SPSO Individual Decisions

Mrs C complained about the care and treatment provided to her late husband (Mr A) who had a rare and aggressive form of bladder cancer. Mr A received care and treatment at the Royal Infirmary of Edinburgh and the Western General Hospital. We took independent advice from urology (specialism that deals with the male and female urinary tract, and the male reproductive organs), oncology (cancer) and general surgery advisers. We found that the time taken to investigate and begin treatment for Mr A's bladder cancer was reasonable and in accordance with the Scottish Government's cancer waiting time targets. We also found that chemotherapy treatment commenced within a reasonable timescale. The level of information about treatment options, including their risks and benefits, provided to Mr A was also reasonable. This included sufficient information about the specific risk of pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs), a complication Mr A subsequently experienced. In the context of Mr A's rapid deterioration, the level of planning for end of life care was reasonable. When Mr A subsequently experienced bowel obstruction, it was reasonable that he was treated on a surgical ward. While Mr A's pain was difficult to manage, the attempts by the clinical team were reasonable, as was the aim to discharge Mr A home. When Mr A's condition deteriorated, he was transferred to a hospice without unreasonable delay. We did not uphold Mrs C's complaints. Related reading View Decision Report 201806790 as a PDF (24.5 KB) Updated: March 18, 2020

Miss C complained about the care and treatment she received following elective abdominal surgery. When Miss C awoke following the surgery, she had considerable pain in her leg. She was given pain medication but her leg became significantly worse the next day. Compartment syndrome (when pressure rises in a compartment bordered by a facial covering because of a reduction in the blood flow to the muscle) was suspected and later diagnosed. Miss C underwent surgery but suffered outer muscle loss on her left leg. Miss C complained that there had been a delay in diagnosing compartment syndrome in light of her symptoms. She also complained that the board failed to provide proper treatment because of this delay. Finally, Miss C complained about how the board handled her complaint. We took independent advice from a surgeon. We found that there had been an unreasonable delay in diagnosing compartment syndrome. Specifically, the signs and symptoms Miss C experienced should have led to an earlier orthopaedic consultant (specialist in the treatment of diseases and injuries of the musculoskeletal system) review and diagnosis of compartment syndrome. In light of this, we upheld this aspect of the complaint. In respect of Miss C's second complaint, we considered that her symptoms were well-monitored and recorded. We considered the failing to be in the interpretation of the clinical observations. Outside of this failure, we considered Miss C's management to be good and as expected following significant surgery. Once compartment syndrome was diagnosed, we found the care and treatment to be reasonable. We concluded that the failing had been the unreasonable delay in diagnosing compartment syndrome and not in the treatment provided. Therefore, we did not uphold this aspect of the complaint. Finally, we concluded that it took an unreasonable length of time for the board to carry out their stage 2 complaint investigation and that Miss C was not appropriately updated about t

Ms C saw her dentist about a number of issues and agreed to undertake a course of dental treatment which included denture fittings over a number of months. However, Ms C told us that once treatment had been completed the dentures were ill-fitting and the cost of the planned treatment had not been made clear to her. We took independent advice from a dental adviser. We found that the evidence from Ms C's dental records showed the standard of treatment provided at each appointment during this period was reasonable and that treatment decisions were in line with options under the NHS. We also found that the evidence showed the planned treatment costs were discussed with Ms C and adjustments were made to meet Ms C's communication needs. We did not uphold the complaint. Related reading View Decision Report 201805107 as a PDF (24.08 KB) Updated: March 18, 2020

Mr C complained to us that his GP practice had unreasonably notified the Driver and Vehicle Licensing Agency (DVLA) that he had alcohol issues. We found that the practice had previously discussed this matter with Mr C and that it had been reasonable for them to contact the DVLA regarding their concerns about Mr C's health and alcohol intake. We did not uphold Mr C's complaint. Related reading View Decision Report 201805856 as a PDF (23.87 KB) Updated: March 18, 2020

Ms C complained to us that a dentist had failed to provide reasonable care and treatment to her. She said that the dentist inappropriately removed an inlay despite the fact that this had not caused her any problems. We took independent advice from a dental adviser. We found that it had been reasonable for the dentist to remove the inlay, as there was evidence of decay, and to carry out drilling on the tooth to do so. We also found that it was reasonable for the dentist to refer Ms C to a specialist for root canal treatment. There were no failings by the dentist that led Ms C to develop an infection. The presence of decay meant that there was a risk of infection for Ms C, with or without treatment, and this risk would increase through time, given that the decay would most likely spread further. However, we found that there was insufficient evidence that the dentist gave Ms C adequate information about the likelihood of infection. Therefore, we upheld the complaint for this specific reason.

