SPSO Individual Decisions

Mrs C, an advocate, complained on behalf of her client (Ms A) about the care and treatment they received from the board. Ms A was seen by an ophthalmologist (a specialist in medical and surgical eye problems) and complained that they did not carry out an appropriate assessment and did not record their observation that the discs at the back of her eyes were enlarged. Ms A also complained that her discharge was inappropriately handled and that a mix up regarding her blood test results caused a delay to her discharge. The board advised that it was determined by the ophthalmologist that no further follow-up was required. The board acknowledged that there was confusion about how long Ms A had to wait following a procedure before she could be discharged and that her blood test results had been misread. We took independent advice from a consultant ophthalmologist and from a consultant physician. We found that the ophthalmologist's assessment was reasonable and that the swelling identified at the back of Ms A's eyes did not require to be acted upon. We did not uphold this aspect of the complaint. With regards to Ms A's discharge, while we noted that there was a mix up regarding Ms A's blood test results, we considered that the board acted in the best interest of the patient, in light of the information available to them at the time, and it was therefore appropriate to require Ms A to remain in hospital for one further night for observation. Therefore, we did not uphold this aspect of the complaint. Related reading View Decision Report 201807430 as a PDF (24.42 KB) Updated: March 18, 2020

Mrs C complained about the care and treatment she received at University Hospital Monklands where she had surgery to remove her gallbladder. Mrs C said that she developed a number of unpleasant symptoms following the surgery and, despite seeking treatment for these from the board, including attendance at the hospital's emergency department, they remained unresolved. We took independent medical advice on the complaint from a consultant general surgeon and a consultant in emergency medicine. In her complaint, Mrs C said that the consent process followed by the board did not include reasonable information about the consequences of gallbladder removal. We found that the symptoms Mrs C experienced were not recognised as complications directly related to her gallbladder surgery and were, therefore, not discussed with her prior to her surgery. We found that efforts were made to ensure that reasonable explanations were given to Mrs C on the risks and benefits of her surgery and her consent form listed the risks of the surgery. We did not uphold this aspect of the complaint. Mrs C said that the care and treatment provided to her in the emergency department was unreasonable. We found that the treatment Mrs C received was reasonable and there was no reason to admit her to hospital at that time. While we note that the time that Mrs C waited to be seen was slightly outwith the triage timescales, we did not identify this as a failing or evidence of unreasonable care. Therefore, we did not uphold this aspect of the complaint. Mrs C also complained that the follow-up surgical care and treatment was unreasonable. We found that once Mrs C made the board aware that she was experiencing significant symptoms following her surgery, and given her anxiety issues, they should have offered her an early out-patient appointment within a few weeks. It would also have been reasonable to have arranged to see her in clinic to discuss her endoscopy and biopsy results and options open to h

Miss C complained about the care and treatment provided to her late mother (Mrs A) prior to her death. Mrs A was admitted to Hairmyres Hospital after having a fall and developing chest pain. Miss C had a power of attorney (POA, a legal document appointing someone to act or make decisions for another person) in respect of her mother. Miss C complained that the POA was not appropriately taken into account; communication in relation to Mrs A's deterioration was unreasonable; and the nursing care and treatment provided to Mrs A was unreasonable. The board in response to the complaint carried out a local review of Mrs A's care and also held a debrief action plan meeting, following the local review. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nursing adviser. We found that the POA was respected and there was no indication it was disregarded. In relation to communication concerning Mrs A's deterioration, the clinical records showed that medical staff engaged with Miss C frequently to discuss Mrs A's condition, symptoms and how these were being managed. There was also evidence of frequent and detailed discussions between Miss C and clinical staff at the point at which Mrs A's condition began to deteriorate. We, therefore, found that communication was of a reasonable standard. Miss C raised a number of issues with regards to Mrs A's nursing care. Our investigation confirmed that the shortcomings identified within the local review would not have had an impact upon Mrs A's condition and subsequent deterioration. Whilst we recognised the board had apologised for a number of aspects of Mrs A's nursing care, overall, we considered that Mrs A received care of a reasonable standard. We considered that the local review and work carried out by the board was thorough and showed Miss C's complaint was taken seriously. As a result, we did not uphold Miss C's complaints. Related reading View Decision Report

