SPSO Individual Decisions

Mrs C complained on behalf of her late relative (Mrs A) about the information given to Mrs A by doctors prior to her death in hospital. Mrs C was unhappy that Mrs A was told that she was dying, and that she was asked where she wanted to be when she died. We found that on one occasion Mrs A asked for information about her prognosis and she was provided with an honest response. We also found there was evidence of a further discussion with Mrs A regarding her future care when it was disclosed to her that she was dying. The General Medical Council (GMC) guidance states that a doctor must answer patients' questions honestly. It also states that information necessary for making decisions should not be withheld even if another relative asks the doctor to do this, unless the doctor considers that this would cause the patient serious harm. It was recorded that Mrs A had capacity and that she required to be involved in discussions about her future care. We found that the doctors were required to make Mrs A aware of her situation in order to obtain her consent. We did not uphold this aspect of the complaint. Mrs C also complained about a failure to address her complaint about an item of hers that went missing in the hospital. We did not uphold this complaint on the basis that the board had initially logged the complaint. Although the board delayed in addressing the complaint they proceeded to apologise for the fact that it had not it had been addressed sooner. Related reading View Decision Report 201804499 as a PDF (24.04 KB) Updated: October 23, 2019

Ms C complained about the way in which the board handled her complaint and what she considered to be inaccurate information in their response. Ms C highlighted a section of the response where the board detailed two tests they claimed were previously carried out. Ms C stated that these tests did not, in fact, take place. We reviewed the relevant medical records and were satisfied it was reasonable for the board to state that one of the tests took place. However, there was no evidence of the other test taking place and we concluded that the evidence provided by Ms C supported her account of cancelling the appointment for this test before it took place. It was not clear to us why this inaccurate information was included in the board's response, along with a statement that the results were normal. Therefore, we upheld this aspect of the complaint. Ms C also complained that the board's response contained inaccurate information about whether she had been diagnosed with a type of anaemia (a condition in which there is a deficiency of red cells in the blood). We found that Ms C had previously received the diagnosis. The diagnosis was subsequently questioned by other medical professionals. However, there was no evidence to confirm that this had ever been fully clarified to Ms C. Furthermore, the medical records show that the initial diagnosis, whether correct or not, continued to inform subsequent consultations. In light of this, we upheld this aspect of the complaint. Finally, Ms C complained about the board's failure to respond to her correspondence within an appropriate timescale. We considered her complaint itself to have been handled appropriately. However, we considered the board's handling of her post-complaint correspondence to be unreasonable. Although we considered that the board's complaint and feedback team were not the most appropriate place for Ms C to direct some of her enquiries, it still would have been reasonable to expect the board to respond

Mr C complained about the care and treatment he received at Ninewells Hospital after he ruptured his Achilles tendon. After he was reviewed by a consultant, conservative (non-operative) treatment of his injury was initiated. After a number of reviews, Mr C was discharged. He requested a further review as he was concerned about the progress of his recovery but no further action was taken following this review. Months after his initial injury, Mr C re-ruptured his Achilles tendon. He was reviewed the following day and it was decided that surgery was necessary. There was a delay in surgery taking place, partly due to the surgeon being on annual leave. When Mr C attended the hospital to receive surgery, he remained on the ward all day before being told in the evening that surgery would not be required. He then underwent surgery two days later. Mr C complained to us about the care and treatment he received for his initial injury, including the fact that he did not receive physiotherapy after his cast was removed. He also complained about what he considered to be unreasonable delays and communication after he re-ruptured his Achilles tendon. We took independent advice from an adviser with a background as a trauma and orthopaedic consultant (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the board had failed to provide reasonable or appropriate care and treatment to Mr C following his initial injury. Although conservative treatment was appropriate for this kind of injury, we did not consider that other treatment options were fully discussed with Mr C. In addition to this, we concluded that it was unreasonable for an appropriate form of physiotherapy not to be suggested or discussed with Mr C. We highlighted that there was no evidence to suggest that this contributed to Mr C re-rupturing his Achilles tendon. However, we concluded that there were failings in Mr C's care and treatment that had had a negative i

