SPSO Individual Decisions

C complained on behalf of their late partner (A) about the care and treatment they received at the Royal Infirmary of Edinburgh for heart disease. A’s condition deteriorated and they were transferred to the intensive care unit and then ultimately referred to another health board for a heart transplant. A died five days later. C said that the board did not treat the left side of A’s heart which resulted in a grave outcome for A. C also said that the board did not notice that A was deteriorating and that A should have been transferred to the other health board earlier. The board said that when A was admitted they had a blocked right coronary artery and treatment was given for this. They explained that there was no viability in the left side of A’s heart (due to damage caused by a previous heart attack) and therefore, to treat that side would have subjected A to additional risk. The board said that A was very unwell, but reasonably stable until their sudden deterioration. They said that there was no indication that an earlier referral outwith the health board was warranted or would have altered the outcome. We took independent clinical advice from a consultant cardiologist (a doctor that that deals with diseases and abnormalities of the heart). We found that it was reasonable for the board not to have a treatment plan for the left side of A’s heart as it would have exposed A to increased risk and there would have been no benefit to A (due to irreversible damage caused by a previous heart attack). The board reasonably monitored A’s condition and provided appropriate care and treatment in response to their deteriorating condition. We also found that the board’s decision to refer A to another heath board was reasonable and that there was no indication this should have been done earlier. As such, we did not uphold this complaint. We did, however, provide feedback to the board regarding their communication with A. Related reading View Decision Report 202005961 as a PDF (24.

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

C complained about the care and treatment their parent (A) had received from the board. A had a terminal cancer diagnosis and severe arthritis. C complained about a series of admissions A had to hospital. C said A had been discharged without C being consulted, even though they were A’s main carer. This meant A was discharged to a potentially unsafe environment, and did not receive the necessary levels of care. C said A was readmitted to hospital. A was then discharged to a care home, but was not provided with oxygen. C said that A had required oxygen in hospital and the failure to accept that A required long term oxygen support or to provide A with oxygen meant that A required a further hospital admission. C said that when A was readmitted to hospital, they received substandard care. A was put on a busy ward, that did not specialise in palliative care or geriatric medicine (medicine of the elderly) and that this type of care was only provided once C intervened. We took independent advice from a consultant geriatrician. We found that A’s discharge planning was carried out to a reasonable standard. A had capacity and the board’s actions took into account their wishes and included a reasonable assessment of A’s home environment. We found A was very ill during their final admission and that at times A was dehydrated and eating very little and that this would have been very distressing for C and other family members to have witnessed. We noted that dehydration and low food intake were a common feature of this stage of A’s illness and were not evidence of neglect on the part of staff. We found, based on the advice we received, that communication with A was of a reasonable standard and that their pain and condition was monitored and acted on appropriately. In terms of A’s discharge without oxygen support, we found that staff gave appropriate consideration how best to manage A’s low oxygen saturation levels and that on discharge A’s own preference was a factor in the decisi

C complained to the board about surgery they received on a semi-urgent basis. C complained that the surgery had been inadequate and that they had been unable to fully consent to it due to time pressure and a lack of information. C also complained that the board’s subsequent management of their pain medication was unreasonable. In particular, C complained that they had not been informed of the potential for opiate pain relief to become habit-forming. The board responded that the surgery had been performed correctly and that a lengthy consultation had been held with C prior to surgery by the operating consultant neurosurgeon (a surgeon who specialises in surgery on the nervous system, especially the brain and spinal cord). We took independent advice from a consultant neurosurgeon. We found that the surgery had been performed to a reasonable standard and that the board’s management of C’s pain medication was also reasonable. However, we identified a lack of records illustrating any discussion with C about the potential benefits, risks or complications of surgery prior to the operation. We also identified a lack of records illustrating any discussion with C regarding the potential for opiates to become habit-forming. In the absence of such records we were unable to say whether C received appropriate information. Therefore, on balance, we upheld both complaints.