Mr C complained about the treatment he received at St John's Hospital. He said that his GP had been treating him for a suspected urinary tract infection and referred him to hospital. Initially staff felt that he had a viral infection, but subsequent investigations found that he had a prostatic abscess (accumulation of pus within the prostate gland) and had also developed staphylococcus aureus bacteraemia (a bacterial infection). Mr C felt that there had been an undue delay in reaching an accurate diagnosis. We took independent professional advice from a consultant physician. We found that staff had performed a number of investigations to establish the cause of Mr C's symptoms and that it was not initially unreasonable to have diagnosed him as suffering from a viral illness. His temperature fluctuated and appropriate antibiotics were administered at an early stage. The staff also arranged further appropriate investigations in case there was a danger of Mr C losing his sight or requiring heart surgery. We did not uphold the complaint. Related reading View Decision Report 201902664 as a PDF (24.26 KB) Updated: March 18, 2020

Mrs C complained about the failure of the practice to refer her late father (Mr A) to hospital skin specialists for investigation of a lesion on his forehead. By the time a referral was made, it was too late to attempt surgery and palliative care was instigated. Mr A had a previous history of skin cancer and Mrs C felt that an early and urgent referral to the skin specialists should have been made. We took independent medical advice from a GP. We found that it was not unreasonable for the practice to have thought that Mr A had a cyst and that it was appropriate to transfer his care to district nursing staff in order that they could dress the wound. When the district nurses requested antibiotics the practice made out an appropriate prescription. It appeared that there was a change in the appearance of the lesion after Mr C had been seen by the practice. We did not uphold the complaint. Related reading View Decision Report 201904055 as a PDF (24.15 KB) Updated: March 18, 2020

Ms C complained about the nursing care she received at St John's Hospital during two separate admissions. Ms C had a complex medical history and was assessed by a range of clinical professionals during each admission. Ms C was unhappy with the way nurses behaved towards her and communicated with her. We took independent advice from a registered nurse. We considered Ms C's account, staff statements and the clinical records available. Based on the evidence available, we were unable to establish that there had been failings in the way nursing staff behaved towards or communicated with Ms C. We did not find that the care provided was unreasonable and we did not uphold Ms C's complaints about care. We also considered whether the board investigated and responded to Ms C's complaints appropriately. We did not identify failings in the level of investigation performed or the accuracy of the complaint response. However, we found that the board did not meet the timescales for issuing a response set out in the procedure. For this reason, we upheld this complaint. We were satisfied that the board had taken appropriate action to address this issue since the time of the complaint and we did not make any recommendations. Related reading View Decision Report 201805373 as a PDF (24.3 KB) Updated: March 18, 2020

Mr C complained about the care and treatment he received during two admissions at Royal Infirmary of Edinburgh. During our consideration of Mr C's complaint, we received independent advice from a consultant colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus) and a registered nurse. During Mr C's first admission, he was diagnosed with appendicitis and received surgery to remove his appendix. Mr C was unhappy that his appendix was not fully removed during the procedure. We found that the initial assessment and treatment were appropriate and timely. We noted that whilst part of Mr C's appendix was not removed, this was a rare but recognised complication of the surgery. We did not conclude that there was an unreasonable failing by staff that resulted in this complication. We were also satisfied that Mr C's discharge from the ward was reasonable. We did not uphold this complaint. During Mr C's second admission, he was diagnosed with stump appendicitis (recurrent inflammation of the residual appendix after the appendix has been only partially removed during surgery). Further surgery was performed to remove the residual appendix tissue. Following the procedure, Mr C's recovery was complicated by infection. We found that the second procedure had been carried out to a very high standard. We considered that the post-operative care was reasonable and we noted that there were appropriate arrangements made for wound care in the community following Mr C's discharge. We did not uphold this complaint. Related reading View Decision Report 201802832 as a PDF (24.43 KB) Updated: March 18, 2020