Mr C complained about the actions of the prison health care service. Following a medication spot check, Mr C was found to be short of antidepressant tablets, and as a result his medications were stopped with immediate effect. Mr C explained that his medication count was short as his medication safe was broken into recently and everything was taken. In response to his complaint, the board explained they would not reinstate Mr C's medication. They also stated they had made enquiries with the Scottish Prison Service (SPS) and were informed that Mr C had not reported his safe being broken into. Mr C complained to us about his medication being stopped and about the enquiries the board made into whether or not he had reported his safe being broken into. In respect of the complaint about Mr C's medication being stopped, we took independent advice from an GP adviser. We noted that, ideally, a GP would not withdraw anti-depressant medication suddenly. However, we found that this may not be the case if there is poor compliance with the requirements of the medication. We also highlighted guidance about prescribing medication in a prison setting and noted that Mr C had signed a medical agreement treatment form that acknowledged his medication may be stopped if not appropriately managed. After reviewing Mr C's medical records, we noted that an early entry had suggested potential drug misuse. Based on the review of the information available, we concluded that healthcare staff's decision to stop Mr C's medication was appropriate and their actions reasonable. Therefore, we did not uphold this complaint. In respect of the second complaint, the board acknowledged that they had not appropriately described their enquiries in their responses to Mr C. The board had spoken with SPS staff and stated that SPS had confirmed Mr C had not reported his safe being broken into. However, Mr C had, in fact, reported his safe as being broken into to SPS staff. The board accepted this er

Ms C complained about the care and treatment her late child (Child A) received from the board before their death. Child A had been diagnosed with a rare disorder that affected their development. Child A had a CT scan (a scan which creates detailed images of the inside of the body) of their brain, which identified cerebellar tonsillar descent (the lower part of the brain pushes down into the spinal canal). Ms C found out about this after Child A died. She said that Child A's behaviour had changed around that time, and she complained that the board had failed to tell her about this. We took independent advice from a consultant neuroradiologist (a specialist who uses scans to diagnose and characterise abnormalities of the central and peripheral nervous system, spine, and head and neck). We found that it had been unreasonable not to discuss the findings and the clinical implications with Ms C and, therefore, upheld this aspect of the complaint. Ms C also complained that the board had failed to provide reasonable care and treatment to Child A in relation to this. We found that it had been unreasonable not to carry out further investigations, and specifically an MRI scan, to evaluate this. We upheld this aspect of the complaint. However, the evidence suggests that it would not have been possible to prevent Child A's death at that time. Finally, Ms C complained that the board delayed in responding to her complaint. The board had acknowledged that there were delays in responding to Ms C's complaint and that she was not kept updated on the delays. We also upheld this aspect of the complaint, although we noted that the board had apologised to Ms C for this.

Mr C complained that the board's neurology (the branch of medicine concerned with the diagnosis and treatment of disorders of the nervous system) department had unreasonably delayed in diagnosing his epilepsy (a neurological disorder). Mr C was initially diagnosed with chronic fatigue syndrome (a medical condition of unknown cause, with fever, aching, and prolonged tiredness and depression) and said that he was referred to the neurology department on many occasions over a number of years but stayed with this diagnosis. Several years later, Mr C's diagnosis was changed to functional weakness and, several years after this, it was identified that he had epilepsy. Mr C considered that his epilepsy should have been identified earlier. We took independent advice from a consultant neurologist. We found that it was unlikely that the symptoms Mr C initially had were due to epilepsy. He subsequently did develop symptoms that fitted epilepsy, but it was reasonable that it took some time to make a diagnosis, as his symptoms were relatively infrequent. We found that the sequence of investigations undertaken were reasonable and that there were no failings in Mr C's care and treatment. Therefore, we did not uphold this complaint. Related reading View Decision Report 201708302 as a PDF (23.92 KB) Updated: August 21, 2019