C, an advice worker, complained on behalf of their client (B) about the treatment which B’s late adult child (A) received from their GP practice. The practice is being managed by the board. A had contacted the practice on a number of occasions over a six-month period reporting problems with their mental health. A was a student studying away from home. A subsequently completed suicide. B felt that the staff from the practice had failed to take fully into account A’s personal circumstances which all pointed to the fact that A was at increased risk of attempting suicide and that they failed to provide them with appropriate treatment. We took independent clinical advice from a GP. We found that the GPs involved had formed a good relationship with A. They had recorded A’s mental health symptoms and provided a reasonable level of care and treatment by prescribing appropriate medication and monitoring A’s behaviour. There was also the involvement of a counsellor but there was nothing to indicate that A was going to take their own life. We did not uphold the complaint. Related reading View Decision Report 202007689 as a PDF (24.27 KB) Updated: September 22, 2021

C attended the Grampian Medical Emergency Department (GMED) out-of-hours service with severe pain in their arms and shoulders. They were referred to the Acute Medical Initial Assessment Unit (AMIA) and then transferred to the Stroke Unit, a unit that has capacity to receive patients with non-stroke problems when the hospital is busy. C received multiple tests, including multiple electrocardiograms (ECG, test to check a patient’s heart rhythm and electrical activity) in order to diagnose the cause of their symptoms. It was determined to be a trapped nerve in C’s neck and C was discharged from hospital with a prescription for medication for nerve pain and sensitivity. C complained that there were failings in communication and record-keeping during their admission and that this lead to the unnecessary repetition of ECG tests and a delay in administering pain medication. They also raised concerns that they had been told they had a liver infection requiring antibiotics but this was not recorded, meaning that antibiotics were not prescribed. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the treatment C received during their stay in hospital was reasonable and consistent with the symptoms they experienced and that the communications recorded were reasonable. Therefore, we did not uphold these complaints. Related reading View Decision Report 201904735 as a PDF (24.46 KB) Updated: September 22, 2021

C complained about various aspects of the care and treatment their late spouse (A) received from the board. A had a history of vascular (relating to a vessel or vessels, especially those which carry blood) surgery and was admitted to hospital for the removal of a benign tumour. The procedure took place, however, A’s condition deteriorated and they were moved to an infectious diseases unit with suspected sepsis (blood infection). A’s condition deteriorated further and they were transferred to a vascular and critical care ward in a different hospital on an emergency basis. Later that day, A underwent surgery to remove an infected synthetic artery graft (a piece of living tissue that is transplanted surgically). A experienced an abdominal bleed and was transferred to a critical care unit. After treatment, A was reviewed by a consultant and returned to the vascular and critical care ward. A experienced a fall on the ward. A later developed a lung infection/sepsis and died. C complained that the board failed to screen, manage or treat A’s infection. C said that A had been discharged from the critical care unit onto the ward too soon. C also complained that the board had failed to properly assess A’s fall risk or treat A properly after their fall. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a registered nurse. We found that the screening, management and treatment of A’s infection and their discharge from the critical care unit was reasonable. We did not uphold these complaints. However, we found that the board had failed to adequately complete risk assessments, including a falls risk assessment, for A. We upheld this complaint. We also considered that the board made an error of communication while responding to C’s complaint when they referred to MRSA (a bacterial infection that is resistant to a number of widely used antibiotics) instead of MSSA (a bacterial infection which is not resistant to certai

C was removed from their GP practice patient list. The practice were contacted by Practitioner Services (part of NHS National Services Scotland who support primary care providers) after this and suggested the practice refer C to the board's Challenging Behaviour General Practice (CBGP). The practice referred C to the CBGP. C complained that the practice had unreasonably referred them to CBGP. C said the practice were not required to refer C to CBGP, did not have a good reason to refer them and did not follow the correct procedure. We found that once the practice’s request to have C removed from their patient list was actioned, they were not obliged to arrange any future care for C. However, Practitioner Services found themselves unable to place C on a patient list of another GP practice in the area. They went back to C’s most recent practice and asked them to refer C to the board’s CBGP. The referral the practice sent meant C might (if the referral was accepted) have access to primary care services. We decided that the decision to refer C to CGBP was reasonable in the circumstances. As such, we did not uphold this complaint. However, we found that the processes in place were not helpful to guiding the situation C found themselves in. Understandably C was left confused about why the referral was made and had to contact the practice themselves to find this out. We passed on our feedback to the relevant health board. Related reading View Decision Report 201910147 as a PDF (24.43 KB) Updated: September 22, 2021