Mr C complained on behalf of his wife (Mrs A) about the care and treatment she received at Western General Hospital. Mrs A was admitted to the surgical assessment unit in the evening with a serious bowel condition. She experienced severe pain in the overnight period whilst she waited to receive surgery. The following morning surgery was successfully performed. Mrs A remained critically unwell for a number of weeks following the procedure. In response to Mr C's complaint, the board acknowledged that better care could have been provided overnight and the operation should have been performed sooner. Mr C remained concerned about what happened and brought his complaint to us. We took independent advice from a colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus), a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques) and a registered nurse. We identified a number of issues with the care and treatment provided to Mrs A in the overnight period. In particular, we found that the CT scan performed was not reported accurately as it failed to mention the radiological evidence of mesenteric ischemia (a serious condition involving sudden interruption of the blood supply to a segment of the small intestine). We also found that the medical review and nursing monitoring in the period under consideration were unreasonable, and we noted issues with record-keeping. We also found that nursing and medical staff had failed to escalate matters to senior medical staff when this would have been appropriate. Finally, and in line with the board's findings, we found that there was an unreasonable delay in transferring Mrs A to theatre for emergency surgery. We considered that earlier surgery would not have impacted on the extent of surgery required, but might have mitigated the severity of Mrs A's critical illness. We upheld Mr C's complaint and made a number

Ms C complained about the care and treatment she received when she was admitted to A&E at the Royal Infirmary of Edinburgh. In particular, that she had been catheterised without her consent and against her will. She also complained that unnecessary restraint had been used. We took independent advice from a consultant in emergency medicine. We found that the care and treatment given to Ms A was reasonable, and that the history, examination and investigations had been appropriate and reasonable. In particular, we found that this had been a potentially life threatening emergency and the decision to insert a catheter had been reasonable. We considered that it was extremely unlikely that Ms C would, at that time, have had the capacity to consent to medical treatment. As such, an adult with incapacity assessment had been completed before the decision to insert the catheter had been made. We also found there was no evidence in the medical records that unnecessary constraint had been used. We did not uphold Ms C's complaint. Related reading View Decision Report 201803475 as a PDF (24.19 KB) Updated: March 18, 2020

Mr C complained about the change in the way his medication was administered at the Royal Infirmary of Edinburgh. In the past, Mr C received IV morphine (injection into a vein) but had now been changed to subcutaneous morphine (injection under the skin). Mr C believed that the change meant he was in pain for a longer period of time and that it was not as effective. He believed that the decision to change the method of administration of the morphine was unreasonable. We took independent medical advice from a clinician and found that the board had implemented a new Recurring Pain Pathway which included guidance in appropriate cases that morphine should be given subcutaneously (under the skin). This would have the effect of a slower absorption with fewer side effects. We also found that the board staff had explained the rationale for the change to Mr C in a sensitive manner taking into account his other health issues. We did not uphold the complaint. Related reading View Decision Report 201901747 as a PDF (24.2 KB) Updated: March 18, 2020

Mr C complained that St Johns Hospital did not provide reasonable treatment to his late father (Mr A) during his hospital admission. During admission Mr A received an incorrect dose of paracetamol which the hospital recognised and responded to. The board determined that the medication error was not a contributory factor to Mr A's death. We took independent advice from a consultant geriatrician (a doctor who specialises inmedicine of the elderly). We found while the general treatment provided to Mr A was reasonable, a significant error occurred, leading to Mr A receiving an overdose of paracetamol. Therefore, we upheld the complaint. Wenoted that the board have already taken action to address this failing so madeno further recommendations. Related reading View Decision Report 201808122 as a PDF (23.71 KB) Updated: November 20, 2019

Mr C complained about the care which he received from the practice when he reported urinary problems. In particular, he had attended four consultations at the practice to report his symptoms, and despite them carrying out investigations it turned out that he had suffered a prostatic abscess. By the time Mr C was admitted to hospital the abscess had grown to 4cm, and he believed that the GPs involved in his care should have noted the abscess at an earlier stage when it would not have been as large. We took independent advice from a GP. We found that initially Mr C's symptoms were indicative of a urine infection, and when Mr C attended hospital, a subsequent diagnosis of prostatitis was made. Again, the GPs managed this appropriately. It was only when Mr C's clinical condition deteriorated that it was appropriate to refer him to hospital where the final diagnosis was made. We found no evidence of failings or delays by the treating GPs. We did not uphold the complaint. Related reading View Decision Report 201902666 as a PDF (23.83 KB) Updated: November 20, 2019

