SPSO Individual Decisions

Ms C complained to us about the care and treatment that her late partner (Mr A) received at Aberdeen Royal Infirmary when he attended on two separate occasions with severe chest pain. Mr A died during his second attendance at the hospital. On Mr A's first attendance at the hospital he was seen in the Acute Medical Initial Assessment Unit and the Ambulatory Emergency Care Unit. Ms C complained about the assessment and examination that Mr A received and that he was diagnosed with musculoskeletal chest pain. We took independent advice from consultant in acute medicine. We found that assessments and examinations were reasonable and in accordance with the relevant guidance for chest pain. In particular, Mr A's chest pain was viewed as cardiac until it was positively excluded by the results of a troponin blood test and an electrocardiogram (ECG - a test which measures the electrical activity of the heart to show whether or not it is working normally). We did not uphold this aspect of Ms C's complaint. Around two months later, Mr A attended the emergency department at the hospital. Ms C complained that Mr A's condition was too serious for him to be asked to sit and wait for an initial assessment. Mr A collapsed in the emergency department waiting area. He then went into cardiac arrest (where the heart suddenly and unexpectedly stops beating) and died. We took advice from a consultant in emergency medicine. We found that it was unreasonable that Mr A was asked to sit and wait for an initial assessment when he presented to the emergency department with chest pain and shortness of breath. We upheld this aspect of Ms C's complaint.

Mrs C, an advocacy and support worker, complained on behalf of her client (Mr  A) who is in the process of gender transition. Mr A heard that a consultant in the Gender Identity Clinic (GIC) was going on extended leave, with no cover being provided, and therefore requested an out of area referral. He had been advised by his psychiatrist to seek the extra-contractual referral for medical reasons. Mrs C complained that the board failed to address Mr A's request in their response to his complaint and failed to provide an adequate service. After Mrs C brought the complaint to us, the board wrote to Mr A and apologised for not having addressed his query about extra-contractual referral when they originally responded to the complaint. They explained that they would not support a referral to another board because they were continuing to offer the same level of service as previously. Given that the board had not addressed this referral request at the time it was made, we upheld this aspect of Mrs C's complaint. In relation to the complaint about service provision, we took independent advice from a psychiatric adviser (a medical practitioner who specialises in the diagnosis and treatment of mental illness). We found that the level of service at the GIC had not changed and that there were plans in place and enacted to cover the period of leave taken by the existing consultant. We also noted that given there were no additional risk factors identified such as major mental or physical illness, there would be no indication to go outwith the normal process followed by the board. We considered that the board had gone to significant effort to ensure their service was not adversely affected by the period of leave and provided Mr A with a reasonable service. We did not uphold this aspect of Mrs C's complaint.

Mrs C, an advocacy and support worker, complained on behalf of her client Mrs A about the care and treatment Mrs A received at Dr Gray's Hospital. Mrs A suffered a miscarriage and attended hospital for an assisted delivery. She signed a consent form for the treatment and indicated that she wanted to take her baby home with her following the procedure. Mrs A believed she had passed her baby's foetus on the first day she was in hospital but was assured that this was not the case by her midwife. When Mrs A was to be discharged, the hospital were unable to locate the tub used for storage of what Mrs A believed to be the remains of her baby. We took independent advice from a midwife. We found that the midwifes failed to follow the correct procedures in relation to the storage and disposal of pregnancy loss products. Therefore, we upheld this aspect of Mrs C's complaint. Mrs C also complained that the board failed to take adequate steps to address the acknowledged failings in Mrs A's care. Mrs A contacted the hospital following her discharge to discuss her treatment and the location of the tub. After discovering it had been incorrectly disposed of, Mrs A asked for an explanation from the board. Mrs A was told that actions had been taken to prevent a reoccurrence. Mrs A contacted the board's complaint department some weeks later and was told that the incident had not been reported formally or logged as a complaint. We found that there was no evidence of any actions taken by the board to learn from the incident. We also found that the board had told Mrs A, in their first response to her, that action had been taken and the incident formally logged, which was incorrect. The board then failed to identify this inaccuracy in their second response to Mrs A. We upheld this aspect of Mrs C's complaint. Finally, Mrs C complained that the board failed to handle Mrs A's complaint reasonably. We found that the board's handling of the complaint failed to meet the standards

