanted the board to pay for this. The board offered Ms C different treatment options and consultations with different doctors but Ms C declined this offer. The board's response explained why, under the circumstances, they could not pay for Ms C's private treatment. We considered that the board's response to Ms C was reasonable. Therefore, we did not uphold the complaint. Related reading View Decision Report 201800737 as a PDF (23.78 KB) Updated: March 20, 2019

Mrs C complained that the board unreasonably delayed in diagnosing secondary breast cancer. Following treatment for breast cancer, Mrs C underwent annual check-ups with a consultant surgeon where she complained of a lump and pain near her reconstructed breast (a breast that has been reshaped following a mastectomy (breast removal)). Mrs C said that these reports were not appropriately investigated. We took independent advice from a specialist in breast cancer. We found that investigations were carried out when Mrs C first reported a lump near the reconstruction and that relevant guidelines did not recommend routine mammography (x-ray of the breast) of the reconstructed site and associated axilla (underarm). We considered that the board had practised within the national recommendations and Mrs C was followed up and examined regularly. We also found that when Mrs C presented with a new lump it was investigated and treated in a timely manner. We found that the standard of medical care was reasonable and there had not been an unreasonable delay in diagnosing the recurring cancer. We did not uphold the complaint. Related reading View Decision Report 201803163 as a PDF (23.87 KB) Updated: March 20, 2019

Mr C complained that his wife (Mrs A) had undergone open heart surgery at Edinburgh Royal Infirmary when she had been due to undergo a less invasive procedure. Following surgery, Mrs A was transferred to another hospital where she died shortly afterwards. Mr C said that his wife suffered from dementia and could not have understood the decision to change the procedure or have provided informed consent. Mr C noted he had welfare power of attorney and accompanied his wife to all her appointments. Mr C said that he had not been informed about the change of procedure. Mr C also complained that Mrs A was unreasonably discharged to another hospital. Mr C felt that Mrs A would have survived if she had been treated differently. We took independent medical advice from a consultant cardiothoracic surgeon (a specialist who operates on the heart, lungs and other chest organs). We found that Mrs A's procedure was changed after an appropriate assessment of the risks of both types of surgical procedure and that it was reasonable to proceed with open heart surgery. There was no evidence that Mrs A's chances of survival were compromised by this decision. We also found that an assessment had been carried out which found that Mrs A had a mild memory impairment, however, medical staff were satisfied that she had the capacity to understand and consent to the change in procedure. We considered that this was reasonable. Therefore, we did not uphold these aspects of Mr C's complaint. In relation to the hospital transfer, we found that this was unreasonable given Mrs  A's condition. We upheld this aspect of Mr C's complaint. However, we could not determine that Mrs A would have survived if this had not taken place. In relation to the board's communication with Mr C and his family, we found that Mrs A had been in hospital for over a week prior to the procedure due to a chest infection and that Mr C had been present every day. We considered that the board should have discussed Mr

Miss C complained about the antenatal care and treatment she received when she was pregnant with her child (Baby A). Miss C also complained that the board did not communicate reasonably with her about her antenatal care and treatment. At Miss C's 20 week anomaly scan it was identified that Baby A was measuring larger than expected. Baby A was born prematurely with severe and complex needs and died a few days later. We took independent advice from a midwifery adviser and a sonography (the medical diagnostic imaging technique used to see internal organs, muscles, etc) adviser. We found that No alternative arrangements were made for bloods to be obtained as requested by Miss C's GP during one of her antenatal appointments. There were no records of: one of Miss C's antenatal appointments discussions that the midwife had with the sonographer and the consultant obstetrician (a doctor who specialises in pregnancy and childbirth) the management plan, reason for changing the management plan and the details of what was communicated to Miss C. The reason for not repeating the anomaly scan and requesting a growth scan instead was not explained to Miss C. The sonographer did not seek medical advice regarding Baby A's measurements at the time of Miss C's 20 week scan or as soon as reasonably practicable. The board identified that inappropriate comments were made to Miss C about Baby A's size. The sonographer did not communicate Baby A's measurements to Miss C at the time of her 20 week anomaly scan. Therefore, we upheld Miss C's complaints. We noted that the board had already apologised for some of these failings and had taken action to prevent these reoccurring. We asked the board for evidence of these actions and made further recommendations. Miss C also complained that the board failed to handle her complaint reasonably. We found that the board did not inform Miss C at the earliest opportunity that a Significant Adverse Events Review would result in a delay in respondin