C complained that the practice failed to appropriately investigate their urinary symptoms over a two-month period; in particular, that they failed to take blood tests and arrange a prostate check. C was later admitted to hospital with an acute kidney injury and urinary retention. We took independent medical advice from a GP, who considered that the practice had unreasonably failed to examine C's prostate in light of their persistent urinary symptoms and repeated negative results for infection. Therefore, we concluded that there was a failure to reasonably investigate C's urinary symptoms and we upheld this complaint. However, the practice provided us with evidence that reflection and learning had already taken place through a Significant Event Analysis and we were satisfied that appropriate learning had been demonstrated. We recommended that the practice should apologise to C for the identified failings but made no further recommendations.

C complained about the treatment provided at the Royal Infirmary of Edinburgh to their late parent (A) after they were admitted having suffered a stroke. C complained that the board failed to discharge A in a reasonable timescale. We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We considered that, while medically well, A was not fit for discharge, requiring a further period of in-patient care to recover prior to being ready to return home. As such, we did not uphold this aspect of C's complaint. C complained that the board failed to provide reasonable care to allow A to maintain function in their legs. We found that board staff were trying to maximise what A could do, however due to their stroke, pre-existing conditions and subsequent infection, their attempts were unsuccessful. Physiotherapy input started two days after A's admission, which we considered to be prompt. We also found evidence that A attended sixteen physiotherapy sessions, with more offered but A was not well enough to accept them. This indicated that there was regular input by physiotherapists. As such, we did not uphold this aspect of C's complaint. During A's admission, they contracted influenza (flu). C complained that the board failed to provide reasonable treatment after they contracted influenza. We found that antibiotics were administered reasonably and A's condition was appropriately monitored. We noted the challenges in determining if a worsening of someone's condition was related solely to the initial influenza infection, or if an additional (secondary) infection with another organism was involved. Therefore, we did not uphold this aspect of C's complaint. However, we noted that consideration should have been given to anti-viral treatment for A, as indicated by the guidance available at the time and we fed this back to the board. Related reading View Decision Report 202002290 as a PDF (24.67 KB) Updated: August 18, 2021

C complained that their adult child (A)'s dyslexia was not taken into account when the board provided them with care and treatment, and that the care and treatment was not of a reasonable standard. C believed that if A's treatment had been better, then they would have had a better chance of surviving their cancer diagnosis. C felt that A's condition had been misdiagnosed because of A's age, as they were much younger than most people who suffered from this type of cancer. We took independent advice from an appropriately qualified adviser. We found that the board accepted that they had not been aware of A's dyslexia. We also found that there was no evidence that A lacked the capacity to make decisions about their care and treatment and that at the majority of their appointments, they had been accompanied by their other parent. Therefore, we did not uphold this aspect of C's complaint. In terms of their care and treatment, we found that A had been difficult to diagnose because the options were limited for medical staff, due to A's unwillingness to agree to treatment. However, it would have been appropriate for A's case to have been discussed earlier at a multidisciplinary team meeting. This might have resulted in A's cancer being identified sooner. We upheld this aspect of C's complaint. However, this did not mean that the outcome for A would have been different, as the cancer was very aggressive, and it was unlikely that its progression could have been slowed or halted.