Ms C complained about the treatment which she received at Peterhead Hospital and Aberdeen Royal Infirmary. Ms C had been treated for heart issues although she had not been reviewed by a cardiologist (a doctor who specialises in disorders of the heart). Ms C was subsequently admitted to hospital on two occasions where the medication for her heart issues was continued. Ms C sought a private opinion which found that she did not have a heart problem and her medication was withdrawn. As a result of the medication withdrawal, Ms C's health improved. Ms C complained that she was unreasonably prescribed heart medication and that this medication was not kept under regular review. We took independent advice from a consultant cardiologist. We found that it was appropriate for Ms C to have been treated for suspected angina (chest pains) in view of her presenting symptoms. We considered the prescription of heart medication to be appropriate and did not uphold this aspect of Ms C's complaint. However, there was a failure to keep Ms C under review pending the outcome of further out-patient cardiology investigations which may have identified that she was suffering from potential side effects of the medication. There was an incident on discharge from hospital that Ms C had been prescribed two calcium channel blockers (medication to relax and widen the blood vessels) which was inappropriate, although it was unlikely that harm was caused due to the low dosages involved. We also found that there were failings in record-keeping regarding discussions with cardiology staff and that it would have been advisable that Ms C should have been physically examined by a consultant cardiologist. We considered that the board failed to keep Ms C's medication under review and upheld this aspect of her complaint.

Mr C's child (Child A) was born with several rare conditions that threaten life, affect physical and mental development and require extensive clinical and day- to-day management. Mr C complained that the board unreasonably failed to identify any indication of developmental conditions from scans of Child A during his partner's pregnancy. The board said that Child A's conditions were not identified earlier because they were either not detectable by ultrasound at any stage of pregnancy, were not part of the routine checks undertaken or appeared to be within normal limits for the relevant stage of pregnancy. Mr C was unhappy with this response and brought his complaint to us. We took independent advice from an obstetric and sonography adviser (a specialist in the use of ultrasound in pregnancy). We found that Child A's kidneys did not appear normal in the 20 week scan and that immediate referral to a specialist would have been reasonable practice in those circumstances. Therefore, we upheld Mr C's complaint.

Mr C complained on behalf of his late grandmother (Mrs A) about the care and treatment she received at Aberdeen Royal Infirmary (ARI) and Kincardine Community Hospital (KCH). Mrs A suffered from severe pain in her back and a suspected chest infection. She was referred by her GP to ARI, discharged on day five and then re-admitted to KCH ten days later. Mrs A was transferred back to ARI over a month later, and then back to KCH, where she later died. Mr C complained that the board failed to provide a reasonable standard of medical care and treatment, failed to provide a reasonable standard of nursing care and failed to handle his complaint appropriately. Regarding medical care, Mr C complained about Mrs A's pain management and a lack of communication around her treatment. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that Mrs A did not receive sufficient attention for her pain relief requirements. We found that this was an issue that could have been easily avoided, and one that caused Mrs A pain and the need for readmission. We also found that there was a lack of consideration for Mrs A's decision-making capacity regarding an operation that she underwent, and that there was a failure to discuss her care with Mr C and the family at this time. We upheld this aspect of the complaint. With regards to nursing care, we took independent advice from a nursing adviser. We found that, while the communication did not meet Mr C's family's needs for specific periods of time, there was no evidence in the nursing records to indicate that the overall level of nursing care Mrs A received was unreasonable. We did not uphold this part of the complaint. Lastly, regarding the board's handling of Mr C's complaint, we found that the board had apologised to Mr C for a delay in handling his complaint. However, we were concerned that, having given Mr C a revised timescale for providing a response, this was not

Mr C made a number of complaints about an inginual hernia repair (an operation to repair a weakness in the abdominal wall) he underwent at Dr Gray's Hospital. Mr C required to have further surgery a week later to remove a testicle due to a rare but recognised complication of the surgery. Mr C complained that he had not been reasonably informed of all the recognised complications when consenting to his surgery. Mr C was also concerned that his surgery was not carried out properly, that he was discharged too soon from hospital after the inginual hernia repair, and that there was an unreasonable delay in receiving a review appointment following the operation to remove his testicle. The board apologised that they were unable to offer him a review appointment within the original planned timescale due to a high volume of patients and took action to address this problem. The board identified no other issues with Mr C's treatment. He was unhappy with this response and brought his complaint to us. We took independent advice from a consultant general surgeon. We considered that the board's handling of the consent process was below a reasonable standard. It was not clear to what extent the term testicular atrophy (shrinkage/wasting) was explained to Mr C at the time of his clinic appointment or whether he understood this, nor was any additional patient information on the procedure provided to Mr C for reflection at this time. In addition, the consent form Mr C signed was completed on the day of surgery instead of at the out- patient clinical consultation and it did not list the possible but rare risk of testicular complication. Therefore, we upheld this aspect of Mr C's complaint. In relation to the procedure, we considered that this was completed to a reasonable and appropriate standard. The adviser noted that the rare complication Mr C suffered was not a result of a failing in the surgery. However, we noted that the board incorrectly suggested in their response t