Mr C reported experiencing unpleasant side effects when taking methadone (a drug used medically as a heroin substitute) and felt the prison health centre unreasonably dismissed his symptoms. Mr C also complained that the board would not ask for a second opinion from someone outwith the health centre. The board explained that clinical and nursing staff felt the symptoms reported by Mr C were likely caused by opiates, rather than methadone. It was noted that Mr C did not accept that position, but the board explained medications were prescribed based on evidence that indicated their effectiveness whilst remaining mindful of guidelines in place. The board told Mr C that methadone was considered the best option available for those with opiate misuse. We took advice from an independent clinical adviser. We found that the board had appropriately considered Mr C's concerns about the side effects of methadone. We considered that the board had explained their position reasonably to Mr C and their actions were in line with good practice guidance. We also found that the steps taken by the board in having another doctor from the health centre review the matter was in line with good medical practice. We concluded that the board responded reasonably to Mr C's reports of unpleasant side effects from methadone and dealt with Mr C's request for a second opinion reasonably. Therefore, we did not uphold the complaints. Related reading View Decision Report 201806236 as a PDF (24.39 KB) Updated: March 18, 2020

Mrs C, an advice and support worker, complained on behalf of her client (Mr A) regarding the decision by a psychiatrist to change Mr A's antidepressant medication. Mr A felt that the change in medication had resulted in him suffering agitation and insomnia and that he had to approach his GP to have the dosage of medication altered. We took independent medical advice from a psychiatric consultant. We found that it was reasonable from a clinical perspective for the psychiatrist to change the medication. If a patient remains on a particular medication for a prolonged period this can lead to a lack of symptomatic relief. It is accepted practice to gradually reduce the dosage of the previous medication while at the same time gradually increase the dosage of the new medication in an effort to prevent withdrawal symptoms. We did not uphold the complaint. Related reading View Decision Report 201902691 as a PDF (24.13 KB) Updated: March 18, 2020

Mrs C complained about the treatment her husband (Mr A) received during his admission to Wishaw General Hospital. Mr A was admitted with abdominal pain and a temperature and was discharged the same day with a principal diagnosis of gastritis (inflammation of the lining of the stomach). Mr A latter suffered a ruptured appendix and damaged bowel which required emergency surgery. Mrs C complained that if Mr A had received the correct diagnosis in his initial admission, with reasonable investigations carried out, the rupture could have been avoided. We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found that the treatment provided to Mr A was unreasonable. Insufficient notice was taken of Mr A's raised temperature, white cell count and CRP (inflammatory marker) as objective evidence together with lower abdominal pain. We considered that appendicitis should have been considered as a possible diagnosis. We also found that Mr A was discharged too early without a second examination and on discharge the wrong diagnosis was recorded and advice on what to do next was unclear. We upheld this aspect of Mrs C's complaint. Mrs C also complained about the board's response to her complaint. Mrs C raised a number of questions about the treatment Mr A received. The board explained the actions taken and why they considered this was reasonable. We sought advice about the accuracy of the board's response in terms of Mr A's presentation and treatment. We found that the board failed to provide a reasonable response to Mrs C's complaint. While the board responded to the questions Mrs C raised, the medical records did not evidence the board's outline of the treatment provided, including that appendicitis was considered in Mr A's initial admission and the advice provided when discharging Mr A. We also upheld this aspect of Mrs C's complaint.

