SPSO Individual Decisions

Ms C complained that the board unreasonably failed to identify her hip fracture. Following a referral to Ninewells hospital, Ms C was reviewed by a consultant orthopaedic and trauma surgeon who considered that she had strained a ligament in her knee. She was then referred for physiotherapy for mobilisation and rehabilitation. Ms C was reviewed over the following months and developed progressively worsening pain. A subsequent x-ray identified a hip fracture. We took independent advice from a consultant orthopaedic surgeon and a physiotherapist. Ms C noted that no x-ray was performed at the consultation with the surgeon. The board said that an appropriate examination was carried out, and that this examination gave no indication that an x-ray was required. The orthopaedic surgeon adviser said that the examination was not recorded in sufficient detail in Ms C's medical record, and that it provided inadequate evidence that a hip fracture was excluded. Ms C also raised concern about the subsequent physiotherapy appointments. The physiotherapist adviser considered that, throughout the physiotherapy sessions, there were indications that the initial diagnosis of ligament strain of the knee may have been incorrect. We found that there was a failure to re-evaluate the situation in light of Ms C's increasing pain and deteriorating mobility. We considered that this contributed to the delay in identifying the hip fracture. Finally, we found that there was failings in recording of assessments and pain scores during these appointments. However, we noted that the board had acknowledged this failing and had taken steps to address this. Overall, we found that the board unreasonably failed to identify Ms C's hip fracture and upheld the complaint.

Ms C, who is an advocacy and support worker, complained on behalf of her client (Mr A). Mr A had an operation at Ninewells Hospital and continued to suffer pain for over a year after the operation. Ms C complained that: Mr A suffered unreasonable pain after his operation; Mr A had to wait an unreasonable amount of time to be assessed about his pain management; the board took an unreasonable length of time to establish the source of Mr A's pain; the board provided an unreasonable treatment pathway for Mr A's chronic pain; and the board unreasonably failed to tell Mr A that he could have obtained alternative treatment outwith their area. We took independent advice from consultants in surgery, anaesthetics and pain management. We found that Mr A did have to wait too long for a referral to the pain clinic, where there were further delays in him being seen. We upheld Ms C's complaint that Mr A had to wait an unreasonable amount of time to be assessed about his pain management. We found that Mr A did suffer from pain after his operation, but that the care and treatment he had been given had been reasonable. We also found that the approach used to assess Mr A's pain was the correct approach, though it did take time. We found that Mr A's treatment options within the board had not been exhausted. We, therefore, did not uphold any of the other aspects of Ms C's complaint.

Ms C, an advocacy and support worker, complained on behalf of her client (Mr A) about the care and treatment he received at Ninewells Hospital. Mr A suffered an injury in which his fingertip was severed at the joint and he wanted to have surgery to have it reattached. However, he was referred for terminalisation surgery (where the finger is shortened and the remaining soft tissue is used to cover the amputated finger stump) instead. Following the surgery, Mr A experienced severe pain and his injury did not heal as quickly as he had hoped. Ms C complained that the board failed to provide Mr A with appropriate medical treatment and that nursing staff failed to appropriately assess and manage Mr A's pain before discharging him home. We took independent medical advice from a plastic and hand surgeon, and from a nurse. The plastic and hand surgeon adviser considered that terminalisation surgery was the appropriate treatment for Mr A's injury. They explained that the outcome of reattachment surgery was likely to be poor and had higher risks than terminalisation surgery. Therefore, we did not uphold this aspect of Ms C's complaint. The board accepted that Mr A's pain was not assessed and managed by nursing staff prior to his discharge and apologised for this. They explained that action had been taken to ensure learning from this case. The nursing adviser considered the nursing care was unreasonable so we upheld this aspect of Ms C's complaint. We asked the board to provide evidence of the action they have taken. Related reading View Decision Report 201701995 as a PDF (11.32 KB) Updated: December 2, 2018

Miss C attended the dentist to receive restoration treatment which included having a filling replaced, and previous fillings smoothed over as they still had overhangs of amalgam (mixture used to fill the teeth). The dentist who provided the treatment was undergoing vocational training, and was supervised by another dentist. Miss C complained that the treatment she received was below a reasonable standard. We took independent advice from a dentist and found that overhangs of amalgam were still partially present, despite having been smoothed, and a significant gap was created between two teeth. Both the remnant amalgam and the gap were risks to Miss C's dental health, in particular as she had an underlying risk of tooth decay. We found that the treatment provided to Miss C was below a reasonable standard and, therefore, we upheld the complaint.