Mr C complained about the dental treatment he received over a number of years from a number of dentists. Mr C had recently moved to a new dental practice, where the dentist discovered that he had a blood clot in his lower jaw which had been present for some time and caused the bone to degrade. Mr C felt that the previous dentists should have discovered this at an earlier stage. We took independent advice from a dentist. We found that there was no evidence that Mr C had reported any problems with his lower jaw, or that the lower teeth were unstable. We found that Mr C had had reasonable assessments in view of his reported symptoms over a number of consultations. We did not uphold the complaint. Related reading View Decision Report 201709200 as a PDF (10.92 KB) Updated: December 2, 2018

Mrs C complained about the care and treatment she received from her dentist. When Mrs C developed toothache, she was advised by a different dentist that her tooth needed to be extracted. Mrs C questioned why her tooth was left to decay to such an extent without any prior treatment. She complained that the first dentist failed to record the findings of an x-ray taken of her teeth which led to her tooth not being monitored properly. The dentist acknowledged that they did not record the findings of the x-ray, however they expected any subsequent dentist to review the patient's dental records, including the x-ray. We took independent advice from a dentist. We found that it would not be reasonable to expect a subsequent dentist to review the x-ray, as they would expect a report of the findings to be included in the patient's records. We concluded that Mrs C's dentist had failed to record the findings of the radiograph in line with the relevant guidance, and we upheld the complaint.

Mr C complained about the practice’s management of his longstanding bladder and penile problems. He was diagnosed with an enlarged prostate (a gland in the male reproductive system) and underwent a surgical procedure. This was followed by further surgery to address a complication. After an initial improvement, his symptoms returned. He also began experiencing a lot of penile pain and irritation, for which he was referred to dermatology (the area of medicine concerned with the skin). Mr C complained that the practice failed to arrange appropriate investigations and treatment in response to his symptoms, including delays in referring him to urology (the area of medicine concerned with the male and female urinary-tractt, as well as the male reproductive organs) and prolonged ineffective treatment with antibiotics and creams. We took independent advice from a GP who considered that Mr C’s symptoms were appropriately managed by the practice. We identified two occasions where earlier referrals to urology might reasonably have been considered. However, we did not find that the delays in referring to urology materially impacted on Mr C’s ongoing issues or the outcome for him. We considered that the practice appropriately managed Mr C's bladder and penile symptoms and did not uphold his complaints. Related reading View Decision Report 201703286 as a PDF (11.24 KB) Updated: December 2, 2018

Mr C complained that the practice refused to register himself and other members of his family as new patients. He also said that the practice failed to make reasonable adjustments to accommodate the needs of disabled family members. We found that the practice had followed their policy in relation to Mr C's registration. The practice declined to register Mr C on the basis of being unable to form a doctor / patient relationship with him because of his conduct which they are entitled to do. Therefore, we did not uphold this part of Mr C's complaint. Mr C also wanted to register other members of his family as new patients. The practice said that they could not do so unless they came to the practice so that their identification could be verified. This was in line with the practice policy. The practice made this clear to Mr C, however, we found that some later communication was not appropriate. The practice appeared to link the decision to not register Mr C's family to Mr C's behaviour in their communication. However, we noted that the practice acknowledged this mistake and confirmed that members of Mr C's family could still register as new patients, provided that they comply with the registration policy. On balance, we did not uphold this part of Mr C's complaint. In relation to the practice failing to make reasonable adjustments, we found that Mr C had declined to provide sufficient information about the disabilities of members of his family. Therefore, we considered that the practice did not have enough information to assess whether the adjustment requested was reasonable, or not. We did not uphold this part of Mr C's complaint. Related reading View Decision Report 201704515 as a PDF (11.28 KB) Updated: December 2, 2018