Mr C complained about the antenatal care which his wife (Mrs A) received at the Royal Infirmary of Edinburgh. Mr C felt that Mrs A was not appropriately monitored by the community midwives, that they had been difficult to contact for advice when Mrs A started to suffer from swollen legs, and that she went on to develop pre-eclampsia (a pregnancy-related condition involving a combination of raised blood pressure and protein in the urine) which required an emergency hospital admission. We took independent advice from a midwife and found that Mrs A's antenatal care was shared between the community midwives and her GP practice. Mrs A was appropriately monitored during the antenatal period although the nursing documentation could have been clearer. We also found that appropriate advice was given that Mrs A should take paracetamol for her swollen legs and to seek further advice if the symptoms did not improve. Appropriate contact details were contained in Mrs A's nursing records. There was also no indication from the nursing records that Mrs A had reported symptoms which were suggestive of pre-eclampsia. We did not uphold the complaint. Related reading View Decision Report 201802902 as a PDF (23.9 KB) Updated: October 23, 2019

Ms C complained about the care and treatment her late mother (Mrs A) received at the Royal Infirmary of Edinburgh. When Mrs A was admitted, it was recorded that she had known lung cancer and she was initially treated for pneumonia (inflammation of the lungs). It was subsequently planned that Mrs A would be discharged, but a CT scan showed that she had an accumulation of blood in her abdominal muscle. Mrs A later had a fall. She was monitored overnight, but died the following day. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the medical treatment provided to Mrs A had been reasonable. We did not uphold this aspect of the complaint. Ms C also complained about the nursing care provided to Mrs A. We took independent advice from a nursing adviser. We found that there was no evidence of any failings that had led to Mrs A's fall in the hospital or that a specific injury sustained in the fall led directly to her death. A robust post falls assessment was also undertaken after the event, which did not indicate any specific injury. Overall, the nursing care provided to Mrs A had been reasonable. However, there were gaps in the nursing notes provided. There was also a lack of evidence of communication with Mrs A's family. In addition, the board's response to Ms C's complaint did not address many of the points she had raised. Given these failings, we upheld this aspect of the complaint.

Ms C complained that the board failed to diagnose a ruptured Achilles tendon when she attended Western General Hospital. We took independent advice from a consultant physician in acute internal medicine. We found that given the specific test for excluding a ruptured Achilles tendon was carried out, which resulted in a negative finding, it was reasonable that the ruptured Achilles tendon was not diagnosed. We did not uphold this aspect of Ms C's complaint. Ms C also complained about the care and treatment she received at the Edinburgh Royal Infirmary after the ruptured Achilles tendon had been diagnosed. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the care and treatment provided to Ms C was reasonable and did not uphold this aspect of her complaint. Ms C complained that the board failed to communicate reasonably with her. We found that there was no record of any detailed discussion with Ms C prior to her surgeries about the risks or benefits of the proposed operations, the alternatives to surgery or the varying degrees of success and the possibility that her condition could be made worse. The board had a document for recording fasting and insulin instructions for diabetic patients but this was not completed in Ms C's case. Therefore, we upheld Ms C's complaint that the board's communication with her was unreasonable. Ms C complained about the way that that the board handled her complaint. We found that Ms C's complaint was not acknowledged within three working days. There was also a delay in responding to Ms C's complaint and the board did not proactively keep her updated about the reason for the delay in responding to her complaint and provide a revised timescale for when she could expect to receive a response. We upheld this aspect of the complaint.

Mr C complained about the care and treatment his late wife (Mrs A) received from the practice during a number of attendances. We took independent advice from GP adviser. We found that the care provided to Mrs A by the practice, when she presented with a swelling in her groin and a lump on her breast, to be reasonable. Mrs A had also attended the practice with a swelling in her neck. We found that there was a failure by the practice to document a full history relating to the neck swelling, how long it was there for, and to consider further investigation of the swelling and safety netting. We considered this to be below a reasonable standard and upheld this aspect of Mr C's complaint. However, we also acknowledged that by the time Mrs A presented with the swelling in her groin, she already had incurable cancer. While earlier referral for investigation of the neck swelling could have possibly led to an earlier diagnosis, it was unlikely to have changed Mrs A's overall outcome. Mr C also complained that Mrs A had been treated in an unsympathetic and dismissive manner by the practice, and said that he and Mrs A were unaware that she had suspected heart failure. Our investigation found no evidence of this. Mr C also complained about the way in which the practice had responded to his complaint. We found that the practice responded to Mr C within a reasonable time, and did not identify any inaccurate information in their response. We also acknowledged that the practice had offered to meet with Mr C. We did not uphold this aspect of the complaint.

