SPSO Individual Decisions

Mrs C made a complaint on behalf of Mrs B about the care and treatment her late husband (Mr A) received at his GP practice. Mr A had a number of health issues including epilepsy for which he had been prescribed medication for many years. Mr A had attended the surgery for worsening upper abdominal pain following a two day history of vomiting. Mr A was admitted to hospital where he died several days later. Pancreatitis (inflammation of the pancreas) was recorded as one of the causes of Mr A's death. Mrs C complained that the practice had failed to provide Mr A with reasonable care and treatment. In particular, that Mr A's GP had failed to recognise that Mr A's epilepsy medication could cause pancreatitis. We took independent advice from a GP. We found that the care and treatment provided to Mr A by the practice was reasonable. Mr A's health concerns were appropriately investigated and blood tests and referrals were made as appropriate and in a timely manner. We also noted that pancreatitis is a very rare side effect of the medication Mr A was taking for his epilepsy. We considered that the care provided to Mr A by the practice was of a reasonable standard and in line with good medical practice. Therefore, we did not uphold Mrs C's complaint. Related reading View Decision Report 201704771 as a PDF (23.96 KB) Updated: December 19, 2018

Miss C complained about the antenatal care she received from the community midwifery team when she was pregnant. Miss C was informed she was on the "red pathway care" for her pregnancy which meant her antenatal care would be led by a consultant obstetrician (a doctor who specialises in pregnancy and childbirth) and supported by the community midwifery team. Miss C complained that she was told by her midwife at her first appointment that she would not need to have future appointments with her midwife and would only see her consultant. Miss C also complained that she missed out on vital check ups and she did not receive her relevant maternity forms on time. The board apologised that the consultant did not provide Miss C with the appropriate forms. We took independent advice from a midwife. We found that when Miss C contacted the community midwifery team, the midwife acted appropriately and offered to meet with Miss C to provide her with the necessary forms and information, however, Miss C refused this offer and did not engage in the service. We found at this point, Miss C was still within the required timescale for submitting her forms, therefore, she did not suffer any significant injustice as a result. We did not find any evidence that Miss C was advised at her first appointment that she was not required to see her midwife again. We did not uphold Miss C's complaint. Related reading View Decision Report 201801666 as a PDF (23.98 KB) Updated: December 19, 2018

Ms C complained about the nursing care her mother (Mrs A) received at Raigmore Hospital. Mrs A suffered from osteoporosis (weak or fragile bones) and fell during an admission to the hospital. A number of weeks following her discharge from hospital, Mrs A's GP arranged for x-rays to be taken which showed that she had suffered two fractures to her spine. Ms C complained that nursing staff failed to appropriately care for Mrs A following her fall. We took independent advice from a nurse who is experienced in hospital falls prevention. We found that the nurses who attended Mrs A failed to act in accordance with falls prevention guidance. There was no record that an adequate assessment had been carried out to establish if Mrs A had sustained an injury following the fall. There was also a failure to arrange a medical review for Mrs A. We were unable to find out when the fractures actually occurred as Mrs A did not report to staff that she was in pain at the time and the actual diagnosis of fractures was not made until a number of weeks following the fall. However, we considered that the failings identified were unreasonable and upheld Ms C's complaint.

Mr C complained about the health care and treatment he had received in prison. In particular, he complained about problems he had experienced in receiving all his prescribed medication within the prison regime. The board acknowledged that there had been problems with Mr C receiving all his prescribed medication and they suggested that he discuss this with the GP. Mr C was unhappy with this response and brought his complaint to us. We took independent medical advice. We found that the prison healthcare team were responsive to Mr C's concerns, including altering his medication to ensure he receives all of it, and liaising with pain specialists. We considered this treatment to be reasonable and did not uphold Mr C's complaint. Related reading View Decision Report 201802054 as a PDF (10.91 KB) Updated: December 2, 2018