Mrs C complained about the care and treatment provided to her father (Mr A) during two admissions to Ninewells Hospital. Mrs C complained about nursing care, medical treatment, surgical treatment, communication, and complaint handling. During our investigation we took advice from a nurse, a consultant in acute medicine, a dermatologist (a specialist in diseases of the skin, hair and nails), a plastic surgeon, and a vascular surgeon (a clinician who treats disorders of the circulatory system). In relation to nursing care, we found that there had been failings in relation to wound assessment and management; pressure ulcer prevention and management; mouth care; medication administration; adhering to fluid balance; and involving palliative care specialists. We were also concerned that the board's own investigation had not identified these failings. We upheld Mrs C's complaint about nursing care. In relation to medical treatment, we found that many aspects of this were reasonable and that dermatology care was of a very good standard. However, we identified that there was a delay of around 12 hours in Mr A receiving antibiotics at one point and on this basis, we upheld this aspect of Mrs C's complaint. We found that the surgical treatment provided to Mr A by both plastic and vascular surgery was reasonable and did not uphold this aspect of Mrs C's complaint. With regard to communication, we found that the communication between the different teams and clinicians had been of a good standard. We also found that in general, there was good communication with Mr A and his family. However, at a point when Mr A's condition was deteriorating and it was unclear how much information he could understand and retain, there was a gap in communication with his family and we considered this to be unreasonable. We therefore upheld this aspect of Mrs C's complaint. We considered the board's handling of Mrs C's complaint. We found that there were significant and unacceptable delays t

Ms C attended Perth Royal Infirmary where she was treated for a suspected stroke. Her condition improved but she was found to have sustained brain damage, leaving her with ongoing communication difficulties. Ms C complained that her symptoms were misread, and that she was misdiagnosed and mistreated for a stroke. She considered that the treatment (thrombolysis injection to dissolve a suspected clot) contributed to her brain injury and resulting speech difficulties. We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We considered that Ms C's symptoms, together with CT scan findings, supported the diagnosis of a stroke. We found that the treatment given was appropriate to the findings, and did not cause any direct side effects. Therefore, we did not uphold this aspect of Ms C's complaint. Ms C also complained about a delay in responding to her complaint, and errors and inconsistencies in the response. The board had acknowledged that the response was delayed and apologised to Ms C. They told us that they had reminded staff of the need to ensure complainants are provided with updates if deadlines are not going to be met. We recognised the complexity of the complaint contributed to the delay and, on balance, considered that the response was reasonable and proportionate. However, we did not consider that the board fully explained the reasons for the delay to Ms C and found that they did not agree a revised target timescale as they are required to do. For this reason, we upheld this aspect of Ms C's complaint but made no further recommendations. Related reading View Decision Report 201708211 as a PDF (24.12 KB) Updated: August 21, 2019

Mr C complained about the actions of a court appointed psychologist who interviewed him after he had been convicted of an offence. In their response to the complaint the board set out the reasons why the court decided to appoint the psychologist. They also explained that specific information was required from Mr C so that the psychologist could prepare a report for the court, prior to Mr C being sentenced. We found that the board investigated the complaint and clearly explained why the psychologist had to ask for the information. Therefore, we did not uphold this complaint. Related reading View Decision Report 201705215 as a PDF (23.59 KB) Updated: July 24, 2019

Mr C complained about the treatment which he had received at Ninewells Hospital. Mr C said that he had problems with a left-side perianal abscess (a local accumulation of pus that forms next to the anus, causing tenderness and swelling) and that he was taken to theatre for surgery. When Mr C recovered from the surgery he noted that there was a dressing on the right side of the anus and that the abscess on the left side was still present. Staff assured Mr C that the surgery had gone ahead as planned. Mr C attended his GP a few days later and the GP confirmed the abscess on the left side was still present. Mr C felt that the board staff had operated on the wrong side of his anus. We took independent advice from a colorectal (bowel) surgeon and a consultant radiologist (a specialist in the analysis of images of the body) and found that Mr C's records showed there was some confusion over the position of the abscess. Examination prior to surgery showed the problem area was identified on the left side and although the doctor who conducted the examination was present at the operation, surgery was carried out on the right side. The doctor did not raise their concerns with the operating consultant. We also found that international guidance states that to reduce the possibility of surgery being performed at the wrong site then the planned site should be marked. This did not happen in Mr C's case and although there was an area of concern on the right side, the area complained about by Mr C was on the left side. Therefore, we upheld the complaint.