Mr C complained about the care and treatment he received in relation to a coronary artery bypass graft (a surgical procedure used to treat coronary heart disease) at the Royal Infirmary of Edinburgh. We took independent advice from a consultant cardiologist (a specialist in diseases and abnormalities of the heart). We found that Mr C was identified as having ostial left anterior descending artery disease (a narrowing in the blood vessels of the heart) and that the initial choice of treatment for this, bypass surgery, was reasonable. Mr C then had an uncommon but recognised complication of bypass surgery. We found that the decision to perform a second procedure to implant a stent (a small tube used to keep passageways open) was reasonable. We also noted that there was no reason to believe that performing a stent procedure earlier would have translated to any clinical benefit for Mr C. We considered that the clinical care Mr C received was reasonable and did not uphold this aspect of his complaint. Mr C also complained about aspects of his nursing care during his hospital admission when the stent procedure was performed. We took advice from a consultant nurse in cardiology. We found that Mr C was not prescribed appropriate pain relief and that there was contradictory evidence in the records around the management of his pain. Mr C's pain should have been managed better and the failure to do so was unreasonable. We also identified failings in record-keeping, in particular, a failure to complete care documentation, around communication with Mr C and his family, and his discharge from hospital. We considered that the nursing care Mr C received was unreasonable and upheld this aspect of his complaint.

Mr C complained that that board failed to provide his late wife (Mrs A) with reasonable care and treatment at Western General Hospital and that they did not respond reasonably to his complaint. We took independent advice from a consultant radiologist (a specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans), a consultant surgeon and a consultant oncologist (cancer specialist). In relation to a CT scan, we found that a lymph node which was partially visible at the bottom of the CT scan, despite being enlarged and abnormal looking, was not noted by the reporting radiologist at the time. The failure to identify the abnormal lymph node was an unreasonable error. We also noted that the review of the CT scan showed concerning nodes with an increase in size in comparison with a CT scan of Mrs A's chest carried out previously. Given this and Mrs A's clinical history, this should have been noted in the scan report. We considered that, had these nodes been noted on the CT scan report, it was likely further investigation would have occurred as a result. We acknowledged that the board had accepted there was a missed potential to make a detailed diagnosis of Mrs A's condition and said they have taken action to learn from this. We asked the board to provide us with evidence of this. We also found that a haematology consultant (a specialist in blood and bone marrow) appropriately referred Mrs A to the surgical department for an excision biopsy of the lymph node. However, due to poor communication between the haematologist and the surgeon about the exact anatomical position of the lymph node, the wrong lymph node was removed for biopsy and the diseased lymph node was left in Mrs A's groin. As a result, the pathology report of the biopsy was falsely reassuring. We also considered that the errors identified in Mrs A's care and treatment led to a delay in the diagnosis that she had terminal metasta

Mrs C complained on behalf of her late husband (Mr A) that the Royal Infirmary of Edinburgh Hospital failed to call Mr A to a follow-up review appointment with the cardiology department. Mr A had been diagnosed with heart disease. He attended an out-patient appointment and saw a consultant cardiologist. During that appointment, it was agreed that Mr A should be reviewed two years from then. Some years later, Mr A collapsed. An ambulance took Mr A to hospital, but he died on arrival. On becoming aware that Mr A had not attended his follow-up appointment with cardiology, Mrs C wrote to the board to ask why he had not been called back to the follow-up appointment as agreed. The board said that Mr A had been asked to make a follow-up appointment but nothing was noted in the system, and they were unable to explain this conclusively. Mrs C complained about the board's failure to call Mr A in for his review appointment. She said that the appointment system seemed flawed and there needed to be a backup system in place so no one else missed an important appointment. We found that at the time when Mr A was advised to make a review appointment, all patients were advised during their consultation if and when a follow-up appointment was required. The patient would be asked to book an appointment accordingly at the reception desk. Once the appointment was booked, a letter was sent out confirming the date and time of the appointment. No further letters or reminders were sent. It was the patient's responsibility to remember to attend the appointment. The board told us that having reflected on Mr A's case, they acknowledged that there were failings in the appointment process. They told us that going forward, when staff typed the clinic outcome letter, they would now check that any requested follow-up appointments had been made. If an appointment had not been made, staff would contact the out-patient department requesting that the appointment be made and confirmation se