Mr C complained about the treatment which he received at A&E of University Hospital Monklands. Mr C had injured his foot and a doctor diagnosed him as having a sprained ankle. Mr C continued to suffer discomfort and attended his GP several weeks later who referred him back to the hospital. Further investigation revealed he had suffered a ruptured Achilles tendon. Mr C believed that the rupture should have been diagnosed at his initial attendance at A&E. We took independent advice from an A&E consultant. We found that the records indicated that the doctor had carried out an appropriate examination and reached a reasonable diagnosis of a badly sprained ankle. Although it turned out that Mr C had possibly suffered a partial rupture of the Achilles tendon at the time of the attendance, the actions of the doctor in wrongly diagnosing a sprained ankle was not unreasonable in the circumstances. We did not uphold the complaint. Related reading View Decision Report 201901653 as a PDF (23.77 KB) Updated: November 20, 2019

Mr C complained about the care and treatment his sister (Miss A) received after she was admitted to Hairmyres Hospital, specifically about the medication prescribed, the standard of communication and the discharge planning. Mr C also complained about the community care, mainly the lack of care plan and the actions of a staff member. We took independent advice from a consultant psychiatrist and from a mental health nurse. In terms of the hospital care, we found that the medication changes made during Miss A’s hospital admission were both appropriate and consistent, with established and agreed treatment protocols, and that the approach taken was reasonable. We also found that there was evidence to support a reasonable level of communication, and that the discharge planning was appropriate, as Miss A discharged herself voluntarily, and staff had no power to stop this or to detain her. Therefore, we did not uphold this aspect of the complaint. In terms of the community care, we found that the records did not show that Miss A's risk to herself was underestimated by staff and that the incident which caused her admission to hospital was not predictable. We found that the care planning was reasonable, noting specifically that staff identified Miss A’s health and social-care needs, her goals for care and interventions, and that these were evaluated and updated. Importantly, there was also clear evidence that Miss A was involved in this process. Therefore, we did not uphold this aspect of the complaint. Related reading View Decision Report 201802161 as a PDF (24.02 KB) Updated: November 20, 2019

Mrs C, an advocate, complained on behalf of her client (Mrs B) about the medical and nursing care that Mrs B's late husband (Mr A) received at Wishaw General Hospital. Mrs B was concerned that a urine sample was not taken around the time Mr A was admitted to hospital; that sepsis may not have been treated properly; that staff did not recognise the severity of a fall Mr A sustained; and an opiate painkiller was not given at a particular time. Mrs B was also concerned that; no falls assessment was carried out and wheelchair transportation was inappropriate after Mr A's second fall; record-keeping regarding a fall was contradictory and did not capture the severity; intravenous paracetamol should have been given instead of oral paracetamol; and Mr A's blood pressure and heart rate were not properly monitored. We took independent advice from a GP consultant and from a registered nurse. We found that there was a failure to take a urine sample which the board had accepted and apologised for. However, overall we did not identify any significant failings in Mr A's medical care and did not uphold this aspect of the complaint. However, we found that it was unreasonable that Mr A was not transported by trolley to have his scan carried out and that there was a failure to escalate his worsening blood pressure reading to medical staff. Therefore, we upheld the complaint that Mr A's nursing care was unreasonable.

Mrs C complained about the care and treatment provided to her late daughter (Ms A). Ms A had a history of breast cancer and she had been complaining of severe leg pain. She attended A&E to request an emergency MRI scan, however, she was advised by hospital staff that she did not meet the criteria for an emergency scan. An out-patient referral was made instead. Ms A was later diagnosed with cancer and underwent surgery to repair a cancer related fracture of her hip. Following the surgery, it was identified that Ms A had a neck fracture. Mrs C complained that the hospital staff unreasonably refused to perform the MRI scan when Ms A attended A&E and that the board failed to provide a reasonable explanation for the cause of Ms A's neck fractures. We took independent medical advice from an orthopaedic (conditions involving the musculoskeletal system) surgeon. We found that an emergency MRI scan can only be performed if the patient is suffering from a neurological deficit, therefore it was correct that Ms A was advised she did not meet the criteria. We also found that there was no evidence to suggest that Ms A's neck fracture occurred during surgery, and it was reasonable to conclude that the fracture developed due to the progression of the cancer into her bones. We did not uphold the complaints. Related reading View Decision Report 201807843 as a PDF (23.96 KB) Updated: September 18, 2019