Miss C complained to us that the medical practice had failed to provide her with appropriate care and treatment. She had attended the practice for a medical certificate following her recent attendance at A&E where she was diagnosed with a fractured finger and had her fingers strapped. Miss C said that the practice failed to manage her care appropriately in liaising with hospital staff and delayed making a referral to the hand clinic. Related reading View Decision Report 201805197 as a PDF (23.51 KB) Updated: June 19, 2019

Mr C complained that his stoma reversal surgery (a surgery to reconnect the bowel) was delayed because of his mental health. We took independent advice from a consultant colorectal (bowel) surgeon. We found that the surgeon acted unreasonably in failing to seek specialist advice from the mental health team when initally considering Mr C for surgery. In addition, we found that the surgeon did not respond when advice from the mental health team was offered. Mr C's maximum waiting time for treatment under the requirements of the Patients Rights (Scotland) Act 2011 was exceeded by ten months. There was no evidence that consideration was given by the board to arranging treatment by another provider or if any decision was made that this would not be an efficient and effective use of healthcare resources. We concluded that there was an unreasonable delay in the stoma reversal surgery going ahead, and upheld the complaint.

Mr C complained about the information which a GP entered on a form for Employment Support Allowance (ESA). The GP had included historical information in Mr C's medical records, which Mr C felt was not relevant. We took independent medical advice from a GP. We found that although the information was contained in Mr C's medical records, it was not relevant to the reasons why Mr C was unable to work at that time. The form does not ask for a summary of a patient's past medical history but rather about the patient's current medical conditions which may be a barrier to them being fit for employment. We upheld the complaint.

Mrs C complained on behalf of her husband (Mr A) regarding the delay in reaching a diagnosis of prostate cancer during consultations at Perth Royal Infirmary. In response to Mrs C's complaint, the board explained that a number of factors had contributed to the time taken to diagnose Mr A. The board said that Mr A's symptom pattern was unusual, and investigations were initially performed to rule out bladder and kidney cancer. Mrs C was unhappy with this response and brought her complaint to us. We took independent advice from a consultant urologist (a specialist in the study or treatment of the function and disorders of the urinary system). We found that it was reasonable of the board to first exclude the possibility of bladder or kidney cancer before investigating the possibility of prostate cancer. We also found that the department had carried out appropriate tests prior to Mr A being reviewed by the consultant. We considered that the board had met the waiting time targets and did not uphold Mrs C's complaint. Although we did not consider that the delay in diagnosis was unreasonable in this case, we gave detailed feedback to the board regarding areas for potential improvements in practice. Related reading View Decision Report 201705936 as a PDF (23.93 KB) Updated: May 22, 2019

Ms C complained about the care provided to her late mother (Mrs A) by the practice. Mrs A had attended the practice on a number of occasions with chest pains, confusion, arm weakness and sight problems. Mrs A also had a history of high cholesterol (a fatty substance found in the body that can increase risk of health conditions) and a family history of heart problems. Mrs A later died at home and Ms C felt that the GPs involved in her care should have made earlier referrals to hospital specialists. We took independent medical advice from a GP. We found that although Mrs A had attended the practice on a number of occasions before her death, she had not reported chest pain for a period of six months and it was felt reasonable that the staff had assumed her previously reported symptoms had resolved. During previous consultations with GPs they had considered a number of diagnoses and prescribed appropriate medication for the symptoms which were reported. There were also attendances at hospital where scan results were reported as being normal. Therefore, we did not uphold Ms C's complaint. However, we provided feedback to the practice that on one occasion, there was a need to make a referral to cardiology for further investigation and to provide Mrs A with safety netting advice. While there was no evidence that this would have prevented Mrs A's death, it may have led to an earlier diagnosis of heart problems and allowed treatment options if required. Related reading View Decision Report 201800557 as a PDF (24.08 KB) Updated: May 22, 2019

Mrs C complained about the treatment which she received at Ninewells Hospital. Mrs C had been receiving iloprost infusions (intravenous medication) for a number of years for her medical conditions which included Raynaud's disease (numbness in fingers or toes). However, the board had changed the criteria for iloprost infusions and advised Mrs C that the infusions would stop. Mrs C felt that this was unfair as the treatment had provided her with relief from her symptoms. We took independent advice from a consultant physician and rheumatologist (a doctor who specialises in the diagnosis and treatment of rheumatism, arthritis, and other disorders of the joints, muscles, and ligaments). We found that the criteria followed by the board in relation to iloprost infusions was reasonable and that while Mrs C may have benefitted from the treatment, there was no clinical evidence that this was the case. We also found that the board had offered to refer Mrs C to another health board who would offer the treatment as a temporary measure. The board also suggested reasonable alternative treatment options and were continuing to do so. Therefore, we did not uphold the complaint. Related reading View Decision Report 201708281 as a PDF (23.92 KB) Updated: April 17, 2019

