SPSO Individual Decisions

C complained to the board about the treatment provided to their late relative (A) who died of a ruptured bowel. A had been in University Hospital Ayr two weeks previously with symptoms of severe pain. Staff had carried out tests and a scan, and discharged A home without follow-up. C believed that the board should have carried out more intensive investigations, which may have discovered A was still having bowel problems and provided additional treatment. The board believed that appropriate treatment had been provided. We took independent advice from a consultant in acute medicine (a specialist in the immediate and early management of adult patients with a wide range of medical conditions who present in hospital as emergencies) and 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 that staff at the hospital provided a reasonable standard of treatment based on A's reported symptoms. We also found that it was not unreasonable to discharge A home with antibiotics based on the diagnosis of pyelonephritis (kidney infection) following a CT scan. Although a subsequent CT scan carried out on readmission showed evidence of infarct (a small localised area of dead tissue resulting from failure of blood supply) which might have been evident on the original scan, it was not unreasonable to have diagnosed pyelonephritis following the original scan. We therefore did not uphold the complaint. Related reading View Decision Report 202102504 as a PDF (24.5 KB) Updated: July 20, 2022

C is an advocate who complains on behalf of A. A has a brain injury which impacts on their daily living tasks and functioning. C complained that A received poor treatment from their GP practice and that there were delays in making referrals for specialist input following a fall down stairs which made A’s existing health conditions worse. We took independent advice from a GP adviser. We found that A's treatment had been reasonable. We noted that A had come to the practice with a number of previous unresolved problems. We considered that A's new GPs were right to be mindful that A's neurological symptoms had already been assessed as 'functional', meaning they had no known physical cause. C also complained about repeated prescription of antibiotics. We found that this did not seem excessive given the poor general state of A's health and that referrals for specialist input had been appropriate. Therefore, we did not uphold C's complaints. Related reading View Decision Report 202008029 as a PDF (24.23 KB) Updated: July 20, 2022

C's parent (A) had been treated for kidney cancer and then developed cancer of the bladder. They were receiving dialysis three times a week. The GP practice in this case is managed by the board. A developed back pain and called out a GP, who prescribed dihydrocodeine (an opiate painkiller). They remained in pain the following day and called out another GP, who prescribed diazepam (a medicine used to treat anxiety) and told A to double the dose of dihydrocodeine. After increasing the dosage of dihydrocodeine A became drowsy and unresponsive. They were admitted to hospital and transferred to the Intensive Care Unit for dialysis but did not improve and died of multiple organ failure, and presumed ischaemic bowel disease (lack of blood flow to the intestine). Their death certificate also recorded end stage renal failure and a trial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). C complained that A's GPs should not have prescribed these medications because of A's renal failure. We took independent advice from a GP adviser. We found that each GP had assessed and treated A appropriately, taking into account their presenting symptoms and existing health concerns. We noted that A's treatment options were significantly limited by their renal failure. We found that it was appropriate to prescribe opiates, as pain control was the objective and A was due dialysis which would significantly reduce the risk of toxicity. We found that although the medications had a sedative effect, they did not cause A's subsequent death. We found some shortcomings in documentation but were satisfied that the board had addressed this matter. We found that the GP treatment provided to A was of a reasonable standard and therefore did not uphold this complaint. Related reading View Decision Report 202003195 as a PDF (24.68 KB) Updated: June 22, 2022

C has Asperger's Syndrome (a form of autism, in which people may find difficulty in social relationships and in communicating) / Autistic Spectrum Disorder and a diagnosis of chronic fatigue and Functional Neurological Symptom Disorder (symptoms in the body which appear to be caused by problems in the nervous system but which are not caused by a physical neurological disease or disorder). They were referred by their GP to neurology (specialists in the nervous system) to explore a possible neurological basis for their pain symptoms. C raised a number of concerns about this consultation. C complained that no meaningful assessment took place, that the conclusions were unreasonable and that the consultant neurologist wrongly stated a psychiatric opinion by stating that they had a complex personality disorder. C also noted that there were inaccuracies in the board's response to their complaint. The board responded to C's individual concerns and concluded that overall, they considered the assessment was reasonable. We reviewed the relevant medical records, evidence provided by C and took independent advice from a consultant neurologist adviser. We found that there were not any significant failings and that the assessment was of a reasonable standard, consistent with General Medical Council guidelines and that the reasons for the referral were reasonably addressed. We did not uphold the complaint. Related reading View Decision Report 202005840 as a PDF (24.45 KB) Updated: June 22, 2022

