SPSO Individual Decisions

Mr C complained that the practice failed to appropriately manage pulmonary fibrosis (a lung condition) in his late mother (Mrs A). The condition was first identified in a scan carried out five years prior to Mrs A's death and she regularly attended the practice over the intervening years with symptoms that included breathlessness. We obtained independent medical advice and we identified that there were missed opportunities to appropriately refer Mrs A to respiratory medicine. In particular, we considered that a referral should have been made following the initial scan. We also considered that a referral should have been made a year before Mrs A's death, when an x-ray reported progression of the pulmonary fibrosis. We found that all tests in between these times were not reported back to the practice in terms that would have prompted referrals. However, we noted that one GP expressed awareness of the condition during this period and made a referral to a geriatric clinic. While we considered it appropriate that further investigation was arranged, we noted that a respiratory referral would have been more appropriate. We were assured that the limited available treatment options for pulmonary fibrosis meant an earlier referral was unlikely to have altered Mrs A's prognosis. However, we recognised that earlier specialist intervention would have afforded Mrs A and her family the opportunity to better understand the nature of her condition and be assured that her symptoms were being appropriately managed. We upheld the complaint.

Mrs C complained about the care and treatment she received in relation to her labour at Forth Valley Royal Hospital. Mrs C had a long and difficult labour, and her baby was born with the use of forceps. An episiotomy (a surgical cut of the area between the vagina and anus) was performed and Mrs C suffered a fourth degree tear (a severe tear in the vaginal tissue), which was repaired that day. A few months later, Mrs C was diagnosed with a recto-vaginal fistula (an abnormal connection between the rectum and the vagina) and disrupted anal sphincter (muscle that surrounds the anus), for which she underwent several unsuccessful operations. Nine months later, Mrs C was referred to a specialist at Glasgow Royal Infirmary, who decided that a colostomy bag (a pouch placed over one end of an intestine) was required to allow healing before further procedures to repair the fistula. We took independent obstetrics and gynaecology advice and surgical advice. In relation to Mrs C's complaint about the standard of obstetric care and treatment provided, we found that the fourth degree tear was properly identified and repaired within a reasonable time, but that the board failed unreasonably to arrange an obstetric review before discharge from Mrs C's first admission to hospital (which also had an adverse effect on communication) and that there was confusion about postnatal appointments and delays. Regarding the standard of surgical care and treatment provided, while we were satisfied that medical staff managed the fistula in a reasonable way, we found that they failed unreasonably to obtain consent for one of Mrs C's operations. Finally, we were critical that the board failed to respond formally to the surgical aspect of Mrs C's complaint.

Mr C complained about the care and treatment provided to him by the prison health centre. He said that he was not being provided with appropriate pain relief for a number of complex medical problems and his complaints about these issues had not been properly investigated. Mr C said that the GP he saw in prison changed his prescription from that provided to him in the community. Mr C said his mobility and balance had been severely affected. We took independent medical advice on Mr C's prescriptions. The adviser said that Mr C was properly reviewed and the changes to his prescriptions were in line with national guidance on the management of chronic pain and the prescribing of pain relief within a prison setting. Mr C had been reviewed and his medication discussed with him. The adviser did not find evidence that Mr C had been significantly affected in the ways he described by the changes to his medication. Our investigation found that Mr C's complaints were responded to promptly and addressed the issues he raised. There was no evidence that complaint procedures were not properly followed. Related reading View Decision Report 201507795 as a PDF (11.1 KB) Updated: March 13, 2018

Ms C had an operation on a toe of her left foot at Forth Valley Royal Hospital. Ms C's foot was put in a plaster cast and when she returned the following month for it to be changed, a member of staff tried to realign the toe contrary to the instructions in Ms C's medical records. We did not take the complaint further because Ms C decided to pursue an alternative way to remedy her complaint. Related reading View Decision Report 201508664 as a PDF (10.77 KB) Updated: March 13, 2018