Ms C complained to us about the care and treatment her son (Mr A) had received at Ninewells Hospital. Mr A was admitted to the Intensive Care Unit (ICU) with pneumonia (an infection of the lungs) and died within a month of his admission. In particular, Ms C complained that there was a delay in referring Mr A for surgery to treat his pneumonia. We took independent advice from a consultant in intensive care medicine. We found that there were no failings in the management of Mr A's pneumonia and that his treatment was reasonable and appropriate. Ms C also complained that Mr A was kept awake during his time in the ICU, even though he had mental health issues and he was experiencing alcohol and nicotine withdrawal. We found that Mr A's level of sedation was assessed appropriately on a daily basis and that he was given a combination of sedative medication that was appropriate for his individual needs. However, we found that in future, the board may wish to consider the use of nicotine patches for patients withdrawing from nicotine. Ms C raised concerns that there were delays in treating Mr A's diarrhoea. We found that he was appropriately investigated for any underlying infection and in the meantime, his diarrhoea was managed appropriately through the use of a flexiseal device (a bowel movement management device). We considered that the care and treatment Mr A received was reasonable and did not uphold Ms C's complaint. Related reading View Decision Report 201707309 as a PDF (24.02 KB) Updated: April 17, 2019

Mr C complained about the treatment he received from the board for pain in his thigh. Mr C said that he attended Perth Royal Infirmary and Ninewells Hospital over nearly a three year period for treatment for his condition and was seen by three different consultant vascular surgeons (a specialist in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels). Mr C said he was not satisfied with the treatment suggested by the consultants and was subsequently seen and assessed by a surgeon at a private hospital, who carried out treatment which cured the pain in Mr C's thigh. We took independent medical advice from a consultant vascular surgeon. We found that Mr C's treatment by the board was reasonable and found no failings in the treatment offered. Therefore, we did not uphold this part of Mr C's complaint. Mr C also complained that the board failed to provide him with an adequate response to his complaint. We found that aspects of the board's response to Mr C's complaint did not appear to match with the evidence in the medical record and the response also failed to answer all Mr C's questions at the end of his letter of complaint. Therefore, we upheld this part of Mr C's complaint.

Mrs C complained that certain risks associated with knee replacement surgery she underwent at Ninewells Hospital had not been explained to her when she consented to the operation. She also complained that the wrong size of implant was used and that cement had leaked and caused nerve injury. Mrs C underwent additional surgery a couple of days later to remove the cement. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the recognised risk of some complications were not documented as having been explained to Mrs C in line with the General Medical Council's consent guidance. We considered this was unreasonable and upheld this aspect of Mrs C's complaint. Whilst we could not say for certain what caused Mrs C's nerve damage (a recognised risk of surgery that was explained to her during the consent process), we considered it was unlikely to be related to the cement leakage. However, we were concerned about actions of staff in relation to the sizing of the implants and the lack of experienced staff present in the theatre at the time of implantation. Therefore, we upheld this aspect of Mrs C's complaint.

Mr C complained that the practice unreasonably removed him from the patient list. Mr C had been in correspondence with the practice about matters not connected with his NHS treatment. Mr C received a letter from the practice in which the suggestion was made that perhaps it would be for the benefit of all concerned that he should move to another GP practice. Mr C was dissatisfied with the practice letter and wrote back to them asking for more clarification. He then received a further letter from the practice advising him that they had requested that the health board remove him from their patient list due to a breakdown in the relationship between himself and the practice. Mr C complained about his removal from the list and the fact that he was not given any specific information about why he was removed. We took into account the contractual regulations and relevant guidance regarding the removal of patients from the practice list. This sets out that, other than in cases involving violence or aggression, a patient whose behaviour is giving cause for concern should be given a written warning informing them that they will be removed from the practice list if they do not alter their behaviour. The warning should last for 12 months. While the practice did have concerns about Mr C's correspondence, staff did not formally bring them to Mr C's attention in line with the regulations and guidance and, therefore, he was unaware of the practice's concerns. We upheld the complaint.