Ms C complained on behalf of her late mother (Mrs A) who was admitted to Aberdeen Royal Infirmary after complaining of severe back pain. On admission to hospital, Mrs A was also suffering from vomiting, constipation and had an infection. Ms C considered Mrs A did not receive reasonable care and treatment during her admission. In particular, that the board should have performed an MRI scan on Mrs A's back as she had previously had surgery for a spinal fracture. We took independent advice from a consultant in geriatric medicine (specialist in care of the elderly) and a nurse. We found that the actions of staff following Mrs A's admission to treat the cause of her dehydration and to determine why she was unwell and in pain were reasonable. We considered that all the relevant tests had been carried out and action taken by medical staff was reasonable. We also considered that the pain relief medication prescribed for Mrs A during her admission was appropriate. However, we noted that on one occasion Mrs A did not receive a dose of paracetamol when she should have and it was possible she may have suffered an increase in her pain as a result. The adviser noted that Mrs A's pain relief medication was an important part of her treatment. This incident was referred to by the board as an adverse event and was recorded on their Datix system (a system for tracking and reporting incidents). It was also noted that Ms C had not been made aware of this incident at the time. Therefore, we upheld Ms C's complaint. Ms C also complained that the board did not respond reasonably to her complaint. The board acknowledged that there were factual errors in their complaint correspondence and we considered that they had appropriately apologised to Ms C for this. We found, however, that there was an unreasonable delay by the board in informing Ms C that an adverse event had been recorded and this was compounded by their failure to tell Ms C the specific details of this event, despite

Mrs C complained that the practice had failed to provide appropriate care and treatment to her husband (Mr A) when he reported mobility problems following a fall where he was hit by a car door. Mr A had a history of ankylosing spondylitis (a type of arthritis in the spine). Following the fall, a nurse practitioner made a home visit and, after speaking to a GP, a diagnosis of a dead leg syndrome was made. Mr A continued to deteriorate and a further call was made to the practice the following day. Mr A was then admitted to hospital where he was diagnosed as having two unstable fractured vertebrae (bones in the spinal column). We took independent advice from a GP adviser and from a nursing adviser. We found that, based on the symptoms first reported by Mr A, there was no indication of a serious illness and that he did not require a hospital admission that first day. We found that it was appropriate that it was only when his condition deteriorated and he reported some numbness that it was deemed necessary to contact the hospital specialists and arrange for Mr A to be admitted to hospital. We did not uphold the complaint. Related reading View Decision Report 201707783 as a PDF (11.16 KB) Updated: December 2, 2018

Mr C complained about the care and treatment his daughter (Mrs A) received at Royal Cornhill Hospital. In particular, he complained that the board had failed to carry out appropriate risk assessments for Mrs A. We took independent advice from a consultant psychiatrist. We found that Mrs  A had been been provided with reasonable care and treatment and that regular risk assessments were carried out. We also noted that Mrs A had been appropriately assessed on her return to the ward after absconding from the hospital. However, we were concerned that, when Mrs A first went missing from the hospital, the board did not follow their missing persons policy. We found that there was a delay in the board contacting the police and that their missing persons policy did not specify a time period within which to initiate the actions to be followed when an in-patient goes missing from care. We were also concerned that the nursing records did not state when the first ward check was carried out after Mrs A went missing, and that there was no record of the actions taken by the board between the first check and a later check at 21:30. Therefore, we upheld this complaint. Mr C also complained that Mrs A had not been provided with appropriate medication. We found that the board's approach to medication treatment was appropriate and reasonable and in line with relevant guidelines. Therefore, we did not uphold this complaint.

Mr C complained about the care and treatment that his wife (Mrs A) received at Aberdeen Maternity Hospital. Mrs A called and was seen at the hospital over a number of weeks with symptoms, including bleeding, before she suffered a miscarriage at 20 weeks into her pregnancy. Mr C was concerned about the care she received and that alternative action could have prevented the miscarriage. We took independent advice from a consultant obstetrician (a doctor who specialises in pregnancy, childbirth and the female reproductive system). We found that the care Mrs A received at the hospital was reasonable and that there was no treatment to prevent spontaneous miscarriage at that stage of a pregnancy. We did not uphold the complaint. Related reading View Decision Report 201704183 as a PDF (10.94 KB) Updated: December 2, 2018