C complained that the board failed to provide their child (A) with reasonable care and treatment. C understood that A had a condition known as paediatric acute-onset neuropsychiatric syndrome (PANS) or paediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS, infection-induced autoimmune conditions that disrupt children's normal neurologic functioning). A had been given intravenous immunoglobulin (IVIG, the use of a mixture of antibodies to treat a number of health conditions) treatment but this had been discontinued and stopped suddenly. C stated that the treatment should not have been stopped and wanted this treatment to be available to A in the future if A needed it. We took independent advice from a consultant neurologist (a specialist in the diagnosis and treatment of disorders of the nervous system). We found that the treatment was not suitable for A and the possible diagnoses for A's condition. We considered that it was appropriate the treatment stopped. However, we noted that it should never have been given as a treatment at any stage. We also found that the board sent spinal fluid for testing to a laboratory in England that did not arrive there. While this was not the outcome C was seeking, we upheld the complaint on the basis that IVIG should not have not have been given to A at all.

C complained about the treatment that their parent (A) received at the ophthalmology department (the branch of medicine concerned with the study and treatment of disorders and diseases of the eye) at Aberdeen Royal Infirmary. A had been referred to the hospital by two opticians who believed that A's eyes required a review from hospital specialists. Following the consultation, A was told to use a magnifying glass but that further medical intervention was not required. However, A continued to have problems with their sight within the next year and while abroad had to seek emergency medical review. A had to have surgery for the removal of both cataracts (when the lens, a small transparent disc inside the eye, develops cloudy patches). C believed that A did not receive appropriate treatment at the consultation and that consideration should have been given to the removal of their cataracts. We took independent clinical advice from an ophthalmologist (a doctor who examines, diagnoses and treatsdiseases and injuries in and around the eye). We found that A was appropriately assessed and treated and at that time there was not a clinical need or indication for eye surgery. It appeared that A's sight deteriorated following the consultation and that could not have been predicted. We did not uphold the complaint. Related reading View Decision Report 202006727 as a PDF (24.39 KB) Updated: August 18, 2021

C complained that the practice had unfairly accused them of being threatening and aggressive, resulting in their removal from the practice list and that C had been unreasonably placed on an opiate reduction programme. C said that they had been targeted because they had successfully complained about the services provided by the practice in the past. C said that the practice had misrepresented the opiate reduction as mandatory, when in fact they were only required to review opiate use. C said that the practice had not taken into account the impact of the opiate reduction on them. The practice said that they had a zero tolerance for aggressive or inappropriate behaviour. C had abused the prescription request service and had entered the practice and refused to leave unless they were provided with an additional prescription. The practice had, after review, reinstated C to the practice, but C had continued to request medication early, breaching their agreements with the practice. This had resulted in their removal from the practice lists. The practice had reviewed and reduced C's medication in line with best practice and health board guidance. C had previously sought medication early and was considered by the practice to meet the criteria for opiate reduction. We took advice from an independent medical adviser. We found that the practice had acted reasonably in seeking to reduce C's opiate use. We also found that arguably the practice should have provided C with a written warning prior to the first decision to remove them from the practice list. When C had appealed against this decision, however, the practice had reviewed it and agreed to reinstate C subject to commitments about their behaviour. C's second removal had been due to the practice's view that the agreements reached with C had been breached. The practice were entitled to reach this decision and had acted reasonably. Therefore, we did not uphold the complaint. Related reading View Decision Report 2

C complained about the care and treatment provided to their spouse (A). A suffered from progressive lung disease and required prostate surgery. There was a significant delay in performing A's surgery, during which time A's health deteriorated. A was discharged home following their operation, but was readmitted the following day and died shortly afterwards. C believed that A would have survived had the operation been performed sooner, as their health would have been better. C also said that A's death certificate was inaccurate, as it stated that A had died from community acquired pneumonia. C said that A had not been well when they were discharged, had been at home for less than 24 hours and had spent the majority of that period in bed. We took independent medical advice. We found that A's condition had not been properly monitored following their operation, as the board's assessment had been based on assumptions about A's condition prior to admission. This meant that A had been discharged without evidence of a deterioration in their condition being properly considered. We also noted that it was not possible to determine that A's pneumonia was 'community acquired'. We considered that A's care and treatment had fallen below a reasonable standard. However, we noted that it is not possible to be certain what the outcome would have been had A been operated on sooner. We also found that C's complaint had not been handled to a reasonable standard. The board had initially informed this office that it had nothing to add to its response to C's complaint. However, following our enquiries, the board accepted that it was unlikely that A had acquired pneumonia in the community. Additionally the board's complaint investigation had failed to identify that A's condition was not properly assessed prior to discharge. We upheld both of C's complaints.