Ms C, who works for an advocacy and support agency, complained on behalf of Mr B regarding the care and treatment provided to Mr B's father (Mr A) during his admission to Forth Valley Royal Hospital. Ms C complained that Mr A's falls risk was not appropriately assessed on two different wards, that the nursing care provided to him was not reasonable, and that staff attitude and communication with Mr A's family was unreasonable. During our investigation, we obtained independent advice from a nursing adviser. We found that whilst Mr A's assessment and care in relation to falls on the first ward he stayed on was reasonable, on the second ward his levels of confusion were not taken into account when assessing the risk of falls. We considered this to be unreasonable. We also found that whilst the nursing care provided to Mr A was reasonable in terms of personal care and administration of medication, the nursing care plans had not taken into account Mr A's need for emotional support. We also found that the use of bedrails for Mr A had been inconsistent. We did not consider this to be reasonable and upheld this complaint. In terms of staff attitude and communication with Mr A's family, we found that communication had often been unplanned and ineffectively co-ordinated, but that this was often due to short-notice changes to plans for Mr A given his fluctuating physical state. We considered that a planned approach to communication may have been beneficial, but that there was no evidence of unreasonable staff attitude towards the family. We made several recommendations to the board to address the failings identified.

Mrs C complained that over a 12-month period, two doctors at her medical practice failed to provide her with appropriate clinical treatment for her back. Mrs C said that when an MRI scan was eventually arranged, this showed that she had a tumour on her spinal cord which she had surgery to remove. Mrs C said the two doctors at the practice failed to listen to her when she explained her ongoing symptoms and asked for help, failed to undertake appropriate assessments and investigations, and failed to arrange appropriate specialist referrals. We took independent medical advice and found that the two doctors communicated reasonably with Mrs C, undertook appropriate assessments, investigations and referrals and provided her with appropriate treatments based on her clinical symptoms at the time. We found that the doctors followed the Scottish Government back pain guidelines and the Healthcare Improvement Scotland referral guidelines for suspected cancer and said that the care Mrs C received was of a reasonable standard. The adviser also explained that GPs could not arrange referrals for MRI scans and that such scans could only be requested by a physiotherapist or a hospital specialist. We therefore concluded that the doctors did not fail to provide Mrs C with appropriate clinical treatment in view of her reported symptoms and we did not uphold her complaint. Related reading View Decision Report 201508517 as a PDF (11.23 KB) Updated: March 13, 2018

Mr C complained about an endoscopy procedure that he had undergone at Forth Valley Royal Hospital which he found painful. Mr C died while our investigation was ongoing. Mr C's death was not connected to the endoscopy procedure about which he complained. After making further enquiries, we decided that the most appropriate course of action was to discontinue our investigation. Related reading View Decision Report 201507577 as a PDF (10.76 KB) Updated: March 13, 2018

Ms C had surgery for breast cancer in her right breast. She reported a lump in her breast 11 years later. Further tests were carried out at Forth Valley Royal Hospital but did not show evidence of cancer. Ms C was followed up with repeat tests which identified a local recurrence of cancer. Ms C then had a mastectomy (an operation to remove the breast), which showed no evidence of cancer. Later, a marker clip (a small titanium clip used to mark the site) initially placed at the time of the biopsy was removed along with surrounding tissue, which also did not show evidence of cancer. Ms C complained that she should have undergone more tests and should have been reviewed every four weeks after the lump was identified. She also complained that the mastectomy may not have been required and had concerns about the lack of action taken in response to the marker clip that had not been removed at the time of the mastectomy. We took independent medical advice from a consultant breast surgeon and a consultant radiologist. We did not find failings in Ms C's care and treatment before or after the mastectomy. We considered that she received appropriate tests and was reviewed within a reasonable timescale. In addition, given there was evidence of invasive cancer identified from a biopsy and Ms C's history of previous radiotherapy for breast cancer, we considered that the mastectomy was warranted. In terms of the marker clip, we found that there were no failings in relation to mastectomy technique and that reasonable steps were taken to remove it and check the surrounding tissue. We did not uphold Mrs C's complaint. Related reading View Decision Report 201508040 as a PDF (11.36 KB) Updated: March 13, 2018