C complained about the care and treatment provided to their late spouse (A) by the practice. A died due to invasive bladder cancer and urinary sepsis (blood infection). C complained that the practice unreasonably delayed referring A to secondary care for investigation despite presenting with recurrent urinary tract infections (UTIs) that did not respond to antibiotic treatment. C considered that A's bladder cancer may have been identified earlier, and that their death avoided, had the practice referred them for investigation much sooner. The practice's position was that A had a long history of intermittent UTIs, which were usually treated with antibiotics. At one point, all of A's urine samples showed pus cells but a normal range of red cells, which was suggestive of simple UTIs. The early signs of bladder cancer such as blood in the urine were not apparent in A's case until a relatively late stage. The practice considered that abnormalities in A's blood results (increased platelet and white cell count) were caused by A's unrelated medical conditions. We took independent advice from a general practitioner adviser. We noted that patients over a certain age with recurrent or persistent UTIs (i.e. three episodes in 12 months) associated with haematuria (blood in the urine) should be referred for urgent investigation in accordance with national guidelines. In A's case, they had attended the practice three times in four months with recurrent UTIs and haematuria found on dipstick testing. At this point, we found that A should have been referred on an urgent basis in line with the guidance but that the practice did not do so for a further ten months. We found that the practice had failed to identify that A's blood results showed signs of recognised malignancy and that they had repeatedly failed to record A's clinical history and review the results of investigations performed. As such, we upheld this complaint.

A was admitted to A&E at the Royal Hospital for Sick Children with symptoms including retching, a purple rash on their leg and feeling agitated. A had a diagnosis of quadriplegic cerebral palsy (form of cerebral palsy in which all four limbs are affected), was non-verbal and received PEG feeding (passing a thin tube through the skin to give food, fluids and medicines directly into the stomach). A was subsequently admitted to hospital after assessment. A was observed in hospital and underwent a number of investigations. A gastrojejunal tube (when a thin, long tube is threaded into the jejunal portion of the small intestine) was inserted to address concerns about A's nutrition. A became increasingly distressed following the procedure and their condition deteriorated. A underwent emergency surgery where a caecal volvulus (obstruction of the bowel) was diagnosed. C complained to the board that they had missed several opportunities to diagnose and treat the bowel obstruction which was causing A's symptoms. The board produced a report detailing the history of A's care and decision making during the period. The main finding was that there were no identified failings in the care provided to A and that there was no misdiagnosis of A's condition. Dissatisfied with the board's response to the complaint, C brought their complaint to our office. We took independent advice from a paediatric gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas) and a paediatric radiologist (a specialist in the analysis of images of the body). We found that the investigations and treatment provided were appropriate. There was a delay in obtaining a CT scan, however the delay was relatively small in the context of the period of A's admission. As such, we found that the care and treatment provided to A was reasonable and we did not uphold the complaint. There were some aspects of care which we identified as being suitable to f

C complained that there had been an unreasonable delay in their late parent (A) receiving a prescription of antibiotics following a consultation with an out-of-hours GP from the unscheduled care service, operated by the board. During the consultation, the GP considered that A had developed a lower respiratory tract infection (an infection of the lungs), which should be treated with Co-amoxiclav (a type of antibiotic). However, the GP had attended the consultation without a prescription pad and did not carry the medication in their vehicle. The GP subsequently arranged for A's prescription to be faxed to a pharmacy on their return to base to be provided to A the next day. However, the pharmacy to which the prescription had been faxed was closed the following day due to a public holiday, which resulted in a delay of 48 hours before the prescription could be provided to A. In response, the board apologised that the GP had attended the consultation without a prescription pad and for the distress that this had caused A and their family. The board stated that it could not explain why the GP had attended without a prescription pad but had reminded staff in a monthly update to ensure that prescription pads were checked prior to carrying out home visits and that prescriptions were only faxed to pharmacies that could provide medication in a timely manner. The board also confirmed that it was in the process of developing a checklist system and a written policy and protocol specifying the checks that staff were required to complete at the start of each shift prior to commencing home visits. We took independent advice from a GP. We found that it had been unreasonable for the GP to attend the consultation without a prescription pad and to fail to ensure that the antibiotics A required were available to them sooner based on A's presentation at consultation. We also considered that the reminder provided by the board to staff was insufficient to ensure that a similar occurre