C complained to us on behalf of their late relative (A) regarding treatment A received from the board leading up to their death. C said that the board had failed to provide reasonable nutritional care and treatment after A was admitted to the Royal Infirmary of Edinburgh suffering from complications due to poor nutritional intake. They considered that the board had unreasonably delayed in diagnosing the likely cause of this nutritional deficit. C also said that the board had failed to reasonably communicate with A and their family, as they were only informed of the likelihood that A would die with around 48 hours' notice, previously believing A was due to be discharged. We took independent advice from an appropriately qualified adviser. We found that the board had provided reasonable nutritional care and treatment, with no delay in diagnosis. We therefore did not uphold those aspects of the complaint. However, we also found that the board had failed to appropriately assess A's likely prognosis and communicate this to them or to their family. As such, we upheld this aspect of the complaint.

C, a support and advocacy worker, complained on behalf of their client (B) about the care and treatment their child (A) received in the early months of their life. A was born prematurely, suffered a number of medical problems following their birth and died a few years later. A was initially cared for in Aberdeen Maternity Hospital's neonatal unit. A was transferred for treatment in the High Dependency Unit (HDU) at Royal Aberdeen Children's Hospital. C asked us to investigate the standard of care and treatment that A received at Royal Aberdeen Children's Hospital. B said that A suffered a number of desaturation episodes which caused A to turn blue. They attributed this to staff being slow to react. A's feeds were increased upon admission to Royal Aberdeen Children's Hospital. B said that A's health began to deteriorate from this point. B said that A should have remained in Aberdeen Maternity Hospital's neonatal unit given A's weight at five months was still below that of many neonates, or else transferred to another neonatal unit elsewhere in Scotland. They complained that, whilst A was in Royal Aberdeen Children's Hospital, the level of supervision was insufficient, particularly over weekends. We took independent advice from a consultant paediatrician and a paediatric nurse. We found that, while A's condition was complex, there was nothing to suggest that moving A to the HDU at Royal Aberdeen Children's Hospital resulted in a drop in the level of care and support available. We also found that the overall approach to managing and monitoring A's weight was reasonable. We did not uphold these aspects of C's complaint. In relation to nursing supervision, we found that nursing staff reasonably monitored A throughout their time in the HDU, maintaining detailed and thorough records and appropriately escalating any issues identified to the medical team. We did not uphold this aspect of C's complaint. In relation to medical supervision, while the nursing staff

C complained about a failure to diagnose that their new born baby (A) had a dislocated hip from birth. A was reviewed by a physiotherapist (a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) at the Royal Hospital for Sick Children, and C raised concerns that their request for an ultrasound scan was refused despite the presence of a number of red flag risk factors for hip dysplasia (where the 'ball and socket' of the hip are not properly formed). A's condition was not diagnosed until some months later. The board noted that the physiotherapist found A's hips to be functioning normally. They accepted that initial screening will always have the opportunity for human error. They said that this is mitigated by regular teaching and peer review, and ensuring staff are competent in examination before reviewing patients. However, as a result of this complaint, they made changes to their hip screening procedures. We took independent advice from a paediatric physiotherapy specialist. We considered that the presence of a number of recognised risk factors of hip dysplasia, together with a doctor's prior positive clinical assessment of hip instability, should have led the physiotherapist to arrange an ultrasound. The decision not to carry out a scan of A's hips was unreasonable and resulted in a delayed diagnosis. We upheld this complaint. We were advised that the changes already made by the board to their hip screening procedures should improve the clinical process going forward.