Mrs C complained about the treatment she received from a podiatrist (a medical professional who specialises in the feet and ankles) when she attended a consultation to remove some hardened skin around her toe. Mrs C believed that the podiatrist had removed too much skin as her toe became painful and she was subsequently diagnosed with an infection. We took independent advice from a podiatrist. We found no evidence from the clinical records that there was a problem for the podiatrist when treating Mrs C's toe. We noted that they gave Mrs C appropriate advice on changing the type of footwear she wore as this would have contributed to her foot problems. We also found that Mrs C had other health conditions which may have contributed to her being susceptible to skin infections. We did not uphold the complaint. Related reading View Decision Report 201801682 as a PDF (10.98 KB) Updated: December 2, 2018

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs B) about the care and treatment provided to Mrs B's late husband (Mr A) at Belford Hospital. Mr A was admitted to hospital on a number of occasions over a short period of time for breathlessness and chest pain. Ms C complained about the clinical care and nursing treatment provided to Mr A, the board's communication with Mrs B about her husband's deterioration, and the post-mortem care (care after death) provided to Mr A. We took independent advice from a consultant physician and from a nursing adviser. We found that there were a number of failings with regards to the clinical treatment provided to Mr A, and we upheld this aspect of the complaint. However, we found that the nursing care had been reasonable and so we did not uphold this part of the complaint. Regarding communication, we found that there was a failure to discuss Mr A's deterioration with Mrs B in a timely manner, and so we upheld this part of the complaint. We found that the post-mortem care provided to Mr A was reasonable, and we did not uphold this aspect of the complaint. However, we found that the board had not addressed Ms C's concerns around post-mortem care in their original complaint repsonse. We, therefore, made a recommendation regarding this.

Ms C complained that the physiotherapy treatment she had received at Lorn and Islands Hospital had been unreasonable, inappropriate and had caused her injury. We took independent advice from a physiotherapist. We found that there was no evidence that the assessment or physiotherapy treatment Ms C received had been unreasonable or inappropriate. Ms C had given consent to all of the treatments she received. We were also satisfied that the board had tried to address her concerns and to explain the reasons for the treatment she had received. In addition, they had produced an information leaflet for patients about the nature and range of treatment options available. Therefore, we did not uphold Ms C’s complaint. Related reading View Decision Report 201703481 as a PDF (10.9 KB) Updated: December 2, 2018

Ms C complained about the care and treatment provided to her late partner (Mr A) during his time as an in-patient at New Craigs Psychiatric Hospital and after his discharge. Ms C was concerned that the potential physical causes of Mr A's psychosis (a mental health problem that causes people to perceive or interpret things differently from those around them) were not appropriately investigated, and that the approach taken to his anti-psychotic medication was unreasonable. We took independent advice from a psychiatrist. We found that the potential physical causes of Mr A's psychosis were reasonably investigated. We also found that the anti-psychotic medication Mr A was given was appropriate and necessary for his recovery, and that it was appropriate to continue Mr A on this medication after his discharge. We did not uphold Ms C's complaints. Related reading View Decision Report 201700707 as a PDF (10.98 KB) Updated: December 2, 2018

We closed this complaint before concluding our investigation. The complainant had asked for the investigation to be put on hold while she made a subject access request, but more than six months later had not asked for our investigation to be continued. At the time of closing, more than a year had passed since she brought her complaint to us and her circumstances had changed, meaning the outcome she was seeking was no longer achievable. Related reading View Decision Report 201607509 as a PDF (10.8 KB) Updated: December 2, 2018