Mr C, an MP, complained on behalf of his constituent (Mr B) about the lack of care provided to his late partner (Ms A) who had attended an out-of-hours service after reporting severe pain. Ms A was examined by the GP and sent home with laxatives (medication to help increase bowel movements). Ms A subsequently collapsed at home a short time later and died. Mr B obtained a copy of the death certificate which showed evidence of bowel obstruction. Mr B felt that due to the severity of the condition, the GP should have identified the problem and that the issue could have been rectified in hospital earlier. We took independent advice from an adviser in general practice medicine and concluded that the GP had carried out an appropriate assessment of Ms A given her reported symptoms. She had a history of constipation and was on painkilling medication which would have contributed to her constipation. It would not have been appropriate to have prescribed additional painkillers as that would have worsened the constipation. We also found no evidence of bowel obstruction and, therefore, the decision to send Ms A home with laxatives to allow them time to take effect was reasonable. We found no medical requirement for a hospital admission at that time, and there was no information within the medical history or examination which would have alerted the GP to the subsequent events, or that the laxatives would not be effective. We did not uphold Mr C's complaint. Related reading View Decision Report 201704218 as a PDF (11.33 KB) Updated: December 2, 2018

Mr C complained about the care and treatment provided to his late relative (Mr A) at Dr Gray's Hospital. Mr A was admitted to hospital following a referral from his GP with raised body temperature/fever, an irregular heart rate and a high National Early Warning Score (NEWS - an aggregate of a patient's 'vital signs' such as temperature, oxygen level, blood pressure, respiratory rate and heart rate which helps alert clinicians to acute illness and deterioration). Mr A's condition deteriorated over a few days and he was transferred to the high dependency unit where he died a short time later. Mr C complained that the board failed to provide a reasonable standard of both clinical care and nursing care to Mr A. He also complained that the board failed to respond to his complaint in a reasonable way. We took independent advice from a consultant in acute medicine and a nurse. Regarding Mr A's clinical care, we found that there was poor documentation by medical staff and a lack of concern to Mr A's deterioration and failure to improve. We noted that the severity of Mr A's illness may have been underestimated. Therefore, we upheld this aspect of Mr C's complaint. However, we noted that the board had identified failings and had taken steps to address these. In relation to Mr A's nursing care, we found that there were no shortcomings in personal care of pain assessment and monitoring or blood sugar monitoring. However, we noted that nursing care in relation to fluid balance fell below a reasonable standard and that there were omissions in the recording of NEWS scores. Therefore, we found that the board failed to provide a reasonable standard of nursing care and upheld Mr C's complaint. Finally, Mr C complained that he did not receive a response to his complaint from the board until approximately five months after he submitted it. We found that the board did not keep Mr C informed of their progress and that there was an unreasonable delay in responding to his compla

Ms C complained that the practice unreasonably removed her from the patient list. Ms C had had concerns about the treatment which she had received from the practice previously but these had been dealt with under the complaints procedure. Ms C was surprised to subsequently receive a letter from the NHS practitioners services advising her of the decision taken by the health board to remove her from the practice patient list due to a breakdown in the professional relationship. Ms C then learned that the instruction to remove her came from the practice and that she had not been given an explanation as to how the practice had come to their decision. 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 Ms C's actions, and did discuss the issue with the health board, staff did not formally bring them to Ms C's attention in line with the regulations and guidance and therefore she was unaware of the practice's concerns. We upheld the complaint.

Mr C complained that the practice delayed in referring his late father (Mr A) for appropriate specialist investigation of his iron deficient anaemia (a condition where the blood lacks an adequate amount of healthy red blood cells). Mr C considered that an urgent colonoscopy should have been arranged, in line with cancer referral guidelines. He also raised concerns about the chosen referral pathway once a referral was eventually made, as the referral was to a vascular surgeon rather than directly for colonoscopy. Mr A was subsequently diagnosed with colorectal cancer which was not amenable to treatment and he later died. In responding to Mr C's concerns, the practice said they did not deem an earlier referral appropriate at the time in light of Mr A's other complex medical conditions. We took independent medical advice from a GP, who advised that there were no current complex medical conditions which could have explained the significant deterioration in Mr A's red blood count. As such, they advised that cancer referral guidelines should have been followed and Mr A should have been appropriately assessed and referred for urgent investigation. We found no evidence of an appropriate examination having occurred and a referral was not made until almost nine months after iron deficient anaemia was diagnosed. We found that the referral should have been sent to a gastroenterologist or surgical doctor, rather than a vascular surgeon. In addition, the adviser highlighted that Mr A was prescribed an inappropriate dosage of iron supplements and he was not adequately monitored to assess his response to these. We concluded that there was an unreasonable failure to appropriately assess, treat and monitor Mr A's iron deficient anaemia, and an unreasonable delay in arranging appropriate specialist investigation. We upheld the complaint.