Mrs C complained about the treatment she received at an appointment with a gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines) at Ninewells Hospital and the response to her subsequent complaint. Mrs C said the doctor failed to properly investigate her condition given her symptoms/medical history and that there were failings in communication. We took independent advice from a specialist in gastroenterology. We found that there were failings in relation to documenting Mrs C's medical history and this meant she was left with the impression that the doctor did not take her symptoms seriously, especially her neurological symptoms. While we note not everything that would have been discussed was in the consultation records, we determined that the standard of medical care was not reasonable and this led to a breakdown in the relationship with Mrs C. We upheld this part of the complaint. In relation to complaints handling, we found that the board's response to the clinical issues raised was reasonable based on Mrs C's medical records. Therefore, we did not uphold this part of the complaint.

Ms C, an advocacy worker, complained on behalf of her client (Ms A) about the care and treatment provided by the practice. Ms C complained that there had been unreasonable delays in the diagnosis of Ms A's bladder cancer and that a urology referral should have been made earlier. We took independent advice from a GP. We found that the referral to urology (the branch of medicine that specialises in the male and female urinary tract, and the male reproductive organs) had been made at the appropriate point and that the care provided to Ms A was reasonable for the symptoms she reported across the period covered by the complaint. We did not uphold Ms C's complaint. Related reading View Decision Report 201800504 as a PDF (23.66 KB) Updated: January 23, 2019

Mr C complained that the board delayed in providing his late wife (Mrs A) with a diagnosis of pancreatic cancer. He said that, had Mrs A been diagnosed sooner, her care and treatment may have been different and she could have had a better quality of life. In their response to Mr C's complaint, the board acknowledged a delay in diagnosis and apologised, but they said that Mrs A's illness had been difficult to detect and that her symptoms had been vague. They said that their delay had not affected Mrs C's outcome. We took independent advice from consultants in radiology (a doctor who uses medical imaging such as x-rays, ultrasounds and scans) and oncology (a specialist in the study and treatment of tumours). We found that, while Mrs A had three scans, it was not until after the third scan that her diagnosis was made. However, we confirmed that her symptoms had been subtle and that there could be up to a 20 percent failure rate in detection. We did not uphold the complaint. However, we made a recommendation as the delay had not been without consequences. Had Mrs A's illness been picked up earlier, then she would have had earlier access to palliative care (end of life care) which may have made her final months easier to bear. We considered that there had been an insufficient recognition of this. Mr C also complained that the board delayed unreasonably in responding to his complaint. We found that the board had taken too long to respond to Mr C's complaint, and so we upheld this aspect of the complaint.

Mrs C complained that the dental treatment she received was unreasonable. Mrs  C had been a patient of the dentist for 20 years but received a second opinion from another dentist and was told that she had extensive gum disease. Mrs C was concerned that she was never informed of this and that the treatment she had received was inappropriate. Mrs C also complained that the dentist unreasonably communicated with her about the health of her mouth and that they provided an unreasonable response to her complaint. We took independent dental advice. We found that the patient notes recorded were very limited, with little information about the ongoing overall health of Mrs C's mouth or the investigations or treatments that occurred over the 20 year period. We also found no record of a Basic Periodontal Examination (BPE - a check on gum health that is required to take place at every six month exam). In relation to the dentist's communication with Mrs C, we found that there was little evidence in the dental records that the dentist adequately informed Mrs C about the health of her mouth over the 20 year period. We also found that the response to Mrs C's complaint included inaccuracies and comments that were not supported by the dental record and failed to signpost Mrs C to us at the end of the complaints process. We upheld all of Mrs C's complaints.

Mr C and Ms C complained about the care and treatment provided to their late son (Mr A) and about the practice's response to their complaint. Mr A had a history of mental ill-health and attended his GP practice concerned about a deterioration in his mental health. Shortly after his last attendance at the practice, Mr A completed suicide. Mr C and Ms C were concerned that the GP who cared for Mr A failed unreasonably to recognise that he was at significant risk of suicide and refer him immediately for psychiatric in-patient care. We took independent advice from a GP adviser. We found that the standard of medical care and treatment provided to Mr A in the weeks leading up to his death was reasonable and that his death could not have been predicted or avoided by the GP. We also found that the practice responded to Mr C and Ms C's complaint reasonably. We did not uphold either complaint. Related reading View Decision Report 201706197 as a PDF (11.01 KB) Updated: December 2, 2018