Ms C, who is an advocacy and support worker, complained on behalf of her client (Mr A) about the care and treatment Mr A had received at Raigmore Hospital. Mr A had been diagnosed with terminal cancer. Ms C complained that a consultant oncologist (a doctor who specialises in cancer treatment) unreasonably told Mr A that radiotherapy (a treatment using high-energy radiation) he had received for his cancer had not worked and that he should take pazopanib (a drug used to treat kidney cancer). Mr A considered that the radiotherapy had been effective and that he should be given further radiotherapy treatment. We took independent advice from a consultant uro oncologist (a doctor who specialises in treating cancers of the urinary system and male reproduction system). We found that it had been reasonable for the board to consider that the radiotherapy had not been effective and that Mr A should take pazopanib. We found that there had not been any failings in Mr A’s management by the board. His decision not to take pazopanib was also respected by the clinicians and he was given further radiotherapy. We did not uphold Ms C's complaint. Related reading View Decision Report 201705815 as a PDF (11.1 KB) Updated: December 2, 2018

Mrs C has power of attorney for her son (Mr A) who has a learning difficulty and lives independently. Mr A was awarded an Individual Service Fund (ISF) under self-directed support by the board to support him to achieve his personal outcomes. Mrs C complained that the board did not act reasonably in relation to the ISF. She said that the board unreasonably refused certain funding requests, that they failed to follow procedure and to provide clear information about their policies and procedures. The board acknowledged that their communication regarding their processes was poor, however they did not consider the funding requests sustainably supported Mr A to meet his personal outcomes. We took independent advice from a social worker. We found that it was reasonable for the board to refuse some of the funding requests, but not all. We found the board failed to ensure the ISF agreement was completed and signed and this was not done until more than 12 months after the ISF started. We concluded that the board did not properly follow procedure and that there were failings in their communication with Mrs C. Therefore, we upheld the complaint. We noted the board had made some significant improvements since Mrs C raised her complaint, therefore we did not make any further recommendations. However, we did ask the board to provide us with evidence of these changes. Related reading View Decision Report 201706980 as a PDF (11.26 KB) Updated: December 2, 2018

Mrs C, an advocacy worker, complained on behalf of her client (Ms A) that the board failed to provide Ms A with a reasonable standard of mental health care and treatment. Ms A suffered from long term anxiety and depression and was referred for assessment at New Craigs Psychiatric Hospital. She was diagnosed with hypomania (a less severe form of the manic phase of bipolar affective disorder) and was started on the appropriate medication for this diagnosis. Three months later, Ms A was informed that she had been misdiagnosed and was advised to slowly come off the medication. The board apologised to Ms A for this error in diagnosis and acknowledged the distress the consequences had caused her. Ms A was unhappy with this response and Mrs C brought her complaint to us. We took independent advice from a consultant in forensic psychiatry. They noted that Ms A's medical records did not detail what, if any, action was taken to explore other options to carry out a second opinion following a request from Ms A. We also found that the board unreasonably prescribed Ms A third level medication (medication prescribed if the first two are insufficient) in the first instance. Although this decision may not have been unreasonable itself, we found that the reasoning for this prescription was not clearly recorded. Therefore, we upheld Mrs C's complaint.

Miss C complained to us about the standard of dental treatment provided to her adult son (Mr A) by the dentist over a number of years. In particular, she raised concern that there were delays in referring Mr A to hospital for specialist treatment and that the dentist had failed to listen to her concerns that Mr A should have been provided with braces. We took independent advice from an adviser in general dentistry. Whilst we did note some failings in record-keeping, we found that there was no delay in referring Mr A to hospital. We also found that there was no evidence that Mr A needed braces. We did not uphold the complaint, however, we highlighted our concerns about record-keeping to the dentist to use as a learning opportunity. Related reading View Decision Report 201705833 as a PDF (10.94 KB) Updated: December 2, 2018

Mr C attended the prison health service on a number of occasions with chest infections and high blood pressure. He complained that he did not receive appropriate medication and that there were delays in being referred to specialists. We took independent advice from a GP adviser. We found that Mr C had been assessed and treated appropriately. We also considered that appropriate referrals had been made, and that the waiting times for appointments were normal. We noted that there had been a delay in discussing x-ray results with Mr C, but the board had apologised for this and had provided evidence of improvements in their recording and checking system, to prevent this from happening again. We did not uphold this complaint. Related reading View Decision Report 201706962 as a PDF (10.95 KB) Updated: December 2, 2018