Mrs C complained on behalf of her husband (Mr A) who was treated for cancer at Aberdeen Royal Infirmary. Mrs C complained that there was a lack of communication about Mr A's care between the staff and his family and between the staff themselves. Mrs C also complained that Mr A was over-sedated which was causing periods of delirium and that his feeding and nutritional needs were not met. We took independent advice from a nursing adviser and a consultant physician. We found that communication between hospital staff and Mr A's family and between hospital staff themselves was reasonable. However, Mrs C had raised concerns about Mr A having delirium and this was not appropriately acted upon in line with the Health Improvement Scotland (HIS) programme on identifying delirium in patients. On balance, we upheld this part of Mrs C's complaint. In relation to over-sedation, the adviser said that the medication Mr A received is often accompanied by side effects and that it could have been a contributing factor to him developing a period of delirium. However, these side effects were not sufficient to say that Mr A's care was unreasonable or that he was over-sedated. Therefore, we did not uphold this aspect of Mrs C's complaint. Finally, we found that Mr A was having difficulty eating and drinking and that this was due to damage to his mouth, a common consequence of the cancer treatment he was receiving. The adviser said that the hospital staff took reasonable steps to encourage and promote Mr A's nutritional care. There was evidence that Mr A had declined artificial feeding which would have improved his ability to eat. Therefore, we did not uphold this complaint.

Mr C complained to us about the fact that his medical practice had not carried out a home visit. He had phoned twice on the same day with severe back pain. The duty GP made a diagnosis over the phone and recommended a course of action, but did not arrange a home visit. The next day, Mr C's back pain persisted and he experienced numbness after suffering a fall. The GP on duty that day arranged for a home visit to be carried out and Mr C was transferred to hospital and subsequently diagnosed with cauda equina syndrome (a disorder that affects the nerves). This required surgery which has left him with ongoing difficulties. Mr C feels that the consequences may not have been as severe had the original GP arranged for a home visit to be carried out. In addition to this, Mr C complained about some aspects of the practice's complaints handling. We considered the information provided by Mr C and the information provided by the practice. We also took independent advice from a GP adviser. We found that the original duty GP's actions were appropriate on the basis of Mr C's presenting symptoms. When further symptoms developed, it was appropriate to arrange a home visit but it was reasonable not to on the basis of the original phone calls. We concluded that the original duty GP's actions were in line with the relevant guidance and regulations. We did not uphold this aspect of Mr C's complaint. In respect of the practice's complaints handling, we agreed that there were some measures they could put in place to improve the customer experience. However, we considered their handling and response to Mr C's complaint to be reasonable on the whole. Although we did not uphold Mr C's complaint about this, we did offer some feedback to the board about how they can improve their complaints handling. Related reading View Decision Report 201703523 as a PDF (11.43 KB) Updated: December 2, 2018

Miss C complained on behalf of her brother (Mr A) about the care and treatment provided to him across numerous admissions to Aberdeen Royal Infirmary. Mr A underwent various surgeries to treat spinal cord compression and a spinal abscess. After surgery to drain the spinal abscess, Mr A was left paralysed from his waist down and was left with only partial movement in his upper body. Miss C complained to the board as she felt that Mr A had not been properly cared for and treated. She believed that opportunities were lost to treat him sooner, and that his outcome may have been different if these opportunities had been taken. The board responded, however Miss C remained unhappy and brought her complaints to us. Miss C complained that the board did not provide reasonable treatment to Mr A across his numerous admissions to the hospital. We took independent advice from consultants in radiology and neurosurgery, and from a nurse. We found that there was an opportunity missed to drain the spinal abscess. Had the abscess been drained at that time we considered that Mr A's outcome may have been different. We found that a scan that was carried out by an outsourced company out-of-hours did not meet a satisfactory standard, however this was not identified as having impacted Mr A's outcome. We also found that Mr A's case could have been considered in a more holistic way. We upheld this aspect of Miss C's complaint. In relation to Mr A's discharge home from hospital, Miss C complained that he was unreasonably discharged on one occasion, and that the board unreasonably failed to ensure that there was a suitable home care package in place for him following that discharge. We found no evidence to suggest that Mr A was discharged unreasonably. We found that the relevant paperwork had been completed, and that Mr A had capacity and was in agreement with the decision to discharge him at that time. We also found that there was no evidence of a need for Mr A to have a home care