Ms C complained about the care and treatment her husband (Mr A) had received at St John's Hospital following a suicide attempt. Ms C complained that Mr A was inappropriately given diazepam (a medicine used to treat anxiety), as it can be addictive. We independent advice from a consultant psychiatrist. We found that it might have been appropriate to have given Mr A diazepam on a short term basis but the reason for prescribing it to him was not recorded. We found that when Mr A self-discharged from the hospital, there was a failure to carry out and/or document an appropriate suicide risk assessment. There was no evidence that medical staff considered detaining Mr A. There was also no evidence that they signposted him to any other sources of support or carried out any contingency planning in case his condition or level of risk to himself changed. In addition, we found that a junior medical staff member was not able to reach a senior colleague by phone for advice. Therefore, we upheld this aspect of Ms C's complaint. We also found that the board had not handled Ms C's complaint regarding the diazepam appropriately and we made a recommendation in relation to this. Ms C also complained that there was a failure to provide Mr A with appropriate follow-up care after he self-discharged from the hospital. Mr A had been offered a follow-up appointment in two months' time. When he was unable to attend that appointment due to his poor mental health, he was offered an appointment for six months later. We found that Mr A was not given follow-up care that was appropriate to his needs, and that, in the circumstances, Mr A should have been offered an appointment within a week of him leaving the hospital. When Mr A could not attend that appointment due to poor mental health, he should have been offered a review at home. We upheld this aspect of Ms C's complaint.

Miss C complained about the care and treatment she received at the Western General Hospital. Miss C had a history of breast cancer and at a routine examination a member of staff noticed some discolouration of the skin around the breast. Miss C was told by staff that they felt she may have dermatitis (a skin condition) and an urgent referral was made to the dermatology department (the  branch of medicine concerned with the diagnosis and treatment of skin disorders). Miss C was subsequently told that she had angiosarcoma (cancer of the inner lining of blood vessels, commonly found in the skin, breast, liver, spleen and deep tissue). Miss C felt that it was unreasonable that staff had thought she had dermatitis and by referring her to dermatology there was a delay in the treatment of her returning breast cancer. We took independent advice from a medical adviser. We found that Miss C's original breast cancer had not returned and that she had developed a rare but recognised complication of breast cancer treatment, angiosarcoma. In its early stages, this can often look like dermatitis or bruising. We found that staff acted appropriately by arranging an urgent dermatology review with investigations which resulted in the correct diagnosis. There was no evidence of any undue delay in the diagnosis. Therefore, we did not uphold Miss C's complaint. Related reading View Decision Report 201802900 as a PDF (24.01 KB) Updated: January 23, 2019

Mrs C complained that the board failed to prevent her baby (Baby A) developing hypothermia (the condition of having an abnormally and typically dangerously low body temperature) in the hours after their birth at the Royal Infirmary of Edinburgh. We took independent advice from a midwife. We found that Mrs C and hospital staff had different recollections of what was said about the reason why Baby A developed hypothermia. The medical records noted the likely reasons, such as possible infection or due to medication given to Mrs C during labour, but did not reach a definitive conclusion. We noted that staff gave Baby A antibiotics in line with relevant clinical guidance to ensure they recovered. We did not find evidence that the board acted unreasonably. Therefore, we did not uphold this aspect of Mrs C's complaint. Mrs C also complained that the board's response to her complaint was unreasonable. Mrs C was particularly concerned that Baby A's hypothermia could have developed because the birthing centre was too cold. We found that the board failed to investigate this specific part of Mrs C's complaint, and did not respond to her about it, despite having noted it in their acknowledgement letter. Therefore, we upheld this aspect of Mrs C's complaint.