A firm of solicitors (company C) complained that their client (Mr A) did not receive a reasonable standard of care and treatment from the board for his mental health while in prison. Their concerns included that the board failed to provide Mr A with one-to-one appointments with a psychiatrist when this had been provided for him in a previous prison. They were also concerned that the board incorrectly suggested that Mr A failed to attend appointments, when his disengagement was as a direct consequence of him being unable to participate properly. Mr A died during our investigation of the complaint and his mother (Ms B) gave us her consent to continue the investigation. We obtained independent medical advice from a consultant psychiatrist. The evidence showed that Mr A attended joint assessment appointments with a psychiatrist and a mental health nurse on two occasions. At the first appointment, Mr A voiced his concerns about joint assessment. However, after explanation from the psychiatrist, he appeared to accept this approach and the board then arranged a further joint assessment. The adviser said that when Mr A expressed further concern at the second assessment, it was not reasonable for the board to have attempted to continue joint assessment that day. The evidence also showed that for the period under consideration in this complaint, Mr A only failed to attend one appointment (for a self-referral clinic) and that the board's statement about his attendance was, therefore, incorrect. Whilst noting that it was not reasonable for the board to attempt to continue with the second joint assessment after Mr A had expressed further concern, the adviser said that overall, Mr A received a reasonable standard of care and treatment from the board for his mental health. We therefore did not uphold company C's complaint. However, we made recommendations to address aspects of the board's complaints handling.

Ms C's partner (Mr A) was admitted to the A&E department at Forth Valley Royal Hospital, where he died. Mr A's mobile phone was not listed among his valuables and could not be found. Ms C made a formal complaint to the board but the phone could not be located. Ms C said that the phone contained images of her late partner and their child that could not be recovered. Our investigation focused on the efforts made to locate the phone and/or to find out where and when it had gone missing. We were satisfied that, although ultimately unsuccessful, the board took reasonable actions to try to locate the phone. Related reading View Decision Report 201507834 as a PDF (10.89 KB) Updated: March 13, 2018

Mr C complained that he was being required to work in the prison work-sheds despite it being a source of anxiety for him and causing him to suffer panic attacks. He considered that the prison health centre should have supported him in being excused from work on health grounds. He noted that a mental health nurse had briefly declared him unfit for work but that this decision was reversed following a multi-disciplinary review of his case. The board told us that the decision to declare Mr C unfit for work had been reversed on the basis that it was considered his anxieties were being managed appropriately. They noted that a care plan had been devised to reflect this. We took independent advice from a senior mental health nurse. They noted that the clinical reasoning behind the initial decision to declare Mr C unfit for work, and the content and conclusions reached at the subsequent meeting, were not documented. They were critical of this and the lack of evidence of a comprehensive and structured assessment of Mr C's mental health needs having been carried out. They did not, therefore, consider that Mr C's mental health and fitness to work were adequately assessed prior to the meeting and on this basis we upheld Mr C's complaint. However, the adviser noted that the care plan that was subsequently put in place took a reasonable approach in seeking to support Mr C's continued attendance at work.

Mr C complained about the care and treatment received by his late brother (Mr A) in relation to Mr A's lung cancer and his admission to Forth Valley Royal Hospital following a cardiac arrest. During our investigation we took independent advice from two advisers, a consultant in respiratory medicine and a consultant in anaesthesia and critical care medicine. The board accepted that there had been unnecessary delays in Mr A's cancer care pathway, for which they apologised and outlined the action taken. The consultant in respiratory medicine said that while some delays had been unavoidable, others were unexplained and unreasonable, in particular the delays relating to the referral from primary care to secondary care. They also noted poor communication. We therefore upheld this aspect of Mr C's complaint. However, the advice we received from the consultant in anaesthesia and critical care medicine was that the decisions taken following Mr A's admittance to the hospital and the care and treatment he received were reasonable.