C and B complained about the care and treatment that their adult child (A) received from the practice. A had sought advice and treatment for a lack of energy, loss of libido and difficulty gaining weight. They were referred to the metabolic unit in hospital and, subsequently, to an adult eating disorders service. A had been diagnosed with a hormonal deficiency and a number of potential causes for their symptoms were considered. However, A and their family were concerned about the practice's clinical management of A's condition and the lack of a clear diagnosis or effective treatment plan. A subsequently completed suicide. Following a meeting and written correspondence with the practice, C and B remained dissatisfied with a number of aspects of the treatment A received. We took independent advice from a GP. A's case was complex and whilst with hindsight it was clear that A had an underlying mental health condition, a physical cause for their symptoms could not be ruled out. We were satisfied that the practice arranged numerous tests and investigations to explore a physical cause of A's symptoms. Additional tests were carried out by third parties and we found that the practice appropriately reviewed these and communicated clearly with A as to the results, their significance and the next steps in terms of finding a clear diagnosis. We found that the practice considered at an early stage that there may have been a mental health element to A's condition. However, A was not keen to pursue this. We were satisfied that it would have been inappropriate in the circumstances for the practice to push further investigations into A's mental health. We were also satisfied that the practice communicated well with secondary care specialists and managed A's overall diagnostic pathway reasonably. Therefore, we did not uphold these aspects of C and B's complaint. However, we were critical of the practice's communication with C and B. It was A's clear intention that they be

C complained about the care and treatment provided to their late parent (A) when they were admitted to hospital for investigations of lung cancer. A had an out-patient appointment for a CT scan, however, the day before this appointment, A was admitted to hospital due to increased haemoptysis (coughing up of blood). There was a delay in performing the CT scan due to miscommunication between the clinical team and radiology, which the board have acknowledged. When A was taken for the scan, they suffered a massive haemoptysis and a subsequent cardiac arrest and died. C complained about the communication failures which led to a delay in arranging the CT scan and that insufficient efforts were made to resuscitate A. To investigate C's complaint, we reviewed the clinical records and sought independent advice from a consultant radiologist (a specialist in the analysis of images of the body). Our investigation found that while there were communication failures in arranging A's CT scan on an in-patient basis, we did not consider the delay caused to be unreasonable as A's condition was stable and there were no further episodes of haemoptysis. We did however, uphold the complaint on the basis that there were communication failings. We made no recommendations due to action already taken by the board. Our investigation also found that reasonable attempts were made at resuscitation when A suffered the cardiac arrest. We did not uphold this aspect of the complaint. Related reading View Decision Report 202008128 as a PDF (24.42 KB) Updated: May 18, 2022

C complained about delays in treatment that was meant to be provided to their late spouse (A). They told us that A had been referred to the board from another area for heart surgery, but that this took so long to arrange, A's condition deteriorated to a point that surgery was no longer viable and they subsequently died. C was also concerned about the board's handling of their complaints about the matter. We took independent advice from a cardiology consultant (a specialist in diseases and abnormalities of the heart). We found that, while there were delays in arranging scans, these were the responsibility of the board in A's home area, so Lothian NHS Board could not be said to be responsible for this. With regards to C's concerns about complaints handling, we found that the board's approach had been reasonable, with appropriately empathetic language used throughout and regular updates provided. Given these points, we did not uphold C's complaints. Related reading View Decision Report 201907379 as a PDF (24.23 KB) Updated: May 18, 2022