Mr C complained about the standard of pressure area care which his mother (Mrs A) received while she was a patient in Woodend Hospital. Mrs A was in hospital for a number of months and, due to her reduced mobility, developed a grade two pressure ulcer which progressed to a grade four pressure ulcer. A grade four pressure ulcer is the most severe kind, and people with grade four pressure ulcers have a high risk of developing life-threatening infections. We took independent advice from a nursing adviser who noted that appropriate risk assessments were not carried out and incorrect equipment had been used in an effort to prevent the development of and healing of pressure ulcers. While the staff had taken action to change Mrs A's position in bed and when she was sitting in a chair, these were not changed frequently enough. There was also a delay by the staff in referring Mrs A for an assessment by the tissue viability service. We upheld the complaint. However, we did note that the board have since carried out an investigation and audit which identified learning opportunities for staff in regards to knowledge and awareness of pressure area care.

Mrs C complained about the care and treatment of her late mother (Mrs A). Mrs A became unwell and was seen initially by an out-of-hours doctor, who diagnosed infection and prescribed antibiotics. Mrs C called the practice and spoke to a GP the following day as Mrs A was still unwell, and a home visit was arranged for the following day. When a GP reviewed Mrs A at home the next day, arrangements were made to admit her to the GP unit in a local care home. From there, she was transferred to hospital in the early hours of the following morning, where she deteriorated and died five days later. Mrs C complained that, when she called the practice, they did not arrange for Mrs A to be reviewed that day. We took independent advice from a GP adviser, who considered that the GP carried out an appropriate assessment and, based on the information gathered, took steps to arrange for Mrs A to be reviewed within a reasonable timescale. We accepted the advice and did not uphold the complaint. Mrs C also complained that the GP who reviewed Mrs A at home should have arranged to admit her directly to hospital. She also raised concerns that the GP retrospectively altered Mrs A's recorded oxygen saturation level. The practice indicated that this was to rectify a typing error. We were advised that the originally recorded level should have led to a direct hospital admission, whereas the amended level was in keeping with the actions taken. We were unable to establish the true picture and, therefore, could not conclude that there was an unreasonable failure to admit Mrs A to hospital. As such, we did not uphold the complaint however we made a recommendation in relation to record-keeping.

Mrs C complained about the care and treatment of her late mother (Mrs A), initially by an out-of-hours doctor and then following an admission to Aberdeen Royal Infirmary. The out-of-hours doctor visited when Mrs A became unwell and diagnosed infection, prescribing antibiotics. Two days later Mrs A was admitted by her GP to a GP unit in a local care home. From there she was admitted to hospital in the early hours of the following morning with sepsis (a blood infection) secondary to pneumonia. After an initial improvement, she deteriorated and died five days later. Mrs C complained that the out-of-hours doctor should have admitted her mother to hospital. We took independent advice from a GP adviser, who considered that the doctor appropriately assessed Mrs A and treated her in line with relevant guidelines. We were advised that there were no clear signs at the time that might reasonably have led the doctor to suspect a diagnosis of pneumonia and necessity for hospital admission. We accepted this advice and did not uphold the complaint. Mrs C also complained that the family were told by hospital staff to administer Mrs A's regular medication from her own supply, and also that there was a 12 hour delay in commencing treatment for her presenting condition. We took independent advice from a hospital adviser, who confirmed that it was not good practice to expect relatives to administer medication. However, the board had already acknowledged this and appropriately highlighted the issue to staff. The adviser noted that the medication was appropriately recorded so no safety issues were apparent. In terms of treating Mrs A's presenting condition, the adviser noted that she had a NEWS score (an aggregate of a patient's 'vital signs' such as temperature, oxygen level, blood pressure, respiratory rate and heart rate which helps alert clinicians to acute illness and deterioration. A NEWS score of five or more is linked to increased likelihood of death or admission to a