Mr C had surgery on his prostate at Forth Valley Royal Hospital and he subsequently experienced a common complication of the procedure. He complained that he was not told in advance that this complication would be permanent and he considered that the information he was provided suggested it would only be temporary. He said he would not have gone ahead with the procedure if he had realised that the complication was irreversible. The board noted that the potential risks were explained to Mr C before the procedure and were listed on the consent form which he signed. They also noted that he was given a patient information leaflet, which stated that three out of four men would experience the complication in question. However, Mr C stated that the leaflet said the complication would only last a few weeks. We obtained advice from a consultant urologist, who was not critical of the consenting process and considered that Mr C was in a position to provide informed consent. They noted that the leaflet did not state that the complication would only last a few weeks. They considered that it was implicit in the leaflet that the complication could be permanent, however, they said it could benefit from being changed so that this is stated explicitly. We agreed that the leaflet did not state that the complication was temporary. However, we noted that it did refer to some other side effects as being temporary. Given that there is a 75 per cent chance of the complication in question occurring following surgery, and as it is often permanent, we considered that this position should be made clearer in the board's information leaflet. On balance, we upheld the complaint and made some recommendations.

Mrs C complained that her husband (Mr C) did not receive a reasonable standard of care from the practice. Mr C suffered from a number of health conditions, including asthma, and passed away from sudden cardiac arrest whilst he was a patient at the practice. Mrs C felt that the practice did not investigate Mr C's condition urgently enough, and said that there had been a sequence of failed attempts to diagnose and treat Mr C. We took independent advice from a GP adviser. The adviser noted that the practice had investigated Mr C's condition within a reasonable timeframe and with the appropriate level of urgency. The adviser said that appropriate investigative tests had been arranged and concluded that the care Mr C received was reasonable. We accepted the adviser's comments and we did not uphold Mrs C's complaint. Related reading View Decision Report 201508751 as a PDF (10.98 KB) Updated: March 13, 2018

Mr C, who works for an advice and support agency, complained about the care and treatment of his clients' late daughter (Miss A). Miss A attended the practice on a number of occasions from May 2014 with symptoms including a persistent cough, sore joints, fatigue and weight loss. A number of possible diagnoses were considered and investigated but Miss A's symptoms persisted. In October 2014 following an out-of-hours attendance, Miss A was admitted to hospital and diagnosed with endocarditis (a rare and potentially fatal infection of the inner lining of the heart). Miss A passed away in hospital a few weeks later. Her parents raised concern that a window of opportunity had been missed to diagnose Miss A. They felt that there was a delay in the practice arranging appropriate investigations and referrals. The practice met with Miss A's parents and carried out a significant event analysis. The practice considered the care provided was reasonable, although they identified some learning points for improvement including improving continuity of care and having a lower threshold for investigatory blood tests in young people with persistent symptoms. After taking independent medical advice we did not uphold Mr C's complaint. We found the practice had arranged appropriate investigations in view of Miss A's symptoms, including seeking advice from Miss A's former specialist to check for any connection between her symptoms and another ongoing condition and making referrals to hospital specialists. The adviser explained that Miss A's symptoms varied over this time and appeared more in keeping with a respiratory problem (which the GPs appropriately investigated). The adviser considered symptoms indicating a possible problem with the heart were first documented at the out-of-hours admission in October 2014, so it was not a failing that the practice did not investigate this possibility earlier. Related reading View Decision Report 201508194 as a PDF (11.57 KB) Updated: March

