SPSO Individual Decisions

Ms C complained about the care and treatment her late mother (Mrs A) received at Aberdeen Royal Infirmary. In particular, Ms C complained that her mother was not given appropriate treatment at A&E in response to her symptoms. Ms C also considered that her mother should have been transferred to the high dependency unit when her condition deteriorated. Ms C complained that nurses delayed in administering antibiotics and failed to monitor her mother closely enough. Mrs A died of sepsis (a blood infection) several hours after her admission. The board accepted an unreasonable delay in nursing staff administering antibiotics, but considered the care to have been otherwise reasonable. During our investigation we took independent medical advice from a consultant in emergency medicine and from a nurse. The emergency medicine adviser considered that the standard of medical care and treatment at A&E was of a high standard. They also considered that it was reasonable not to transfer Mrs A to the high dependency unit as her outlook was poor, given her age, the severity of her symptoms and her pre-existing condition. The nursing adviser considered Mrs A was appropriately monitored by nursing staff. We therefore did not uphold these aspects of Ms C's complaint. However, both advisers considered there was an unreasonable delay in nursing staff administering antibiotics, although they considered that this was unlikely to have made any difference to Mrs A's condition. We upheld this aspect of the complaint and we made a recommendation in light of our findings.

Ms C, who is an independent mental health advocate, complained on behalf of her client (Mr A) in relation to community mental health (CMH) nursing care Mr A received after discharge from Dr Gray's Hospital. Mr A took a large overdose of alcohol and prescription drugs two weeks after discharge and said that, without the support of his family, he would have completed suicide. In addition to the complaint about nursing care, Mr A also felt that the introduction of occupational therapy (OT) services prior to his discharge could have benefited him and aided his recovery. We took independent advice from a mental health nursing adviser. We found that the CMH nursing care offered to Mr A had been reasonable. The CMH nurse had visited Mr A within five days of his discharge, which the adviser considered to be good practice. The nurse had appropriately discussed coping strategies with Mr A and had made sure that he was aware of other sources of support available as they were going on leave for two weeks. The working relationship with the CMH nurse broke down after they returned from leave. Mr A requested a different CMH nurse, but his psychiatrist referred him instead to OT services. This referral was not successful either, again due to problems in the working relationship. We considered that the aftercare provided by the board was reasonable, although the adviser highlighted some shortcomings in the records, which we fed back to the board. The board confirmed that Mr A was involved in his discharge planning, but there was no evidence to support this. Aside from shortcomings in record-keeping, we considered the CMH nursing care provided to Mr A to have been reasonable and we did not uphold Mr C's complaint. We considered that OT services would largely have overlapped with the support being offered by the CMH team, and saw no evidence to support the complaint that OT input in hospital would have made a significant difference to how Mr A coped post discharge. We did n

Miss C complained that the dental care and treatment she received at Aberdeen Dental School and Hospital was unreasonable. Miss C was seen by the board's dentists over a period of approximately a year. She said that there was a lack of care, unacceptable waiting times, unhelpful and unsupportive staff, and poor communication. She also raised a specific concern about an appointment where a crown was fitted. We took independent advice from a dentist. While we found that the board provided reasonable treatment in a number of areas, we found that some aspects of the care and treatment were unreasonable. We found that there was no unreasonable delay, and there was no evidence that staff were unhelpful or unsupportive or failed to communicate with Miss C. However, we had concerns that there was no evidence that Miss C was shown the crown when it was placed. We also found that Miss C's latex allergy had not been highlighted in the clinical letters, meaning a treatment area was not prepared appropriately before a procedure, although we noted that this procedure did not ultimately take place. On balance, we upheld Miss C's complaint.