Miss C raised a complaint about the care and treatment she had received from her dentist over an extended period of time. Miss C had suffered from pain in one of her lower teeth and was advised she would require root canal treatment. Miss C continued to be in pain; the treatment had to be repeated and also caused problems with an adjacent tooth. Miss C said she was told the tooth required extraction and was referred to the dental hospital for further treatment. Miss C was dissatisfied with the way the dentist managed her dental care. We took independent advice from a dentist. We found that the dental treatment which Miss C received was appropriate and in accordance with usual practice. The symptoms which Miss C had reported were uncertain, therefore a period of monitoring was required. The suggestion by the dentist for root canal treatment or extraction was reasonable in view of the dental records and x-rays which were taken. We did not uphold the complaint. Related reading View Decision Report 201705986 as a PDF (11.05 KB) Updated: December 2, 2018

Mrs C complained that the care and treatment she received at Raigmore Hospital, in relation to problems with her gallbladder, was unreasonable. She said that on several occasions she attended an out-of-hours GP and the emergency department but her symptoms were not investigated and as a result, when she was diagnosed with cholecystitis (inflammation of the gallbladder), the surgery was complicated and her recovery was difficult. We took independent advice from a GP, a consultant in emergency medicine, and a surgeon. We found that the care and treatment provided to Mrs C was of a reasonable standard and there was no indication of gallbladder problems at her attendances prior to the diagnosis of cholecystitis. We did not uphold Mrs C's complaint. Related reading View Decision Report 201703963 as a PDF (10.94 KB) Updated: December 2, 2018

Mr C complained about treatment that he received at Raigmore Hospital when he was admitted via the emergency department. Mr C had undergone a vasectomy procedure (a procedure where the tubes that carry sperm from a man's testicles to the penis are cut, blocked or sealed) over two weeks earlier and had developed painful swelling. Mr C complained that, after admission for assessment/investigation in the urology department, he was examined and then discharged with advice to manage his symptoms conservatively. Mr C later had to be admitted for a number of days for treatment of an abscess. We took independent advice from a consultant urologist. We found that there were several factors in Mr C's presentation that meant that, on balance, a more proactive approach to his symptoms would have been appropriate. We upheld this aspect of his complaint. Mr C also complained that the board's response to his complaint was inaccurate. We found that key dates in the response were incorrect. We noted that the board acknowledged this failing and advised that they had taken steps to address it going forwards. We upheld this aspect of the complaint.

Mrs C, who works for an advocacy and support agency, complained about the care and treatment that her client (Mrs B)'s adult son (Mr A) received from the board's mental health services. Mrs B and Mr A had been told that Mr A had an assumed borderline personality disorder and that, as part of his treatment, he would attend a specified cognitive behaviour therapy programme. However, the decision was taken that Mr A should attend another course which caused Mr A and his family great distress and they felt that the staff had not diagnosed his condition appropriately. Subsequently, Mr A was reassessed by a consultant psychiatrist as having an Emotionally Unstable Personality Disorder (EUPD) and was placed on the original specified cognitive behaviour therapy programme. The family felt that there was an undue delay in the diagnosis of EUPD. We took independent advice from two mental health advisers and found that Mr A had been seen by a number of clinicians in mental health over an extended period of three years. We found that, although Mr A had displayed some traits of EUPD, no formal structured assessments had been completed which would have led to an earlier diagnosis of EUPD. We found that this was contrary to national and local guidance. The assessments which were carried out during the period lacked detail and consistency. They concentrated on current symptoms, rather than someone taking on collective responsibility and arriving at a diagnosis of EUPD by carrying out a structured assessment using recognised tools. We also found that there was a failure by the board in arranging for Mr A to receive a second medical opinion which had been requested by one of the consultant psychiatrists. We upheld the complaint.