Mr C complained about the way in which his pain relief medication was handled by the prison health centre and that the doctor refused to see him in private. Mr C had been prescribed pain relief for pain in his leg. This was later stopped and an alternative medication prescribed. However, due to concerns that Mr C was failing to take the medication in the way it was prescribed, this medication was also stopped and further alternatives, including anti-depressants, were suggested. We took independent advice from a GP adviser. We found that, when reviewing Mr C's medication, the health centre had acted in line with Scottish national guidelines on the management of chronic pain and on prescribing. We considered the health centre's actions to be reasonable given the assessments carried out for Mr C. The board told us that there were no records of Mr C asking to see health centre staff in private. We considered that in a secure environment, it would not be unreasonable for Mr C to be accompanied at health centre appointments. We saw evidence of only one occasion on which Mr C had been accompanied and that this was reasonable. We therefore did not uphold Mr C's complaints. Related reading View Decision Report 201507826 as a PDF (11.17 KB) Updated: March 13, 2018

Mrs C complained about the level of pain she experienced during a colonoscopy procedure (an examination of the bowel with a camera on a flexible tube) at Forth Valley Royal Hospital. Mrs C's pain was very bad and the procedure had to be stopped. Mrs C felt that the level of pain that she experienced was caused by failure to give her appropriate sedative and pain medication prior to the procedure. Mrs C highlighted that she had previously undergone the same procedure at another hospital with no ill effects. After taking independent advice from a consultant colorectal surgeon, we did not uphold Mrs C's complaint. The adviser reviewed the medication that Mrs C received prior to the procedure and confirmed that this was appropriate. The adviser noted that Mrs C had previously had a similar procedure at another hospital and advised that whilst the reasons why this type of investigation can be successful for the same patient on one day but not another are not clear but that is sometimes the case. It was also noted that Mrs C had undergone major abdominal surgery in the past and the adviser explained that adhesions (scar tissue that can make tissues or organs inside the body stick together) can cause pain during colonoscopy procedures. Although Mrs C's complaint was not upheld, the adviser pointed out that some of the patient information and other guidance did not appear to be current or was due for review, and also that the consent form for the procedure had not been countersigned. We made a number of recommendations to address these issues.

Miss C complained about the care and treatment received by her late father (Mr A). Mr A had an MRI (magnetic resonance imaging) scan at Forth Valley Royal Hospital to investigate leg weakness. The scan revealed an incidental finding of a six centimetre abdominal aortic aneurysm (AAA - a bulging of the aorta, one of the largest blood vessels in the body, which runs from the heart to the legs). This had not yet been shared with Mr A when he took unwell a few days later and, while being transported to hospital in an ambulance, he went into cardiac arrest and died. Miss C complained about the time taken to share and act upon the findings of the MRI scan. The board informed Miss C that, in line with normal practice, the MRI was flagged for urgent reporting within two to three days. They explained that immediate intervention would only be arranged where there was evidence that the AAA had ruptured, which there was not in Mr A's case. They noted that the MRI was reported three days later and an urgent referral was made to the vascular team two days after that. This was the day of Mr A's death. The board noted that further tests would have been required and the national target for elective treatment of aneurysms is 42 days. They therefore considered that even if Mr A had been referred to the vascular team on the same day as the MRI scan, it would have been a few weeks before he received treatment. We took independent medical advice from a consultant physician. They noted that, while they could not be certain of the cause of death, the risk of the AAA rupturing was low and that the board attributed Mr A's death to a heart attack. They noted that Mr A did not have any symptoms suggestive of a rupture at the time of his scan and they considered that the scan was reported and acted on within an appropriate timeframe. We accepted this advice and concluded that the outcome could not reasonably have been prevented. Related reading View Decision Report 201508430 as a PD