Ms C complained about the actions of staff at the GP practice when she had a seizure in the reception area. Ms C has a medical condition in which she experiences seizures. During seizures she is unable to move or speak, however, is aware of what is happening and can feel pain. Ms C complained that when she had a seizure at the GP practice, her dignity and privacy was not maintained. We took independent advice from a GP. We found that Ms C was not given appropriate privacy when she had the seizure, and this was unreasonable. We also found that Ms C's son was called to take her home in a wheelchair, before she had recovered from the seizure. Staff at the practice should have waited until Ms C had recovered in order to assess her clinically when she was fully conscious and allow her to coordinate her own transfer home as appropriate. We upheld Ms C's complaint.

Mr C complained about the treatment which he received from the practice. He reported stomach and bowel problems to a number of GPs. They treated him for irritable bowel syndrome but they failed to diagnose that he had a bowel obstruction and that resulted in him having to have a colostomy (an operation to divert part of the bowel through an opening in the tummy) and undergo chemotherapy. We took independent medical advice from a GP. We found that the GPs who treated Mr C carried out appropriate investigations in view of the stomach and bowel symptoms which he presented with. When Mr C reported passing blood the GPs made a referral for a colonoscopy (examination of the bowel with a camera on a flexible tube). However, before the colonoscopy could take place, Mr C was admitted to hospital as an emergency and was diagnosed with a bowel obstruction. We did not uphold the complaint. Related reading View Decision Report 201810329 as a PDF (23.79 KB) Updated: September 18, 2019

Ms C underwent gallbladder removal surgery at University Hospital Monklands. She became unstable in recovery and needed to return to theatre for open surgery to repair tears in her bowel and an artery. She required a large blood transfusion. Ms C complained that the procedure was described to her as a simple keyhole operation, and she did not recall being told of any potential risks as serious as her bowel or anterior aortic wall being damaged. We took independent medical advice from a general and colorectal (bowel) surgeon. It was noted that steps were taken to obtain Ms C's consent the day before her surgery, and many of the risks were explained to her. However, she received no explanation of the small risk of major vascular (circulatory system) injury, or what actions may be necessary in the event of a serious complication. We, therefore, upheld this complaint. Ms C also complained that a mistake had been made during her surgery. We considered that the major vascular injury could have been avoided if the operating surgeon had exercised reasonable skill and care. In technical delivery, decision-making and note-keeping, the surgical care provided during the operation fell seriously below the standard we would expect of a reasonably competent consultant general surgeon. Additionally, in their failure to undertake a formal investigation into the incident, the board's response also fell seriously below the standard we would expect. We upheld this complaint. Finally, Ms C complained to us about the board's response to her complaint. She was concerned that the board had failed to provide her with a copy of any internal investigation report, and also that they had not spoken to the operating surgeon as they were on a period of extended leave and subsequently did not return to their post. In the surgeon's absence, the board received comments from another surgeon but these were submitted late, after the board had issued their complaint response. The board ackn

Mr C complained that the practice had over-prescribed Diazepam and Nitrazepam (both belonging to a class of sedative medication called benzodiazepines) for a period of ten years. He believed that this had caused long-term damage to his mental health including aggression and anger. He said that the practice had failed in their care by not managing a controlled withdrawal. We took independent advice from a GP. We found that Diazepam was being prescribed along with antipsychotic medication, as instructed and monitored by psychiatry. We noted that the practice closely monitored Mr C, made efforts to refer him to addiction services for Diazepam detoxification and, when he defaulted from the services, they monitored and gradually reduced his Diazepam within the practice. We found that the practice's management of his prescription was reasonable, and we did not uphold this complaint. Mr C also complained that the practice unreasonably removed him from their practice list. The practice said he had been removed from their list due to aggressive behaviour, and that this was not the first instance of such. Mr C felt that this was unreasonable as he considered he had been displaying the symptoms of over-prescription of Diazepam and Nitrazepam. We noted that the records showed Mr C was 'repeatedly harassing the reception staff' and had received previous warnings for inappropriate and aggressive behaviour. We confirmed that benzodiazepines are noted to have a rare side effect of aggression, but having reviewed Mr C's records going back 16 years, we found that suggesting his medication was the cause of his aggression was the least likely explanation. We noted from the records that there had been an irrevocable breakdown in the relationship between Mr C and the practice and we considered it reasonable to remove him from the list. We did not uphold this complaint. Related reading View Decision Report 201707766 as a PDF (24.23 KB) Updated: September 18, 2019