Ms C complained about the treatment she received at the Royal Infirmary of Edinburgh. Ms C had a contraceptive device fitted and a number of months later she developed a number of symptoms including body aches, severe period pain, headaches and joint pain. Ms C only has one fallopian tube (either of a pair of tubes along which eggs travel from the ovaries to the uterus) and understood that the device should not have been fitted in patients with only one fallopian tube. Ms C complained about this and that she was not given anaesthetic during the procedure. We took independent advice from a consultant gynaecologist (a doctor who specialises in the female reproductive system). We found that although the information about the device does caution against patients with only one fallopian tube, it does not give specific reasons why this is so. There was no clinical reason why the device could not be used in Ms C's circumstances. We also found that adequate consent was obtained along with an explanation of the possible side effects which could be encountered. There was also no requirement for an anaesthetic as it was not a surgical procedure. Therefore, we did not uphold Ms  C's complaint. Related reading View Decision Report 201804414 as a PDF (23.94 KB) Updated: January 23, 2019

Mr C complained about the lack of treatment which he received at St John's hospital. He had been referred to the mental health service by his GP for an assessment. Mr C complained that the board failed to carry out appropriate mental health assessments. He was also dissatisfied that the board would not arrange a further medical opinion. We took independent advice from a consultant psychiatrist (a specialist in the diagnoses and treatment of mental illness). We found that Mr C was seen on two occasions by a doctor in training who discussed Mr C with a supervising consultant psychiatrist. There was evidence that thorough assessments were carried out on both occasions which resulted in a reasonable management plan. Mr C was then assessed by another consultant psychiatrist, who again carried out an appropriate assessment in view of Mr C's reported symptoms. The clinicians reasonably concluded that Mr C was not suffering from a diagnosable mental health disorder. We considered the assessments to be reasonable and did not uphold this aspect of Mr C's complaint. In relation to a further medical opinion, we noted that Mr C had been assessed twice by a trainee doctor, under supervision of a consultant psychiatrist, and also by an additional consultant psychiatrist. Therefore, we found that it was not unreasonable that the board did not offer Mr C a further medical opinion. We did not uphold this aspect of Mr C's complaint. Related reading View Decision Report 201802106 as a PDF (23.96 KB) Updated: December 19, 2018

Ms C complained about matters related to the care and treatment of her son (Mr  A), who had been an in-patient at the Royal Edinburgh Hospital. Mr A had a diagnosis of schizophrenia (a long term mental health condition that causes a range of different psychological symptoms) and had been subject to a Compulsory Treatment Order (an order that allows professionals to treat a person's mental illness). During the in-patient admission, the local authority's social work staff were working towards finding a suitable supported accommodation vacancy for Mr A, with input from clinicians. Ms C firstly raised concerns that board staff had contributed to delays in progressing Mr A towards discharge. We received independent advice from a consultant psychiatrist. We found that the clinical team reasonably fulfilled their responsibilities to identify a suitable accommodation placement for Mr A. We did not uphold this complaint. On a particular occasion during the admission, Mr A did not return to the hospital following an agreed one hour period of leave. The hospital notified the police the next morning and informed Ms C later that day. Ms C raised concerns that the board failed to apply the correct risk level to Mr A's absence. We did not find evidence that the board had acted in accordance with the procedure for missing persons that was in use at the time. We upheld this complaint, however, we noted that the board had since revised and improved this procedure. We also noted that the board's complaint investigation referred to the relevant procedure but did not identify that staff had not complied with this. We were critical of the complaint investigation and made a recommendation in relation to this. Ms C was also unhappy with the level of communication with her during the time Mr A was absent from the hospital. In response to her complaint, the board acknowledged that there had been a delay in contacting Ms C to notify her. We found limited documentation of communic

Mrs C complained about the care her mother (Mrs A) received at St John's Hospital. Mrs C complained about the number of ward moves that Mrs A experienced. Mrs A had dementia and Mrs C said that the number of ward moves caused Mrs A to become disorientated. Mrs C also complained about the personal care that Mrs A received and the communication from nursing staff. We took independent advice from a nursing adviser. We found that: • the number of ward moves that Mrs A experienced was unreasonable in view of her reduced cognitive function and delirium (sudden confusion) • the board had failed to keep adequate records regarding the risk assessment and decision making for Mrs A's ward moves and how Mrs A and her family were informed of the ward moves • the board failed to adequately assess and document Mrs A's care needs. In particular there was no care plan in place to cover Mrs A's personal hygiene needs • a “Getting to Know Me” document was not in use during Mrs A's admission to St John's Hospital. In light of the above we upheld Mrs C's complaint.