Mr C, an advice worker, complained about the treatment which his client (Mr A) received when he attended a consultation. Mr A had a previous medical history of facial and arm weakness and was thought to have long-standing hydrocephalus (build-up of fluid on the brain). He saw a GP as he wanted to have further investigations in order to reach a diagnosis. Mr A felt the GP had dismissed his symptoms. Mr A was admitted to hospital two days later with worsening neck and back pain, increasing confusion, poor mobility, right upper limb weakness and urinary incontinence. Over the next six months Mr A was found to have stable chronic hydrocephalus along with possible abscesses (painful swellings caused by a build-up of puss) of his neck and the area between the spine and spinal cord. It was subsequently discovered he had chronic discitis (infection of the vertebral disc space). Mr A believed that the GP had dismissed his symptoms and that his condition had deteriorated because of the delays which he had encountered. We took independent medical advice from a GP and concluded that the GP had provided a reasonable level of care. When Mr A had attended the consultation the GP was aware of Mr A's medical history, including that he had attended hospital the previous day. He carried out an appropriate examination given the symptoms which were presented. There was no indication at that time for a hospital admission. It was clear from the records that Mr A's condition deteriorated two days after the GP consultation and it was only then that a hospital admission was appropriate. We did not uphold the complaint. Related reading View Decision Report 201508752 as a PDF (11.44 KB) Updated: March 13, 2018

Mr C complained that the board had failed to carry out the hernia surgery at Forth Valley Royal Hospital that he had consented to and that they had failed to provide him with appropriate treatment following the surgery. Mr C said as consequence he suffered from regular and severe pain, which impacted on his quality of life and ability to work. We found Mr C underwent surgery in the summer of 2012 without incident, although he did then attend the A&E department at the hospital complaining of pain at the wound site. He was examined and discharged as no cause for alarm could be identified. Mr C was reviewed in late 2012 and early 2013, and although a further review appointment was made, Mr C did not attend. In the absence of contact from Mr C, no further appointments were offered. Mr C was re-referred by his GP and seen in 2015. He was reviewed in clinic by the surgeon who had performed the operation and provided with a scan of the area, which confirmed that the hernia had not reoccurred. Mr C was unhappy with the outcome of this review and a second opinion was arranged. We took independent advice from a consultant colorectal surgeon, who said that the treatment Mr C had received was appropriate. The relevant consent documents had been filled in and signed and the operation had been performed in accordance with normal surgical procedure. There was no evidence that the operation performed was not the one Mr C consented to. The adviser also said the reviews of Mr C had been carried out appropriately post-surgery and it was reasonable to have referred him for a second opinion when the relationship with medical staff broke down. We found there was no evidence Mr C had not consented to the operation performed on him, or that he had received inadequate care following the second surgery and did not uphold the complaint. Related reading View Decision Report 201508153 as a PDF (11.48 KB) Updated: March 13, 2018

Mr C, who works for an advice agency, complained on behalf of Mr A who was concerned about the care and treatment given to his late wife (Mrs A). In particular, he was concerned that there was an avoidable delay by staff at Forth Valley Royal Hospital in establishing that Mrs A was suffering from breast cancer. While the board accepted that there had been a delay and apologised, they said that Mrs A had suffered from a rare form of cancer which had been difficult to diagnose. We took independent advice from a consultant breast surgeon. We found that while Mrs A's form of cancer was a very rare variant, opportunities had been missed to diagnose her sooner. There had also been an initial delay in Mrs A being seen and her cytology (examination of tissue samples under a microscope) results had been incorrectly reported. We therefore upheld the complaint and made recommendations.