C complained to us, on behalf of A, that the board failed to appropriately diagnose and treat A during their attendances at Aberdeen Royal Infirmary. A had chronic obstructive pulmonary disease (COPD, a disease of the lungs in which the airways become narrowed) and had also previously been diagnosed with probable left sided lung cancer several years earlier. At that time, it was agreed that A would receive high dose palliative radiotherapy (a treatment using high-energy radiation). Over a period of eight months, A was admitted to hospital nine times. The first five of these admissions were to a respiratory ward and the last four to a general medical ward. They were treated for worsening of COPD and increasing frailty. A had a fall during one of the admissions, but was subsequently discharged home. C said that at that time, A was not fit for discharge as they required to be readmitted again a few days later when they were told that they had terminal cancer. A's condition subsequently deteriorated further and they died the following month. We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly). Although the board had acknowledged that the clinical records did not show that A's underlying diagnosis of cancer was discussed with them in appointments in the final two years of their life, we found that there was no evidence that the board failed to properly diagnose and treat A during the relevant hospital admissions. We did not uphold this complaint. C also complained that the board failed to communicate appropriately with A during this period, despite them having power of attorney for A. We found that A's care and treatment were discussed reasonably with both C and A and we therefore, did not uphold this complaint. C complained that the board failed to handle A's complaint in line with their obligations. We were satisfied that the board dealt with A's complaint in accordance with their complaints handl

C, a support and advocacy worker, complained on behalf of their client (A) and their partner. A and their partner's child (B) was born at 30 weeks gestation. B was severely disabled and died when they were two years old. B's parents had been told that B had suffered hypoxic ischaemic encephalopathy (HIE, a form of brain injury that occurs when the brain does not receive sufficient oxygen) due to a lack of oxygen in the period prior to their birth. Despite HIE being detailed in B's records as a diagnosis, the board contended that B did not have this condition when responding to B's parents' formal complaint. B's parents considered there to have been an unreasonable delay to A receiving an emergency section following their urgent referral from Peterhead Hospital to Aberdeen Maternity Hospital. C asked us to investigate whether the level of care that A received from the board fell below a reasonable standard and whether any deficiencies in the standard of care may have contributed to B's health problems. We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system) and a senior midwife. We found that A was appropriately given a cardiotacograph (CTG, a way of recording the fetal heartbeat and the uterine contractions during pregnancy) at Peterhead Hospital on the first date complained of, and was appropriately transferred to Aberdeen Maternity Hospital. In relation to the second date complained of, we found that A was again appropriately transferred to Aberdeen Maternity Hospital, although we noted that a CTG was inappropriately stopped at one time, once A had been transferred. However, we also found that transfer to the labour ward took place at an appropriate time and that the decision to move A to theatre and carry out an emergency caesarean section was taken at an appropriate time. The advice we were given did not indicate a connection between the results of

C attended hospital on a number of occasions for the removal of some teeth. At one consultation staff said C was aggressive and asked C to leave the department. C complained about the care and treatment provided to them and that the zero tolerance policy was applied unfairly to them. At a further consultation, C said they were told the hospital would not be able to provide further treatment for them. We took independent advice from a dentist. We found that the care and treatment provided to C was appropriate and the record-keeping was of high quality. There was good evidence of staff spending time with C to explain their treatment options. We found that staff were entitled to ask C to leave when they perceived C's behaviour to be aggressive and threatening. We also noted that the board had reassured C that they could receive treatment at the hospital, but this would be reviewed if C behaved aggressively again in the future. We did not uphold C's complaints. Related reading View Decision Report 201904087 as a PDF (24.18 KB) Updated: June 23, 2021