C complained to us about the care and treatment that they had received from their GP practice. C told us that the practice had failed to carry out appropriate prostate specific antigen (PSA) testing after they found out that C was at increased risk of prostate cancer genetically. They told us that after an initial test, which was normal, there was a delay of around four years in carrying out a further test, at which time the test showed elevated results and they were subsequently diagnosed with cancer. C considered that this delay had a considerable impact on their prognosis, as their cancer had by that time spread, which they had been told was unlikely to have been the case had they been diagnosed earlier. C also complained that the practice had failed to appropriately respond to their concerns about this, both in the way that they had investigated the concerns, and the manner in which they had responded, which C had found to be uncaring. We took independent advice from a GP adviser. We found that the practice had failed to handle C's testing appropriately. In particular, that they unreasonably assessed that regular testing was not required based on guidance intended for those not at increased genetic risk and that they unreasonably failed to seek further advice and clarity from specialist services on the request to consider regular testing. We also noted that when the test was subsequently agreed as part of other blood tests, this was missed in error, and they then failed to identify this had been missed or notify C, leaving them with the impression that this had provided normal results. Therefore, we upheld C's complaint that their testing had been mishandled. Our investigation also found that the practice had not responded reasonably to C's concerns, as the Significant Event Analysis (SEA) they carried out was not of a reasonable standard, and they had failed to provide appropriate apologies for the failures that were identified by their own investigations

C complained about the care and treatment provided to their adult child (A) during two admissions to Aberdeen Royal Infirmary where they had been admitted for investigation and treatment of persistent vomiting and weight loss. We took independent advice from a nurse and asked for their comments on A's care and treatment during both admissions. During the first admission, C complained about A being given incorrect medication, comfort and observation charts being completed inaccurately, and of the poor level of cleanliness in the ward's bathroom. We found that there were failings in these areas, which the board had acknowledged in their own complaint investigation and had identified actions for improvement and learning. Therefore, we upheld this aspect of C's complaint and asked the board to provide evidence of the actions that they had said they planned to take. During the second admission, C complained that A was given the wrong nasogastric feed and failed to take proper action when A self-harmed; was provided with the wrong type of feeding tube; staff failed to communicate properly with C or A during the admission; and A was not given medication on discharge. We found that the care of A's enteral feed (feeding tube leading into the stomach) to be reasonable, however we found that the planning and documentation of A's care after they had self-harmed was unreasonable. We also found that A had been given the wrong length of feeding tube and that the procedure went ahead despite this being known. Therefore, we upheld these aspects of C's complaint. We found that communication with A had been reasonable and we did not uphold this aspect of C's complaint. In relation to communication with C, we found this to be mostly reasonable, however there had been a serious oversight in communicating with C when A had self-harmed. Therefore, on balance, we upheld this aspect of C's complaint. In relation to A's discharge, we found this to be reasonable and we did not uphold t

C was a patient of the practice for a number of years where they were treated for thyroid (a gland in the front inside area of the neck) problems and anaemia (a deficiency in the number or quality of red blood cells in the body). C began to experience changes in their behaviour. Following an incident, the police and social work became involved and C was admitted to hospital. C was discharged the following day after a psychiatric assessment. However, C subsequently had to attend court. When gathering information for their court appearance, C obtained a copy of their medical records from the practice. Upon reviewing these, C considered that there had been failures to diagnose deficiencies of vitamin B12 and vitamin D. C also considered that there had been issues with the practice's management of their anaemia and thyroid problems and the long-term prescription of a proton-pump inhibitor (a class of medications that cause a profound and prolonged reduction of stomach acid production). C submitted a formal complaint to the practice regarding their care and treatment and their handling of C's medical records. C said that, whilst the practice responded to their concerns about the medical records, they did not address the complaints about C's care and treatment due to the time that had passed. We took independent advice from a GP. We found that, whilst C did have some abnormalities in their blood tests, these were relatively minor and would not have caused the behavioural changes C experienced. We found that the long-term proton-pump inhibitor prescription was reasonable and that C's thyroid problem was routinely monitored and managed. We found that the practice failed to notify C of their low vitamin D results, but concluded that the implications of this oversight were minimal. We did not uphold this aspect of C's complaint. With regard to the practice's handling of C's complaint, we found that that their decision to rule the complaint as outwith the time limi

C complained to the practice about the lack of treatment when they attended two consultations reporting a breast lump. C felt that the GPs they saw gave them false reassurance that there was nothing to worry about. C then attended the hospital specialists for an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body), biopsy (tissue sample) and mammogram (an x-ray of the breast) and received results which showed evidence of a cancerous lump which required chemotherapy (a treatment where medicine is used to kill cancerous cells) and surgery. We took independent advice from a GP. We found that the GPs involved carried out appropriate examinations and that it was appropriate to refer C to the hospital specialists for further examination. We did not uphold the complaint although some feedback was provided to the practice in an effort to improve learning. Related reading View Decision Report 202009052 as a PDF (24.2 KB) Updated: April 20, 2022