Mrs C complained about the care and treatment provided to her late mother (Mrs A) by the practice. In particular, she complained that Mrs A had not been seen by a medical professional before antibiotics were prescribed to her, and, futher, that she had not been seen when the antibiotics were subsequently changed. We took independent advice from an advanced nurse practitioner. We found that a home visit should have been carried out before the antibiotics were prescribed to Mrs A and that, as such a visit did not take place, it was even more important that a review should have been undertaken of Mrs A before her antibiotics were changed. The advice we received was that there was a lack of detail in the clinical records and that it was not clear from the records what symptoms Mrs A had when the decision to change antibiotics was made. We were concerned that the practice had failed to follow guidelines that all older patients suspected of having a urinary tract infection, like Mrs A was, should be seen and fully examined. In light of these failings, we upheld this aspect of Mrs C's complaint. Mrs C also complained that the practice had inappropriately decided not to undertake a home visit after she had contacted them a number of times. We found that, when the visit was requested, Mrs A had deteriorated and she needed to be seen or arrangements needed to be made for admission to hospital. We also found that, whilst reasonable advice had been given to Mrs C to contact the ambulance service if Mrs A's condition deteriorated, there was a delay in this advice being given to Mrs C. The practice accepted that a home visit should have been carried out. We upheld this aspect of Mrs C's complaint. Finally, Mrs C complained that the member of staff she was complaining about had responded to her complaint. We found that neither the Scottish Government guidance on complaints handing which was in place at the time of the complaint, or the new NHS Scotland model complaints h

Mrs C complained that the board failed to care for her in a sensitive manner at Aberdeen Maternity Hospital after she had a miscarriage. Mrs C said that she had found staff to be lacking in empathy. There had also been some confusion in relation to the forms which required to be completed to confirm her wishes for disposal of the foetal remains. Mrs C said that she understood that she had completed the forms required and that she would not be contacted again unless there was any foetal abnormality, but she was contacted a couple of days later and asked to return to the ward to complete another form. Although Mrs C had stated her wish for the cremated remains to be scattered without her being present, she then received a phone call several months later advising that the ashes were ready to be collected. We took independent advice from a nursing adviser, who noted that the board's correspondence with Mrs C had been poor, and that their apology in their response to her complaint had fallen short of a reasonable standard. We found that, although the board had apologised for some of the failings in Mrs C's care, they had failed to address all of the questions she had raised with them. We upheld Mrs C's complaint. We noted that the board had changed their processes in relation to recording patients' wishes about foetal remains, so we did not make any recommendations in this regard. However, we did recommend that the board re-issue an apology to Mrs C that is in line with SPSO guidance on apology.

Ms C, who works for an advocacy and support service, complained on behalf of her client (Mrs B) about the care and treatment provided to Mrs B's late husband (Mr A) when he was admitted to Dr Gray's Hospital. Mr A suffered from congestive heart failure and was admitted to the hospital due to feeling tired and unwell, having chest pain, weight gain, nausea and vomiting. Ms C complained that the medical care and treatment provided to Mr A was unreasonable, and that he was not discharged in a reasonable way. We took independent advice from a consultant physician. We found that, whilst overall assessments of Mr A and the general care and treatment provided to him was of a reasonable standard, there were gaps in weight monitoring. We noted that the board had previously addressed this matter. We also found that the issue of Mr A's internal defibrillator (a small device implanted into the body used to treat abnormal heart rhythms) was not recorded as having been discussed when a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR - a decision taken that means a healthcare professional is not required to resuscitate the patient if their heart or breathing stops) was put in place, and that the general record-keeping around the DNACPR decision was poor. We upheld this aspect of Ms C's complaint. With regards to Mr A's discharge, we found that it was not reasonable to discharge Mr A as he had only recently been changed from having his medicine administered intravenously (into a vein) to taking it orally, and he was still on supplemental oxygen therapy at the point of the discharge decision. The adviser was critical that these issues were not monitored further prior to Mr A's discharge. Therefore, we upheld this aspect of Ms C's complaint.