Mrs C complained about the treatment which her son (Mr A) received at Hairmyres Hospital. Mr A was admitted with severe stomach pains, vomiting of blood and blood in his stools. The diagnosis was a bleed within his intestinal tract. Initially the plans were that an endoscopy (a medical procedure where a tube-like instrument is put into the body to look inside) would be carried out while Mr A was a patient. Mr A was then discharged home after a few days and arrangements were made for him have an endoscopy as an out-patient within four to six weeks. A letter was issued to Mr A asking him to make contact for a date for the endoscopy, but he did not respond. He was then admitted to another hospital as an emergency where he underwent surgery for a perforated gastric ulcer (condition in which an untreated ulcer can burn through the wall of the stomach or other areas of the gastrointestinal tract). Mrs C felt that had Mr A received the endoscopy while an in-patient, it may have prevented the ulcer perforation. We took independent advice from a surgeon. We found that while Mr A was in hospital the staff carried out appropriate investigations in order to arrive at a diagnosis. There is guidance that Mr A should have received an endoscopy while an in-patient. However, this would have been for the purposes of establishing whether Mr A was continuing to lose blood; but as Mr A showed signs of improvement, this was not the case. It was appropriate to discharge Mr A from hospital as he appeared to be stable, and the revised plan for an out-patient endoscopy was then reasonable in the circumstances. We did not uphold the complaint. Although we did not uphold the complaint we highlighted issues of concern regarding record-keeping, risk assessment and communication with primary care as feedback to the board in an effort to improve learning. Related reading View Decision Report 201804111 as a PDF (24.27 KB) Updated: September 18, 2019

Miss C complained that the board failed to recognise and treat problems with her nose. Miss C was seen by consultants at both Wishaw General Hospital and Monklands Hospital but felt that her problems were ignored. We took independent advice from an ear, nose and throat surgeon. We found that the assessments and conclusions reached by the consultants who reviewed Miss C were reasonable, and took into account her concerns. We considered that the treatment provided was in line with the findings of the assessments carried out. Therefore, we did not uphold the complaint. Related reading View Decision Report 201707342 as a PDF (23.58 KB) Updated: August 21, 2019

Ms C complained about the care and treatment that her mother (Ms A) received at University Hospital Hairmyres. Ms A attended the hospital with back and chest pain, and her blood count was found to be low. The cause of Ms A's low blood count was suspected to be an internal bleed. Ms C was concerned about the investigations carried out to identify the cause of Ms A's low blood count and that Ms A was discharged home without a final diagnosis. We took independent advice from a consultant hepatologist (specialist treating the liver, gallbladder and pancreas) & gastroenterologist (treatment of the stomach and intestines). We found that the clinical approach used to identify the source of Ms A's bleeding was reasonable. In particular, plans were made for Ms A to have an endoscopy (procedure using an instrument to give a view of the body's internal parts) and a colonoscopy (procedure where a flexible fibre-optic instrument is inserted through the anus in order to examine the colon) on an out-patient basis. We found that it was reasonable for the board to discharge Ms A and that it would not have been possible for the board to make a final diagnosis during Ms A's admission. We did not uphold Ms C's complaint. Related reading View Decision Report 201807306 as a PDF (23.94 KB) Updated: August 21, 2019