Mr C complained on behalf of his friend (Mrs A) about the care and treatment she received at the Western General Hospital. Mrs A was referred to neurosurgery (the branch of medicine that deals with the anatomy, functions, and disorders of nerves and the nervous system) and was found to have signs of wear and tear to the discs in her cervical spine (the soft cushions of tissue between the vertebra), which was causing compression (squeezing) to her spinal cord. A scan showed that this had caused mature damage in one area of her spinal cord. Mrs A was referred for surgery to prevent her condition from worsening. Specifically, an anterior cervical discectomy and fusion (where disc material is removed to reduce spinal cord compression). After her surgery, Mrs A experienced weakness and reduced mobility. The board carried out a further scan, which found that Mrs A had mature damage in a second area of her spinal cord. Mr C complained that the surgery went wrong and that Mrs A was never told that surgery could make her condition worse. We took independent medical advice from a consultant neurosurgeon. We found that Mrs A was appropriately referred for surgery, as she had signs and symptoms of spinal cord compression. However, we found that there was insufficient evidence that the risks of surgery, and of not having surgery, were clearly explained to Mrs A in the consent process. We also found that as Mrs A signed the consent form on the morning of the surgery, she was not given a reasonable timeframe to consider the risks listed on it. We considered that the surgery might have caused Mrs A's new mature spinal cord damage, given the steps involved. However, we also found there were signs that Mrs A's spinal cord compression had worsened in the months before her surgery. Therefore, we were unable to definitely conclude that the surgery had caused her new mature spinal cord damage. Nevertheless, we found that the possibility of this happening and the other risks i

Ms C complained about a number of aspects of the mental health care and treatment provided to her by the board over a number of years. In particular, Ms  C felt that the board failed to provide her with appropriate crisis support and appropriate psychiatric treatment. Ms C also complained that their communication around these matters was unreasonable and that their handling of her complaint was poor. We took independent advice from a mental health nurse and a psychiatrist. We found that some of the crisis care provided to Ms C was reasonable, however, there were a number of areas where care could have been improved. We were not satisfied that the board had taken appropriate action, following an upheld complaint about staff attitude, to ensure that this issue did not impact on Ms C's access to the service in future. The mental health adviser noted that an out-of-hours care plan was not reviewed within the appropriate scheduled timescale and that the board held conflicting information in relation to Ms C's ability to access other services. Therefore, we upheld this aspect of Ms C's complaint. In relation to Ms C's psychiatric treatment, we found that the care provided by a psychiatrist and a psychologist was reasonable. The psychiatric adviser noted that both the psychological treatment that Ms C received, and the administration of medication, was appropriate. Therefore, we did not uphold this aspect of Ms  C's complaint. Additionally, Ms C felt that the board's communication around these matters had been poor as she had been unreasonably excluded from meetings where her care was being discussed. The psychiatric adviser considered that the board followed their usual and appropriate practice in relation to meetings held about a patient. We did not find evidence to suggest that Ms C had been unreasonably excluded from these meetings and that the boards communication with her was unreasonable. Therefore, we did not uphold this aspect of Ms C's complaint. Final

Mrs C complained to us about the nursing care and treatment her mother (Mrs A) had received at the Western General Hospital after she had fallen and injured her head. Mrs C, who had power of attorney for Mrs A, was concerned about the nursing care she received. Mrs C had particular concerns about her falls care and monitoring; pain relief; personal care and hygiene; and the communication with Mrs A. Mrs C also had concerns about a lack of response to Mrs A's weight loss and to her swollen leg. We took independent advice from a nurse. We found that there was a failure to prepare timely and comprehensive care plans in relation to Mrs C's care needs, and to review the ongoing effectiveness of those care plans. We found that this should have been carried out with the appropriate involvement of Mrs C and her powers of attorney but there was no evidence that this had been done. We also found that there were failings in the board's records-keeping, as there were gaps in completing care round checklists which were sometimes not completed fully. We upheld Mrs C's complaint. We noted that the board did not identify the failings we found in the nursing care provided to Mrs C. In addition, the board did not provide us with all relevant documentation at the appropriate point in our investigation. Therefore, we made recommendations in relation to their complaints handling.