Miss C complained that the medical practice had failed to carry out an appropriate assessment or refer her late father (Mr A) to hospital when he attended a consultation. Mr A was very breathless and suffered from pulmonary fibrosis (scarring of the lungs). The GP did not take Mr A's temperature or provide medication, as they felt that no further treatment was required at that time. Mr A was told to wait until his next scheduled respiratory clinic at the hospital, which was in nine days time. When Mr A attended the clinic, a clinician arranged an immediate hospital admission. Mr A deteriorated and died a few days later. Miss C felt that the GP should have referred Mr A to hospital sooner. We took independent advice from an adviser in general practice medicine. We concluded that, although the GP had arranged for an ECG (electrocardiogram - test to check the rhythm of the heart), the GP failed to record Mr A's oxygen saturation, temperature and blood pressure. We found that the GP had failed to carry out an examination of the heart, which would have been appropriate for a patient who had presented with increased breathlessness and chest pains. We also concluded that, while it was possible that the GP's decision for Mr A to wait until his clinic appointment may have been reasonable, we were unable to establish this as the standard of record-keeping for the consultation was inadequate. We upheld Miss C's complaint that the GP failed to provide Mr A with appropriate treatment in view of his reported symptoms. However, in view of the inadequate record-keeping, we could make no finding on the complaint that the GP should have referred Mr A for a hospital assessment.

Mr C complained to us that the practice had failed to manage his medication in an appropriate manner. He had been on pramipexole medication (used as treatment for Parkinson's disease and restless legs syndrome) for four years and he said that during that period the practice had not reviewed the medication. Mr C said that the practice had also increased the medication dosage without telling him and that he had experienced severe side effects. Mr C felt that the practice should have kept the medication under review and informed him of the change in dosage. We took independent advice from a GP adviser. We found that, during the period in question, Mr C had not reported to the practice that he was having side effects from the medication. The practice had invited Mr C to attend for a review of his medication on five occasions, but he had not responded. Mr C was also reviewed on two occasions when he attended the practice to discuss other clinical matters. We also found that it was appropriate for a pharmacist to advise Mr C of the increase in the dosage of the medication, rather than have him make an appointment with a GP. We did not uphold Mr C's complaint. Related reading View Decision Report 201701810 as a PDF (11.14 KB) Updated: March 13, 2018

Ms C, an advocacy and support worker, raised a complaint on behalf of her client (Mr A) about the care and treatment he received for a bunion from Golden Jubilee National Hospital. Specifically, she complained that appropriate surgery was not carried out, that the cause of infection following surgery was not properly investigated and that Mr A had not been advised of the problems which could occur with the surgery. We took independent advice from a consultant orthopaedic trauma surgeon and found that there was evidence to support that discussion had taken place with Mr A about the recognised complications associated with the bunion surgery. Some of these included the possible risk of non-healing and a need for further surgery. We considered that the surgery was appropriate and that, whilst there was no clear evidence of infection post-surgery, it was appropriate to consider the possibility of infection when Mr A experienced problems following his surgery. We noted that the board had apologised to Mr A regarding the lack of communication about this. We concluded that there was no evidence of unreasonable treatment and that delayed healing had been the likely reason for Mr A's protracted recovery. We did not uphold the complaint. Related reading View Decision Report 201605577 as a PDF (11.21 KB) Updated: March 13, 2018

Mrs C complained about the cardiology care and treatment given to her late husband (Mr A) when he was a patient at Aberdeen Royal Infirmary. Mr A was admitted to hospital and reported having chest pains and shortage of breath. During his admission, Mr A was also seen by the diabetic team and urology advice was taken. The next month, he attended the cardiology clinic and he was noted to have continuing and increasing breathing difficulties. It was recommended that he be admitted for tests. However, in order to first rule out an infection, he was referred to the Acute Medical Initial Assessment Unit (AMIA). A few months later, Mr A was admitted to the AMIA for the second time as he was reporting chest pains and breathlessness. The cardiology team were contacted and it was decided only to manage his medical conditions, and not for him to have a clinical review at that time. He was later discharged. Mr A died the following month and Mrs C believed that this was as a result of the pills he had been taking and she said that she felt he had not been treated properly. She also said that communication had been poor and that Mr A's unexpected death came as an enormous shock. She complained to the board and they considered that Mr A had been treated appropriately. Mrs C then brought her complaints to us. We took independent advice from a consultant cardiologist and we found that Mr A's cardiology care had not been of a reasonable standard. We found that Mr A and Mrs C had not been given the opportunity of cardiac rehabilitation education. We found that a diuretic (a drug that enables the body to get rid of excess fluids) was recommended to Mr A during his treatment, but that he declined this. The adviser was concerned that this was not discussed further with Mr A during subsequent admissions to hospital. We found that after his second admission to the AMIA, it may have been preferable for Mr A to have been reviewed by the cardiology team. We also found that duri