Miss C raised her concern about the care she received from Forth Valley Royal Hospital during her pregnancy, labour and postnatal period. During our investigation, we took independent advice from a consultant in reproductive medicine and surgery, a consultant obstetrician and a midwife. We also received advice on general nursing issues from a nursing adviser. The board accepted that there had been errors in relation to the initial ultrasound scans Miss C received and, as a result, she had been incorrectly advised that she had suffered a miscarriage. The board had apologised for those errors and had taken action. The advice we received and accepted from the consultant in reproductive medicine and surgery was that it had been too early to diagnose a miscarriage and that there was no evidence consultant advice had been obtained. The adviser also said that there was a failure to record / obtain a complete menstrual history at the time of the scans. The advice we received from the midwife was that carrying out an ultrasound scan before six weeks gestation would not normally happen. The midwifery adviser also said that it happened in this case in an attempt to meet Miss C's needs, given that she had recently undergone surgery. The adviser said that this was not clinically appropriate. In the circumstances, we considered that the board had failed to provide Miss C with appropriate care and treatment and we upheld this aspect of the complaint. We were satisfied that an appropriate assessment had been carried out when Miss C first attended the hospital when she believed her labour had started. However, while the advice we received and accepted from the consultant obstetrician and the midwife was that aspects of her care and treatment were reasonable when she returned to the hospital (in particular, that the obstetrician adviser did not consider that there was an unreasonable delay before the decision was taken to proceed with a caesarean section), we were concerned ab

Mrs C complained about her mother (Mrs A)'s discharge from Forth Valley Royal Hospital. Mrs A was 82 years old at the time and was admitted with chest pains, later diagnosed as a heart attack. Further to treatment, plans were made to discharge Mrs A but her family were concerned that she remained in poor health. Mrs C said they had alerted staff to Mrs A's breathing difficulties, shivering, leg swelling, lack of appetite and general weakness but were assured that she was fit to go home. Following discharge, Mrs A was readmitted in the early hours of the following morning. She was diagnosed with sepsis and did not recover. She passed away five days later. Mrs C considered that the signs of sepsis were present prior to Mrs A's discharge and were not detected by staff. The board advised that the results of pre-discharge tests were not consistent with a diagnosis of sepsis. We took independent advice from a consultant in general and geriatric medicine. They noted that Mrs A's symptoms, observations and blood test results were considered prior to discharge and were relatively normal. In particular, they noted that her blood test results were sufficiently normal to allow discharge to proceed. They did not consider that there was any evidence Mrs A was suffering from sepsis at the time and, overall, they considered it reasonable for her to have been discharged. They noted that she was re-admitted a short time later and subsequently died but were not of the view that this could have been reasonably predicted at the time of discharge or that it was due to poor medical care during Mrs A's admission. We did not uphold Mrs C's complaint. Related reading View Decision Report 201502620 as a PDF (11.37 KB) Updated: March 13, 2018

Mr C complained to the board about the treatment they offered him for an injury he suffered to his knee. He had originally attended a GP at the prison health centre and received an x-ray which showed no problems. It was therefore decided that he should attempt physiotherapy and return if the pain persisted. However, when he requested a further appointment to see the GP because he felt he should have a scan, his request was triaged by a nurse who advised that as his x-ray had been normal, he did not need an appointment or a scan. We took independent advice from two advisers, one a GP and one a nurse. We found that Mr C's records showed that after the x-ray, his GP mentioned that a scan may be required if problems persisted. The advisers confirmed that the nurse in question should have consulted a GP and that, in line with national guidelines for the management of knee pain, further investigation would have been appropriate in the circumstances. As such, we upheld the complaint.

Mr C complained that a prison health centre failed to refer him to a plastic surgery clinic for scar revision. This was in relation to scars on his abdomen which were causing him pain and discomfort. We took independent advice on the complaint from a GP. We were informed that the prison health centre had sent a referral to the plastic surgery clinic but it was subsequently decided that revision surgery was not appropriate, as Mr C was continuing to self-harm at the time. We were advised that the decision not to progress the referral in such circumstances was reasonable and in line with relevant guidelines. We accepted this advice and did not uphold this aspect of the complaint. Mr C also complained about the way his complaints were handled by both the prison health centre and the board. He noted that he had asked specific questions in his complaints and that these had not been answered. We agreed that the prison health centre had only formally addressed one of the two points raised with them and the board's formal response omitted a reply to one of the four points raised with them. We, therefore, upheld this part of the complaint.