Ms C complained about the care and treatment provided to her late partner (Mr A) by an out-of-hours GP and at Belford Hospital. She complained that the GP did not reasonably assess Mr A and that, when he was later admitted to hospital, there was a delay in diagnosis which resulted in no treatment options being available for his perforated duodenal ulcer (when the lining of the stomach splits due to a sore). We took independent advice from a GP and a consultant physician. We found that the care and treatment provided to Mr A by the GP was of a reasonable standard and that his symptoms were most fitting with a diagnosis of viral illness at this time. We also found that, whilst there was some delay in diagnosing Mr A when he was admitted to hospital (which the board had acknowledged), this did not have any impact on Mr A's outcome as, due to his other illnesses, surgery would not have been an option for him. We did not uphold this complaint. Related reading View Decision Report 201704498 as a PDF (11.04 KB) Updated: December 2, 2018

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Ms A). Over the past twenty years Ms A has suffered from balance issues and problems with her eyes. Over a period of years, Ms A attended the ophthalmology (eye) and neurology (brain and nervous system) departments of Raigmore Hospital. Her symptoms were assessed and investigated and she was referred for a second opinion, but no causes were found for her symptoms. The ophthalmology department decided not to arrange further appointments for her and it was suggested that she attend the rehabilitation clinic. Ms A considered that clinicians had given up on her and that she had been disbelieved. Ms C complained to us that the decision to discharge Ms A to the rehabilitation clinic was unreasonable, as she had not yet been diagnosed. We took independent advice from consultants in ophthalmology and neurology. We found that all of Ms A's care and treatment had been reasonable and appropriate but that, despite this, Ms A's symptoms remained. It was acknowledged that this was very challenging for her, however we considered that the absence of a diagnosis or abnormal test findings did not mean that she had been disbelieved. Furthermore, we found that it was sensible and reasonable to refer her to the rehabilitation clinic which was best placed to deal with her continuing condition. We did not uphold the complaint. Related reading View Decision Report 201704189 as a PDF (11.28 KB) Updated: December 2, 2018

Ms C complained about the care and treatment provided to her late partner (Mr A) by GPs at the practice. Ms C complained that GPs incorrectly diagnosed a viral illness, and that they should have recommended hospital admission at an earlier point. We took independent advice from a GP. We found that, on the two occasions that GPs from the practice attended Mr A, they assessed and examined him reasonably and that, based on this, the diagnosis of viral illness was reasonable as there was no evidence of any more serious cause of Mr A's illness. We did not uphold this complaint. Related reading View Decision Report 201704913 as a PDF (10.87 KB) Updated: December 2, 2018

Ms C complained about maternity care and treatment she received at Raigmore Hospital in relation to her labour and birth. Ms C had previously had a caesarean section and had planned a vaginal delivery for this birth. Ms C went to the hospital as her waters had broken, however, she was not experiencing contractions. She was admitted and the following day, a drip was administered to augment her labour. Ms C's labour progressed with continuous monitoring of the baby's heart rate. When this dropped, the drip was stopped and Ms C had an emergency caesarean section to deliver her baby. During the operation, it was discovered that a scar from a previous caesarean section had ruptured. Ms C complained about the care she received as she considered that she was left too long without action after her waters had broken and that the drip had not been prescribed at a safe level, given her previous caesarean section. Ms C was also concerned about the board's handling of her complaint as there were delays and inaccuracies in the final response. We tookindependent advice from a consultant obstetrician (a doctor who specialises in pregnancy and childbirth). We found that the risks and benefits of vaginal delivery following caesarean section had been discussed during Ms C's pregnancy. We found that the care and treatment Ms C received was in line with local protocols and national guidance. We did not uphold this aspect of Ms C's complaint. However, we made a recommendation that the board consider recording that the Royal College of Obstetricians and Gynaecologists leaflet on birth options after previous caesarean section is provided to patients like Ms C. Regarding complaints handling, we found that during the board's own consideration of the case, they apologised that there had been delays in Ms C's complaint reaching the appropriate team, although we were unable to determine the reason for the delay. We found the board's final response was open to misinterpretation in t