Miss C complained that the board unreasonably refused her breast reduction surgery. She maintained that this should have been done, not for reasons of appearance, but because of her extreme back and neck pain. The board did not agree and said that Miss C failed to meet the criteria necessary for the operation to be carried out. We took independent advice from a consultant in plastic and reconstructive surgery. We found that in consideration of Miss C's case, the board had followed current Scottish Government advice. We did not uphold her complaint. However, we also found that the board had not told Miss C what to do should she continue to suffer severe back and neck pain, and so we made a recommendation about this.

Mr C complained about the care his wife (Mrs A) received at Aberdeen Maternity Hospital after she became unwell following delivery of their child by caesarean section. Three days after the procedure, Mrs A required emergency surgery for a perforated bowel, resulting in a temporary ileostomy (where an opening is made in the abdomen to allow waste to pass out of the body) and further surgery to reverse this, which caused her a difficult and protracted recovery period. Mr C raised concern that they had been told by a doctor that the complications had arisen because the bowel had been accidently stitched to the caesarean section wound. We took independent advice from a consultant obstetrician and a consultant general surgeon. We found that the consent form Mrs A signed, with the assistance of a doctor, agreeing to the caesarean section was not fully completed and did not warn her of the rare but recognised risk of bowel injury, which we were critical of. We also considered that it was likely that the bowel had been caught at the time of stitching, which meant that it was unlikely an adequate check of the wound was carried out by a second doctor at the time of the procedure. We upheld the complaint and made a number of recommendations to address these failings.

Mr C complained about the accuracy of a report which was written following a meeting attended by his ex-wife, a member of the child and adult mental health services, and staff from his son's school. Mr C felt that the report gave an inaccurate description of his behaviour and he was concerned that his ex-wife might produce the report in legal proceedings and that he would have to defend it. We took independent advice from an adviser in mental health services and concluded that the report was factually accurate in that the information which was recorded had been discussed during the meeting. However, we could understand that the report could be interpreted differently by its readers as it was not entirely clear that the information discussed in the meeting was the opinions of those involved rather than actual facts. We noted that the board had clarified the issue in their response to Mr C's complaint. We did not uphold the complaint. Related reading View Decision Report 201700978 as a PDF (11.06 KB) Updated: March 13, 2018

Mrs C, who works for an advocacy and support agency, complained on behalf of her client Mr A. Mr A's late wife (Mrs A) had been diagnosed with lung cancer. Mrs A began to suffer severe neck pain which subsequently spread to her shoulder and arm. Mrs A was admitted to Dr Gray's Hospital at the request of her GP. Given that a recent scan of the shoulder had shown no problems, a further x-ray or scan was not requested by clinical staff at the acute medical assessment unit. Mrs A was discharged home the following day. Mrs A's pain continued and a few days later she was admitted to Aberdeen Royal Infirmary. X-rays and a scan were performed which showed that Mrs A's cancer had spread to two cervical vertebrae (neck bones) and to the brain. Mrs C complained that the board had failed to provide Mrs A with adequate care and treatment during her admission to Dr Gray's Hospital. The board acknowledged that Mrs A should have been referred to the oncology team and that a neck x-ray should have been performed. They apologised for the delay in diagnosis and that they did not recognise or control the cause and nature of Mrs A's pain. The board explained that they have taken action following this complaint, including using the National Cancer Treatment Helpline, as well as considering direct referral to the oncology team. They explained that they are working to maintain the awareness of these mechanisms to prevent a recurrence through information on their intranet and documentation in induction packs. We have asked the board to provide evidence of these actions. We took independent advice from a consultant in acute medicine. The adviser's view was that the possibility of the cancer spreading to the cervical vertebrae or the spinal cord should have been considered. The adviser said that Mrs A's pain should have been managed as a possible malignant spinal cord compression (an issue that develops when the spinal cord is compressed by bone fragments, a tumour, an abscess o