C complained about the treatment a family member (A) had received from the board. A was admitted to hospital three times over a short period with severe stomach and back pain. Following A's third admission, they were diagnosed with kidney failure and discharged to receive palliative care. A died a short time later. C complained that the board had missed opportunities during A's earlier admissions to identify their deteriorating kidney function. C said that an earlier diagnosis could have prolonged A's life expectancy as treatment could have commenced sooner. C also complained that on A's second admission, their discharge had been unreasonably managed by the board. C complained that A was left all day in the discharge lounge in their nightwear and that staff failed to properly communicate A's discharge arrangements to the family. A was later returned to their nursing home in a taxi instead of an ambulance. C said that this was extremely distressing and undignified for A, and had been unacceptable given A's age and poor health. We took independent clinical advice from a consultant geriatrician (a specialist in the care of the elderly). Whilst there had been a reasonable approach to investigating A's symptoms on their first admission, we found that there were missed opportunities by the board to diagnose A's kidney failure and infection, and the family's concerns had not been given appropriate consideration during the second admission. On the third admission, there was a delay in the clinical consideration of A's abnormal blood results, and in recognising the severity of their condition. We also noted from the board's own investigations that there had been a failure to move A's personal belongings between wards. Therefore on balance, we upheld this aspect of the complaint. We also found that A was not clinically fit to be discharged from hospital following their second admission, and given their age, fragility and poor health, that their discharge arrangeme

C complained about the care provided to a family member (A) at Woodend Hospital and Aberdeen Royal Infirmary. Immediately prior to the episode of care we considered, medical investigations had been performed which indicated that A had metastatic cancer (cancer which has spread from one part of the body to another). A was then referred to the urology department (specialists in the male and female urinary tract, and the male reproductive organs). We took independent advice from a urology adviser. In response to C's complaint, the board acknowledged that there had been a failure to request a CT scan as planned and apologised for this. We found that there was a failure to expedite a flexible cystoscopy (bladder examination using a narrow tube-like telescopic camera) and keep A informed about their care. In addition, we found that A should have been referred to oncology (specialists in the diagnosis and treatment of cancer). In view of these findings, we concluded that the care and treatment was unreasonable and we upheld C's complaint. C also complained about the board's actions leading up to the decision whether or not to carry out a full post-mortem examination following A's death. C considered that the board had failed to follow the procedure that applied in the circumstances that the nearest family members did not agree about a post-mortem. C was also unhappy with the lack of communication about this matter. We considered a number of pieces of relevant legislation and guidance and took into account comments from the adviser. The circumstances leading to the decision about post-mortem were complex. On balance, we found that the board acted reasonably in this instance and we did not uphold the complaint. We provided feedback about good practice for the board to consider. Finally, we found that the board's response to C's complaints could have been clearer in one respect. We also found that the board did not respond to a related complaint (about A's treatm

C complained to us on behalf of their child (A) about the care and treatment A received from child and adolescent mental health services (CAMHS). Specifically, C complained that A was unreasonably discharged from CAMHS. We took independent advice from a child and adolescent psychologist and also from a mental health nurse. We found that there was a delay in CAMHS offering A video appointments following the COVID-19 lockdown but we found that the delay was not unreasonable, as they needed time to set up the necessary IT systems. We also found that all relevant information was taken into account about A's condition before CAMHS decided to discharge A. Therefore, we did not uphold the complaint. Related reading View Decision Report 202005289 as a PDF (24.04 KB) Updated: April 20, 2022