C complained to the board about the treatment which they received when they attended the out of hours service (OOHS) at Aberdeen Royal Infirmary. C said that they had already reported problems with back pain and loss of feeling to their GP practice. However, the OOHS doctor who attended to C did not conduct examinations or arrange investigations such as a scan, and told C to see their GP the following day. C was taken by ambulance to hospital the following day and, after a CT scan, they were diagnosed as having cauda equina syndrome. C felt that the doctor at the OOHS should have completed a more thorough examination and that the correct diagnosis would have been reached sooner and would not have had such a drastic effect on their health. We took independent advice from a GP. We found that that although the OOHS doctor obtained a good history from C and conducted a reasonable examination, they failed to action C's progressive neurological symptoms and new onset bladder problems. These required referral for an orthopaedic (conditions involving the musculoskeletal system) opinion or further investigations that day. Therefore, we upheld the complaint.

C complained to the practice about the treatment that they received when they contacted the practice with back problems. C spoke to a GP and an advanced nurse practitioner (ANP) by telephone during that period due to the COVID-19 restrictions and C was advised to make further contact should their situation worsen. C was taken by ambulance to hospital and after a CT scan was diagnosed as having cauda equine syndrome (a disorder that affects the nerves). C felt that the GP and the ANP should have seen them in person for an examination and that had this been the case, the correct diagnosis of cauda equine syndrome would have been reached sooner and would not have had such a drastic effect on their health. We took independent advice from a GP and an ANP. We found that C had a previous history of back problems over a number of years which were felt to be sciatica (back and leg pain caused by irritation or compression of the sciatic nerve) and musculo-skeletal in nature and that it was not unreasonable to attribute C's reported symptoms to those conditions. However, when C attended hospital their condition had deteriorated and they had reported new symptoms which were red flag signs of cauda equine syndrome. We did not uphold the complaint. Related reading View Decision Report 202004100 as a PDF (24.37 KB) Updated: June 23, 2021

C complained on behalf of their late spouse (A) about the treatment provided to them. A had a history of breast cancer and attended the practice with back pain. A was treated for simple back pain with some sciatic nerve irritation (nerve in the lower back area) and prescribed pain relief. A was later diagnosed with kidney failure caused from metastatic disease (secondary cancer) and died. C complained that the practice had failed to give proper consideration to A's history of cancer when assessing their back pain. C considered that an earlier diagnosis may have increased A's life expectancy as treatment could have been commenced earlier. We took independent advice from a GP. We considered that A's symptoms had been reasonably assessed and that A's reoccurrence of cancer was not foreseeable any earlier than diagnosed. When A's presentation changed, appropriate steps were taken, with further investigations and referrals to hospital speciality care. As such, we did not uphold this complaint. Related reading View Decision Report 202003476 as a PDF (24.23 KB) Updated: June 23, 2021

C complained about the care and treatment provided to their late spouse (A). A had surgery to remove their gallbladder. A's recovery from surgery was difficult but they were deemed fit enough to be discharged. However, A had to be readmitted four days later after becoming unwell, and was discharged again two days later. A deteriorated at home and was readmitted two days later and was diagnosed as suffering from a significant bleed. A was taken to the operating theatre but died later that day. C complained to the board that A's symptoms indicated severe illness, that they were not fit enough to be discharged from hospital and that had treatment been provided sooner, they may have survived. The board explained to C the complications with the initial surgery, why they considered discharge was appropriate on each occasion and that the source of the bleed could only be identified during the post mortem. The board acknowledged that there had been delays in A being assessed and treated on their final admission. They apologised for the delays and explained they identified learning as a result. The board's view was that given that the type of bleed was very rare, earlier intervention was unlikely to have resulted in a different outcome for A. We took independent advice from an appropriately qualified clinical adviser. We found that whilst there was complications with the initial surgery, and A's recovery was difficult, the care and treatment provided, including the decisions to discharge A on both accounts, was reasonable. However, on A's final readmission, there was an unreasonable delay in assessing A, diagnosing that their symptoms were caused by a significant bleed and subsequently moving A to theatre for investigations. Whilst earlier treatment was unlikely to have altered the outcome for A, this delay was so serious that we upheld the complaint.