Mr C complained to us that he, his wife and daughter were removed from the practice's list. National Services Scotland (NSS) wrote to Mr C to say that his GP practice had asked NSS to remove him, his wife and their daughter from their patient list because of a breakdown in the doctor/patient relationship. Mr C said it was not clear why they had all been removed and that he had not been given a warning. Mr C believed it was because of a complaint he had made previously to us about the practice. As a result of the decision, Mr C and his family were distressed and left without the care of a GP practice while they found a new practice. We took independent advice from a GP adviser. The advice we accepted was that there was no evidence that the practice had complied with their contractual regulations and General Medical Council guidance. We found that there had been an appointment between Mr C and practice nurses that was difficult for all concerned and that aspects of the appointment were challenging for staff. However, having reviewed in detail the witness statements and the entries in Mr C's medical records, we were not satisfied that it was reasonable for the practice to remove Mr C without first warning him that his behaviour was causing staff concern and giving him an opportunity to help restore the professional relationships. We found that the practice had failed to give him an open and transparent response on their reasons for having him removed and that, as a result, he was concerned that he was removed because he had made a complaint. It is also of concern that the practice failed to take all reasonable steps to restore the professional relationship. We were not satisfied that the professional relationship with the practice had broken down to such an extent following the appointment with practice nurses that it affected the standard of clinical care provided, and so we found it to be unreasonable that Mr C was removed from the list. Similarly, there wa

Mr C complained on behalf of his daughter (Miss A). He complained that there had been an unreasonable delay in her receiving treatment for a foot injury at Aberdeen Royal Infirmary. We took independent advice from a consultant orthopaedic paediatric surgeon. We found that an appropriate initial referral and examination of Miss A's foot had been carried out and that an appropriate treatment plan had been instigated, which included the use of interventional radiology treatment (treatment that is used to precisely target therapy to affected areas). However, we found that due to staff shortages there was an unreasonable delay in Miss A receiving interventional radiology treatment at Aberdeen Royal Infirmary. We found that there were a series of cancellations and that it was then decided that Miss A should be referred onto another board for treatment. We found that there was also a delay in sending that referral. We upheld Mr C's complaint.

Mr C complained that the prison healthcare centre's decision not to prescribe him a medication used to treat insomnia was unreasonable. Mr C said that he had been prescribed the medication in his previous prison, but when he transferred to a new prison, his prescription was stopped which he said caused him significant problems. Mr C also raised concerns that this decision had been taken before he had had a chance to discuss his condition with a psychiatrist and before the prison healthcare centre had access to his community medical records. Mr C wanted to be prescribed the medication again as he felt this would improve his sleep, keep him safe, and reduce the chance that he would be put in an observation cell. We reviewed documents provided by Mr C and the board, and we took independent advice from a psychiatric adviser. We found that the decision to stop the medication was reasonable. However, we noted that Mr C had been on this medicine for some time and that it may have been hard for him to understand why it was suddenly stopped. We found that national guidance said it should only be given for short periods and that it was therefore reasonable to stop it when there was no clear need for it. We were critical that Mr C did not get a full explanation from medical staff about why the medication was stopped, but were satisfied that it was a reasonable decision and we did not uphold the complaint. We noted that the board did not respond well to Mr C's initial complaint as their initial response was inaccurate. We also noted that this response did not signpost Mr C to us if he was still unhappy. The board also only gave a full response to Mr C's concerns when we became involved. We were therefore critical of the board's complaints handling and we highlighted this to them. Related reading View Decision Report 201605370 as a PDF (11.43 KB) Updated: March 13, 2018

Ms C complained that GPs at her medical practice had misdiagnosed her after she attended several appointments complaining of earache. Ms C was later found to have chronic tonsillitis. She complained that the GPs had not diagnosed this when she presented with her symptoms. She also complained that she was not prescribed anything for her pain during this period. We took independent medical advice and found that the GPs assessed and treated Ms C appropriately and in line with her symptoms. An appropriate referral had been made to the ear, nose and throat department. In relation to the matter of pain relief, the practice pointed out that Ms C was already on a number of strong painkillers for other conditions. Ms C complained that the practice's handling of her complaint was unreasonable. We found that their response to her complaint was not professional and lacked objectivity. We upheld this aspect of the complaint.