Mrs C complained about the care and treatment that her late mother-in-law (Mrs A) received when she attended the emergency department at University Hospital Monklands on two separate occasions. Mrs A was also under the care of a consultant surgeon at the time. We took independent advice from a consultant in emergency medicine and a general surgeon. We found that the majority of the care and treatment provided in the emergency department was reasonable. However, we also found that the on-call surgical doctors did not make Mrs A's consultant surgeon aware of her attendances to the emergency department. Therefore, we upheld this aspect of Mrs C's complaint. The board said that they had already taken action to address this issue so we asked them to provide evidence of this. Mrs C also complained that the board failed to handle her complaint reasonably and in particular that the board did not respond to all the points of her complaint. We found that the board provided a response to the majority of the concerns Mrs C raised and, therefore, we did not uphold this aspect of Mrs C's complaint.

Mrs C, a support and advocacy worker, raised a complaint on behalf of her client (Mr B) about the clinical and nursing care and treatment his late wife (Mrs A) received when she was admitted to University Hospital Monklands. We took independent advice from a consultant physician and a nursing adviser. In relation to the clinical care and treatment given to Mrs A, we found that the physiotherapy support had been reasonable. We also found that the administration of medicines and the clinical input at the time of Mrs A's death had been reasonable. However, we found that she should have been referred to the diabetes in-patient team early in her admission to the hospital and, had this happened, it was likely that insulin would have been started which may have avoided the development of a necrotic heel. We also found that there should have been better control of Mrs A's blood sugar which might have reduced her propensity to infection. We noted that communication or documentation of communication with the family could have been better. Given the failings identified, we upheld this aspect of the complaint. In relation to the nursing care and treatment given to Mrs A, we found a number of failings. In particular, that Mrs A did not receive the required interventions to prevent pressure damage and that there had been a delay in obtaining equipment to help prevent pressure damage. We also found there had been confusion over the diagnosis of a sacral wound and that Mrs A's food, fluid and nutrition needs were not met. Furthermore, we found that there was a failure to refer Mrs A to podiatry (medical treatment of the feet and their ailments) and that there were omissions in patient-centred care planning and incomplete documentation. Therefore, we upheld this aspect of the complaint.

Mr C complained about the care and treatment provided to him by the board in relation to a pacemaker implantation (a device that generates electrical impulses delivered by electrodes to contract the heart muscles and regulate the heart). After Mr C had his pacemaker implanted, he attended hospital on several occasions as he was aware of having palpitations (noticeably rapid, strong or irregular heartbeat). Some months after implantation, it was found that Mr C had a heart failure as a result of the pacemaker. Mr C raised concern that it took several months to detect the heart failure and take action on this. We took independent advice from a cardiologist (a medical specialist who diagnoses and treats disorders of the heart). We found that the monitoring of Mr C's pacemaker was reasonable, and that no problems were identified during this monitoring. We found that Mr C was not experiencing any symptoms of heart failure and therefore there would have been no reason for the board to suspect this. We determined that the finding of heart failure was incidental, and when identified it was acted upon in a timely and appropriate manner. We noted that the risk of heart failure was not outlined on the consent form for Mr C's pacemaker implantation and that this was technically a failing. However, we found that national practice does not currently reflect that this risk is not routinely included anywhere on consent forms in the NHS at this point. Therefore, while we considered that it may be good practice to raise the risk of heart failure when taking consent for pacemaker implantation, as the risk is not one that is nationally recognised or currently reflected in practice and guidance, we did not consider this to be a failing of the board with regards to required actions and reasonableness. We did not uphold this aspect of Mr C's complaint. Mr C also complained about the board's communication with him regarding his pacemaker and heart failure. We found that communica