Mr C complained to us about the psychiatric care and treatment his daughter (Miss A) had received from board staff. Miss A was subject to compulsory measures in a care home under mental health care legislation. Mr C complained that the board had failed to consider the family's requests for Miss A to be moved to a different care home. We took independent advice from a consultant psychiatrist. We found that the board had acted reasonably in relation to the family's requests for Miss A to be moved. We found that the issue was discussed with the family and that attempts were made to identify and understand Miss A's views on the subject. We also found that the board had made reasonable efforts to listen to and respect the family's views. We did not uphold this aspect of the complaint. Mr C also complained that the board had failed to provide Miss A with adequate psychiatric care while she was in the care home. He considered that this led to her admission to a psychiatric hospital. We found that there were no significant failings in the psychiatric care provided to Miss A in the care home. Her care plan had been reasonable and she had received adequate psychiatric care and supervision during the relevant period. Additional attempts to monitor or supervise Miss A would not have changed the outcome and board staff had acted reasonably in relation to this. Although we did not uphold this aspect of Mr C's complaint, we found that Miss A's records about her care plan were not of an adequate standard and we made a recommendation in relation to this.

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mr A). Ms C complained that Mr A did not receive a reasonable standard of surgical care and treatment when he was admitted to Raigmore Hospital for an operation. During the operation, Mr A suffered an ureteric injury (an injury or cut to the ureter - a tube that carries urine from the kidneys to the urinary bladder). Ms C said that Mr A was not warned of the risk of ureteric injury when he consented to the procedure and that the injury itself was an unreasonable surgical error. Ms C also said that the injury was not identified and treated within a reasonable time. As a result of the failings, Mr A has endured poor health and the quality of his life has significantly deteriorated. It was also likely that Mr A would require further surgical procedures. We took independent advice from a colorectal surgeon. We found no evidence that the specific risk of ureteric injury was discussed with Mr A during the consent process, which was unreasonable and contrary to the relevant guidance. We also found that the ureteric injury was a surgical error which had an adverse outcome and that it was, to an extent, avoidable. We also found that there was an unreasonable lack of detail in the operation note which may have helped clinicians to be more alert to post-operative complications, although we found that the standard of post-operative care and treatment provided was reasonable. We upheld Ms C's complaint.

Mrs C complained about the care and treatment her father (Mr A) received from the board at Caithness General Hospital. Mrs C complained that the board unreasonably failed to take into account her father's dementia, unreasonably failed to establish that Mrs C held a welfare power of attorney in respect of her father and unreasonably failed to obtain appropriate consent for a gastroscopy procedure (an examination of the inside of the gullet, stomach and the first part of the small intestine). We took independent advice from a nurse and from a consultant in acute medicine. Based on the information in Mr A's records and the advice we received, we considered that the board did not unreasonably fail to take into account Mr A's dementia while he was in hospital and we did not uphold this part of the complaint. However, we were concerned that some documents relating to this were not completed by hospital staff and so we made a recommendation regarding this. On the issue of welfare power of attorney, we found that attempts should have been made to establish if Mr A had a welfare power of attorney within 24 hours of admission. We found that this had taken the board three days and that this was an unreasonably long time for this to take. We upheld this aspect of the complaint. Mr A had more than one gastroscopy and Mrs C's complaint was that the board had not obtained appropriate consent for the first gastroscopy. We found that it was reasonable for staff to conclude that Mr A had sufficient capacity to give his consent for his first gastroscopy procedure and that appropriate consent was obtained. We, therefore, did not uphold this part of Mrs C's complaint. However, we were concerned about the consent process for Mr A's second gastroscopy and we found that an adult with incapacity form (completed for patients deemed not to have capacity to consent) should have been completed and that the procedure should have been discussed with Mrs C. We also found that the board's