C complained about care and treatment provided to their parent (A) by a duty general practitioner (GP) at the practice. C contacted a community nurse team to raise concerns that A's catheter was draining slowly and that there was blood in their urine bag. A nurse visited A at their home later the same day. They changed A's catheter bag and provided advice. After they had left A's home, the nurse discussed their actions with the GP. The GP agreed with the nurse's actions and their assessment of A. Later that evening A's catheter blocked. A was subsequently admitted to hospital and diagnosed with urosepsis (a serious infection of the urinary tract). A subsequently died in hospital. C complained that the GP had failed to visit A despite being provided with information indicating that they had a serious infection. C also complained that the GP failed to provide A with medical treatment. We took independent advice from a GP. We found that the GP acted reasonably and noted that they were not provided with information indicating that A had a serious infection. We found that the GP’s agreement with the treatment and advice provided by the nurse was reasonable in light of the information available to them at the relevant time. We did not uphold C’s complaints. Related reading View Decision Report 201910514 as a PDF (56.61 KB) Updated: March 29, 2022

C complained that the practice failed to provide appropriate care and treatment to their late child (A). A had a lump removed from their eye lid which was subsequently diagnosed to be cancerous. A went to see their doctor with severe pain in their left arm, which moved to their right arm and neck. A was prescribed painkillers and referred to physiotherapy. A returned from a family holiday and, still suffering from severe pain which had worsened, saw another doctor. A's painkillers were changed and they were referred to physiotherapy. After a further consultation, A was referred for an x-ray which identified that A's C6 vertebrae had collapsed and that there was a cancerous tumour. A died a few months later. C complained that doctors at the practice failed to respond to A's symptoms in a reasonable manner given A's history of cancer. C complained that it took A to attend the practice on a number of occasions before appropriate treatment/investigations were undertaken. C believed that had doctors taken account of A's previous history, A would have received appropriate treatment sooner. A considered that the practice failed to investigate and respond to their complaint appropriately. We took independent advice from a medical adviser. We found that the practice's consultations with C were reasonable. There was no unreasonable delay in the decision to refer C for an x-ray. We did not uphold this aspect of the complaint. With respect to the complaints handling, we found that there was a misapprehension on the practice's part about the handling of the complaint which resulted in a failure to communicate with C in accordance with their complaints handling procedure. However, the practice had investigated the complaint and provided an accurate and detailed response within a reasonable timeframe and, on balance we did not uphold this aspect of the complaint. We provided feedback to the practice on their obligations with respect to complaints handling. Related re

C brought a complaint about the care and treatment that their late spouse (A) received during three admissions to Aberdeen Royal Infirmary. C was concerned that A did not receive appropriate treatment and was discharged on each occasion. A was initially admitted following a heart attack, and died a few months later due to heart failure. We took independent advice from a consultant cardiologist (medical specialist dealing with disorders of the heart). We found that the care and treatment A received during two of these admissions was reasonable, including the decision to discharge A. However, during one admission the board acknowledged that there was a missed opportunity to provide cardiology input and seek an in-patient echocardiogram (a heart scan that uses sound waves to create images). We found that it was unreasonable that no input was sought from the cardiology department during this particular admission and that an opportunity was lost to make the correct diagnosis and to optimise possible treatment options. We upheld the complaint but also noted that it was not possible to say definitively whether this would have changed A's survival prospects.

C complained on behalf of their child (A) about the service received from the practice and the way in which their complaint was handled. A commenced a course of treatment with the practice because due to a dental overjet (when the upper teeth protrude outward and sit over the bottom teeth), they qualified for NHS funding. A and C agreed to proceed with a functional appliance to correct the overjet. A wore the appliance some of the time, but they did not comply with the treatment in full. A was warned of the necessity to comply and given several reminders. A also missed an appointment. C was sent a 'wish to continue' letter in which they were advised that they should get in touch within four weeks or A would be discharged back to the dentist. C contacted the practice within this period of time to discuss other options for A. As C did not receive a response, they raised a complaint. During this period A was discharged back to the dentist. We took independent advice from an orthodontist. We found that, although it is accepted that the clinical decision may not have been different, we considered there should have been a further clinical discussion before A was discharged. We upheld this aspect of C's complaint. In relation to the complaint handling, we upheld this complaint on the basis that there was a delay in responding to C's concerns in full and C was not signposted to this office.