Mrs C raised a number of concerns about the care that her mother (Mrs A) received from her medical practice. Mrs A had been diagnosed with terminal pancreatic cancer and was receiving care in her home from a multi-disciplinary team including her GP, district nurses and a Macmillan nurse. Once Mrs A's care needs increased, her GP referred her to a specialist palliative care facility, where she died. We found that in response to Mrs C's complaint, the practice had reflected on the care they had provided to Mrs A and had identified a number of learning points to take forward and act on. We took independent advice on the case from a GP adviser who noted Mrs C's concerns about communication, but did not find evidence that the practice had communicated unreasonably with Mrs C or Mrs A. The adviser was satisfied that the practice had provided appropriate care and treatment for Mrs A's symptoms, and that the GP's role in an investigation into potential diabetes was reasonable. The adviser did not consider that the GP unreasonably delayed visiting Mrs A after she suffered a fall, and considered that the assessment performed at the subsequent home visit and referral to a specialist palliative care facility were reasonable. We did not uphold this complaint. Mrs C also expressed concern about the level of support and information the practice provided to her in her role as a carer. We found that the practice did not send Mrs C the range of leaflets and resources that they usually send to individuals who have been identified as carers in terms of the practice's protocol. The adviser did not consider that this was unreasonable as it was the responsibility of Mrs C's GP, rather than Mrs A's GP, to provide this information. The adviser noted that the practice had provided some information at a late stage to Mrs C and considered the practice might want to consider taking steps to ensure that any information that is provided in these circumstances is provided at an earlier st

Mr C complained about the care and treatment provided by the practice to his late wife (Mrs A). Mr C complained that the practice had missed red flag symptoms prior to her diagnosis of carcinoma of the epiglottis (cancer in the tissue that covers the windpipe). He also complained that the next year, the practice missed red flag symptoms for cancer of the floor of the mouth. We took independent advice from a GP. We found that Mrs A had suffered from throat discomfort for around three months before the practice referred her to a specialist. National guidelines state that persistent throat discomfort for three weeks should have led to an urgent referral, particularly as Mrs A was a smoker. We therefore upheld this aspect of Mr C's complaint, although we found that as the carcinoma of the epiglottis was cured, the delay in referral did not result in any significant injustice. We further found that when Mrs A first presented with oral symptoms, the practice acted in an appropriate and timely manner, therefore, we did not uphold this aspect of Mr C's complaint.

Mr C has suffered from diabetes for some years. He recently changed GP practice and said his life and health had improved dramatically since moving to a new practice. He complained that his old practice failed to manage his diabetes care and treatment appropriately and that this may have contributed to him suffering liver damage. We reviewed the care and treatment provided to Mr C for the management of both his diabetes and his liver. We considered the medical records and took independent advice from a GP and from a nursing adviser qualified in specialist diabetes care. Both advisers were satisfied that the practice had taken appropriate steps to monitor Mr C's condition and to attempt to manage his care. Therefore, we did not uphold the complaint. Related reading View Decision Report 201601978 as a PDF (10.95 KB) Updated: March 13, 2018

Ms C, who works for an advocacy and support service, complained on behalf of her client (Ms A). She complained about the care and treatment Ms A received from Aberdeen Maternity Hospital following the birth of her child by caesarean section. Ms A had a protracted and difficult recovery period requiring further surgical intervention which she felt was due to a delay in diagnosing a hole in her bowel. Ms A was also unhappy that she was not given the opportunity to have Ms C present at a meeting which was arranged by the board's consultant obstetrician to discuss matters related to Ms A's obstetric care following the complaint being submitted. We took independent advice from two advisers, one a consultant obstetrician and the other a consultant colorectal surgeon. We found that the care and treatment provided from the obstetricians and surgeons was of a reasonable and appropriate standard. There was evidence to show that Ms A's symptoms were appropriately monitored, investigated and regularly reviewed following the birth of her child. Given the findings of her assessments, we found that her initial care was reasonable, with no undue delay in surgical treatment going ahead. As such, we did not uphold this part of Ms A's complaint. Whilst we considered that the board's consultant obstetrician acted appropriately in offering Ms A an appointment to review how she was getting on and to discuss her obstetric care, we considered that they should have informed Ms C of the date. It was clear that Ms A had been significantly affected by the events related to her care and required an advocate. We upheld this part of the complaint.