Mrs C complained that she and her family were unreasonably removed from the practice list of patients. Mrs C said that she had no trust in the service provided by the practice and that she had never received explanations about what diagnoses had been reached about her numerous medical conditions. We took independent advice from a GP. We found that prior to removing Mrs C and her family from the patient list, the practice had repeatedly made an offer of a meeting with Mrs C to discuss her concerns. When Mrs C failed to accept the offers, the practice viewed the doctor/patient relationship had irretrievably broken down and that it was in Mrs C's best interests to register with another medical practice. The hope was that she could build up a good doctor/patient relationship with her new practice. We did not uphold the complaint. Mrs C also complained that it was unreasonable to have her family removed from the patient list as well. Guidance suggests that members of a patient's family should not be removed automatically from the practice list where there is a breakdown in the doctor/patient relationship. However, in instances where children and/or carers are involved, it is appropriate to remove the whole family, as this will allow better communication and the sharing of information where all family members are registered with the same practice. Therefore, we did not uphold this complaint. Related reading View Decision Report 201804640 as a PDF (24.01 KB) Updated: September 18, 2019

Mr C complained that the board failed to provide reasonable care and treatment for his foot, and that the board did not respond to his complaint appropriately. Mr C underwent surgery to address a bunion (a type of bony lump that forms on the side of the foot) at St John's Hospital. Mr C experienced problems after his operation, and had further surgery on the same area approximately four years later. At this time, Mr C was noted to have septic arthritis (inflammation of a joint caused by a bacterial infection) and a procedure was performed to wash out the joint and remove infected tissue. Mr C's problems continued to persist, and he required further surgery the following year. We took independent advice from a consultant podiatric surgeon (a clinician who diagnoses and treats abnormalities of the foot). We noted that Mr C had presented with a foot that was difficult to correct surgically. While there was a lack of correction after the initial surgery, we did not conclude that this was an unreasonable failing by the board. Mr C also had concerns about the second procedure. We concluded that this had been performed reasonably. However, we noted that Mr C's foot wound had been slow to heal following the procedure and he had received extensive antibiotic treatment. In these circumstances, a post-operative x-ray should have been performed to determine whether there was evidence of spreading infection. An x-ray was not performed and we concluded that this was unreasonable. On balance, we upheld this aspect of the complaint. Finally, Mr C raised concerns about the board's handling of his complaint, stating he had anticipated a more compassionate response. We found that the board's complaint response acknowledged the problems Mr C experienced appropriately. We also noted the board had not complied with the timescale under their Complaints Handling Procedure. Therefore, we upheld this aspect of the complaint. We noted that the board had acknowledged this failin

Mr C attended the Western General Hospital after he experienced seizures. They carried out scans, which showed a lesion (an abnormal growth) in his brain. Mr C complained that there was a delay in diagnosing that it was brain cancer, as medical staff initially thought that the lesion was an abscess (a collection of infected fluid). We took independent advice from a consultant oncologist (cancer specialist). We found it was reasonable that Mr C's lesion was thought to be an abscess, given the results of the scans and his medical history. We found that it was good practice that they also tested the lesion for cancer. We did not uphold this aspect of the complaint. Mr C also complained that when cancer treatment options were discussed with him, he was not given appropriate support. In addition, he complained that there was a delay in telling him about fertility options before he started his cancer treatment. We found that Mr C had appropriate support from the multidisciplinary team and his family when treatment options were discussed with him. We also found that he was given appropriate written information about fertility options. Therefore, we did not uphold these aspects of the complaint. Related reading View Decision Report 201803683 as a PDF (23.88 KB) Updated: August 21, 2019

Mrs C complained about the treatment provided to her husband (Mr A). Mrs C said that the board unreasonably removed Mr A's right kidney and ureter (the duct by which urine passes from the kidney to the bladder) on the basis of a diagnosis of cancer. We took independent advice from consultants in urology (the medical specialism that deals with the male and female urinary tract, and the male reproductive organs) and pathology (the study of disease). We found that there were failings in relation to record-keeping which we drew to the board's attention. We also found that there had been a delay in the surgery being carried out which the board had apologised for. However, we found the investigations carried out which led to the diagnosis of cancer were reasonable. We also found that the biopsies (tissue samples) taken in this case were appropriately interpreted at the time and that a mistake had not been made. Therefore, we did not uphold the complaint. Mrs C also raised concerns about the Significant Adverse Event Review (SAER) which had been carried out. We found that the SAER carried out was reasonable. We found that a comprehensive review of the case was carried out, and failings in the consenting process were recognised. We also found that there had been a thorough external review of the pathology slides and recommendations made for improvements. We did not uphold the complaint. Related reading View Decision Report 201801028 as a PDF (24.01 KB) Updated: August 21, 2019