C complained about the failure of emergency mental health services to treat them during crisis admissions. C stated that they had been brought to the hospital on multiple occasions by police but that an assessment was not always carried out. C also complained that they had not been allocated a psychiatrist (a medical practitioner who specialises in the diagnosis and treatment of mental illness) or a community psychiatric nurse. The board responded by advising that services treated C appropriately when they attended and completed assessments when required. They also stated that C previously was supported by a psychiatrist but disengaged from this service and did not re-engage with services in the intervening period. C was unhappy with this response and brought their complaint to us. We took independent advice from a psychiatric adviser and a mental health nurse. We found that the medical records showed that the board had acted reasonably and occasions where full assessments were not completed were appropriate and in keeping with strategies put in place to treat C. We considered that the plan to manage C's crisis contacts was in their best interests and we found no evidence of mental health assessment's being unreasonably withheld. Therefore, we did not uphold this aspect of C's complaint. In relation to the allocation of a psychiatrist, we found that C had disengaged with services. However, proposed actions suggested by a psychiatrist to re-engage and support C did not appear to be actioned and records showed an unexplained gap in contact between C and services of around 18 months. Therefore, we upheld this aspect of C's complaint. C requested a review of our decision and the case was reopened for further consideration. Details of this are explained below. C was admitted to A&E at the Royal Infirmary of Edinburgh (RIE). After being transferred to an acute medical unit (AMU) from A&E, they left the ward and returned to their home. The police were contacted

C complained that the practice did not take reasonable action in response to their late spouse (A)'s symptoms and condition. A had a long history of degenerative disc disease affecting their spine (when normal changes that take place in the discs of your spine cause pain) and a history of stomach cancer. A visited or contacted the practice several times over three months regarding pain in the neck and shoulder, numbness in the right hand and jerking of the right leg. Tests were undertaken, medication and therapies prescribed and a referral to an orthopaedic specialist (a specialist in the treatment of diseases and injuries of the musculoskeletal system) was made. Following a fall at home, A was admitted to hospital where a spread of cancer to A's spine was diagnosed. A died shortly after C submitted a complaint to the practice about their response to A's symptoms and condition over the previous few months. In response, the practice recounted the actions they had taken in response to A's visits and contacts in their final months, highlighted blood tests whose results did not indicate any significant abnormality or spread of cancer and explained that A's symptoms were relatable to their ongoing diagnosis of degenerative cervical disc and spinal stenosis (a condition where the space around the spinal cord narrows, compressing a section of nerve tissue). The practice advised that a significant case review had been carried out. This had highlighted that A's orthopaedic referral could have been upgraded to urgent when it was clear A's symptoms were not being controlled, but stated that it was doubtful this would have had any impact on the outcome. C was unhappy with this response and brought their complaint to this office. We took independent advice from a GP. We found that the practice took reasonable action in response to A's symptoms and condition until a point. However, when it was clear that A's symptoms were not being controlled and began to worsen, the pr

C complained on behalf of their late parent (A) about the care and treatment provided by their GP at the practice. A had been attending the practice with shortness of breath and a persistent cough. An urgent referral for suspected cancer was made, however C considered that the practice should have made the referral sooner. We reviewed the relevant medical records and sought independent advice from a GP. We found that as A was high-risk patient who was failing to respond to antibiotics, an urgent referral to the chest clinic should have been made eleven months earlier and as such, we concluded that the practice failed to correctly follow the Scottish Suspected Cancer Referral guidelines. We upheld the complaint.

C attended Aberdeen Royal Infirmary after being referred by their GP for left leg pain and swelling behind the knee. Investigations revealed the presence of a Baker’s cyst (fluid-filled swelling at back of knee) and C was discharged home with no further treatment planned. The pain continued to bother C over the weekend and they sought further medical opinion and returned to the hospital six days later. This time a deep vein thrombosis (DVT, blood clot in a vein) was diagnosed and C was discharged home on blood thinning medication. C believed that the DVT must have been present at their initial presentation to hospital and that action should have been taken at that time to address their symptoms and therefore there was a missed diagnosis. We took independent advice from two clinical advisers: a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant physician. We found that although there was no evidence of a DVT on the original ultrasound scan, staff failed to act in accordance with guidance and arrange a D-dimer test (a blood test that can be used to help rule out the presence of a serious blood clot) and a further ultrasound scan within seven days. Staff gave C advice to seek further medical opinion should their clinical condition deteriorate which C did. There was no delay to the actual diagnosis of DVT and C’s treatment regime would not have altered in the period until the second scan was performed. However, we upheld the complaint on the basis that there was a failure to act in accordance with the guidance.