Mrs C complained about the care and treatment her daughter (Miss A) received when she presented to the board with unexplained weight loss and upper abdomen pain. In particular, Mrs C complained about the investigations carried out to try and diagnose Miss A and the delay in diagnosing her with stomach cancer. We took independent advice from a consultant general surgeon. We found that the majority of the investigations and tests carried out to try and diagnose Miss A were reasonable. However, we also found that: a request for an endoscopic ultrasound (procedure that allows a doctor to obtain images and information about the digestive tract and the surrounding tissue and organs) should have been marked as urgent; that the board did not enquire about the status of the endoscopic ultrasound request with the other hospital when it had not been scheduled within a certain period of time; a lesion on Miss A's skin was not excised urgently; and that the board should have considered requesting another urgent endoscopic ultrasound or a repeat scan when Miss A's symptoms were ongoing. We also found that the interim discharge summaries did not contain sufficient information about the treatment provided, investigations carried out or any follow-up treatment/recommendations and that the formal discharge letters were not sent within a reasonable period of time. In light of the above, we upheld Mrs C's complaints, though we found that Miss A's prognosis would have remained poor even if an earlier diagnosis had been made.

Ms C complained about the care and treatment her mother (Ms A) received from the board following a referral for the suspicion of cancer. We took independent advice from a consultant respiratory physician and a consultant radiologist (a specialist in the analysis of the body). We found that the scan guided biopsies (tissue samples) were not carried out by the radiology department within a reasonable length of time and that there was an unreasonable delay in arranging surgical treatment. We also found that it was unreasonable that the report of a scan did not mention the bony lesions (areas of bone that are changed or damaged) and the pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs). Therefore, we upheld Ms C's complaints. Ms C also complained that the board failed to handle her complaint reasonably. We found that the board's complaint response commented on Ms A's financial difficulty when this was not raised in Ms C's complaint. We upheld this aspect of Ms C's complaint.

Mr C complained about the nursing care and treatment his father (Mr A), who had dementia, received when he was admitted to University Hospital Monklands. He also complained that Mr A had been unfit for discharge on the day of his planned discharge. In addition, Mr C complained about the level of communication with Mr A's family from the board. We took independent advice from a nursing adviser and a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the nursing care Mr A received had been reasonable and we did not uphold this aspect of Mr C's complaint. Mr A's planned date for discharge was modified due to his deteriorating health. We found that there had been a failure to assess Mr A's mental health and the possible presence for delirium prior to the original date for discharge, and as a result, the consultant geriatrician advised that staff could not be confident, or show, that Mr A had improved to a level where it was safe to consider discharge. We were particulary concerned that a dementia test was not carried out. We found that the board had unreasonably considered Mr A fit for discharge on the date of the planned discharge and upheld this aspect of Mr C's complaint. In relation to communication, we found that the nursing communication was reasonable but the board had identified some failings. We also found failings in the medical communication in the initial part of Mr A's admission to the hospital. We upheld this aspect of Mr C's complaint.

Mrs C attended hospital to undergo colonoscopy (a procedure to look at the lining of the large bowel) and gastroscopy (a procedure to look at the inside of the oesophagus and first part of the small intestine). The information booklet she had been given in advance indicated that she would be sedated. However, Mrs C said she was persuaded to go ahead without sedation which she found extremely painful. She said that she felt traumatised and violated. She complained to the board who said that the matter of sedation had been discussed with her and it was her decision to go ahead without it; staff had no recollection of her complaining of pain. We took independent advice from a gastroenterologist and from a registered nurse. We found that the procedures concerned were ones where sedation would normally be given as the information booklet indicated. There was no evidence that medical staff had discussed the procedures with Mrs C and the associated consent forms had not been properly completed. Similarly, we found concerns about the nursing records and although at one point Mrs C was recorded as having a pain score of 2-3 (out of 4) she was not monitored or assessed further. We upheld the complaint.

Mr C complained that the board had not provided him with appropriate care and treatment for pain in his knee and thigh. We took independant advice from a GP. We found that appropriate investigations had been carried out into both issues, appropriate referrals to other services had been made, and pain had been managed in line with guidance. We did not uphold Mr C's complaint. Related reading View Decision Report 201807147 as a PDF (23.48 KB) Updated: June 19, 2019