Mrs C raised a number of concerns about the palliative care that her mother (Mrs A) received. Mrs A had been diagnosed with terminal pancreatic cancer and was receiving care in her home from a multi-disciplinary team including her GP, district nurses and a Macmillan nurse. Once Mrs A's care needs increased, she was referred to a specialist palliative care facility, where she died. Mrs C also complained about the way her complaint was handled by the board. Mrs C complained about the nursing care her mother received. We took independent advice from a nursing adviser and a consultant geriatrician. Although we found that a number of aspects of the nursing care were reasonable, the nursing adviser was critical that nurses did not record the assessment of Mrs A's pressure areas for a number of months. We were also critical that although staff had ordered a pressure-relieving cushion for Mrs A, this was not delivered and the order was not followed up by nurses. We upheld this part of Mrs C's complaint. Mrs C was also concerned about the level of input provided by a dietician. We found that the dietician had visited Mrs A on one occasion, and we were satisfied that the dietician had made a number of attempts to contact Mrs A following this. The geriatrician adviser also felt that Mrs A had received appropriate dietetic input whilst an in-patient at the palliative care facility, and both advisers felt that the board had responded reasonably to this aspect of Mrs C's complaint. We did not uphold this aspect of Mrs C's complaint. Mrs C also complained about the communication with her about the reasons for her mother's admission, as well as the communication with her during her mother's admission. We noted that the Macmillan nurse specialist took a different view about the purpose of admission to that of Mrs A's GP, who had referred Mrs A. The nursing adviser said that staff were entitled to take different views, and did not consider that the Macmillan nurse took an

Mr C complained about the care and treatment provided to his late wife (Mrs A) by the board. Mr C complained that when Mrs A was diagnosed with throat cancer, she was prescribed radiotherapy treatment despite the fact that she had previously undergone radiotherapy some years prior. Mr C said that he had concerns that this contributed to Mrs A's later diagnosis of mouth cancer. Mr C also complained that the board unreasonably delayed in diagnosing Mrs A with mouth cancer. During our investigation, we took independent advice from an oncologist and an ear, nose and throat surgeon. We found that it was reasonable for the board to prescribe radiotherapy for Mrs A's throat cancer, as the area did not overlap with the previously radiated area and therefore would not cause any harm. We did not uphold this aspect of Mr C's complaint. However, we found that prior to Mrs A's diagnosis of mouth cancer, there had been a failure to examine the inside of Mrs A's mouth despite her reporting symptoms and having previously had throat cancer. We found that this resulted in around a month's delay in diagnosing Mrs A with mouth cancer. Therefore, we upheld this aspect of Mr C's complaint. Mr C also complained that the board had failed to deal with his complaint in a timely and reasonable manner. We found that the board had experienced difficulties in locating Mrs A's medical records, but that they had not explained this to Mr C until around two months after the response was due. We also found that the board had advised Mr C that the medical records were lost, when they were not. We found this, along with the lengthy delay Mr C had in waiting for a response to his complaint, to be unreasonable. We upheld this aspect of Mr C's complaint.

Ms C complained on behalf of her late mother (Mrs A) about the care and treatment she received from her GP practice. Ms C considered that Mrs A's medication was changed inappropriately, that Mrs A was not given appropriate treatment for her symptoms and there was a failure to communicate reasonably with Mrs A and her family about her condition. Ms C also complained about the handling of her complaint. During our investigation we took independent GP advice. We found that Mrs A's practice gave appropriate treatment for her symptoms, but delayed in making an urgent referral to a consultant geriatrician and a routine referral to a dietician. They also delayed in issuing Mrs A with a prescription. In light of these delays, we upheld this aspect of Ms C's complaint and made recommendations to address this. We found that it was reasonable that Mrs A's medication was changed, and did not consider that there were failings in communication by the practice. We considered the handling of Ms C's complaint to be reasonable and, therefore, we did not uphold these aspects of her complaint.