Miss C complained about the treatment a dentist provided to her over a number of years. We took independent advice from a dental adviser. We found that there was a failure by the dentist to observe decay in three teeth, and possibly other teeth. Consequently, the dentist failed to plan for the management and treatment of the affected teeth. This meant that Miss C's decay profile was wrong, and she did not receive the level of observation and intervention needed, which led to an increase in the risk of decay and a significant impact on the health of her gums. We also found that fillings placed by the dentist were of a poor standard. We concluded that the treatment provided to Miss C was below a reasonable standard and we upheld her complaint.

Mr C complained that staff at Ninewells Hospital failed to consider a diagnosis of brugada syndrome when he was being investigated for fainting episodes. Brugada syndrome is a condition associated with blackouts, serious arrhythmias (where the heart can beat too slow, too fast or irregularly) and sudden death. The syndrome is characterised by a particular electrocardiogram (ECG - a test to check the heart's rhythm) abnormality, either spontaneously or after a drug test. During investigation of his fainting episodes, Mr C was advised not to work or drive. Mr C experienced a further fainting episode when a cannula was being inserted into his vein prior to an ajmaline challenge (a drug test to identify the characteristic ECG pattern changes associated with brugada syndrome) being carried out. The ajmaline challenge did not go ahead and Mr C was dissatisfied that it was not rescheduled prior to being discharged from the cardiology service. Mr C moved and said that he was diagnosed with brugada syndrome following an ajmaline challenge at a different hospital. We took independent advice from a consultant cardiologist. We found that there was evidence to demonstrate that hospital staff had considered the possibility of brugada syndrome. We considered that from the various tests carried out there was no evidence to support a diagnosis of brugada syndrome. We found that it was reasonable for staff to diagnose Mr C with vasovagal syncope (the temporary loss of consciousness due to a neurologically induced drop in blood pressure) and not to have rescheduled the ajmaline challenge. We did not uphold the complaint. However, we were critical of the time it took the board to investigate Mr C's fainting episodes. We also found that there was no evidence to clearly show that Mr C's diagnosis and the reasons for not rescheduling the ajmaline challenge had been fully explained to him. We made three recommendations to address these shortcomings.

Mr C complained about a consultation he had at the fracture clinic at Perth Royal Infirmary and the following care and treatment he received. Mr C was referred to the clinic after he fell and injured his hip. Prior to attending the consultation, an x-ray of Mr C's hip had been arranged by his GP, whilst an MRI scan had been carried out privately. Mr C brought the written MRI report to the consultation, but did not bring the imaging CD. After examination, the surgeon decided that conservative treatment (medical treatment avoiding radical therapy or an operation) was appropriate and they arranged to review Mr C in three months' time. Mr C obtained a different opinion on the treatment of his injury from a surgeon at a different NHS board. Mr C then agreed to have surgery on his hip at this same NHS board and said that this improved his condition. Mr C raised concern that the surgeon at Perth Royal Infirmary failed to carry out an appropriate assessment of his condition. Mr C felt that the surgeon should have reviewed the MRI images and spoken to the radiologist who carried out the MRI privately. We received independent advice from a consultant orthopaedic surgeon. They said that Mr C was responsible for providing the MRI images, if he wished for them to be considered. The adviser considered that the assessment carried out was reasonable, and we did not uphold the complaint. Mr C also complained that the board had failed to provide him with the same care that he subsequently received from another health board. In response to our enquiries, the board said that, based on the information available to them, they could see no reason for surgery and were satisfied that conservative treatment was appropriate. The adviser was satisfied that the surgeon's diagnosis was reasonable and consistent with Mr C's symptoms and the radiological findings. The adviser said that it was appropriate for the surgeon to arrange to review Mr C again, but suggested that an earlier re

Mrs C complained about the care and treatment provided to her at Perth Royal Infirmary when she had back problems. Mrs C complained that when she attended the A&E department on two occasions, she was not appropriately assessed before being redirected to another service. Mrs C also complained that, when she was admitted to the hospital, she was not provided with appropriate pain relief medication and that there was a delay in her being given surgery. Mrs C further complained that the information passed from A&E to her GP was not appropriately detailed. We took independent advice from an A&E consultant and from a neurosurgeon. We found that the first time Mrs C had presented to A&E she was appropriately assessed. However, we found that the second time she presented there was a failure to accurately document the assessment undertaken, which meant that it was not possible to say whether it was appropriate to have redirected Mrs C to another service. We upheld this aspect of Mrs C's complaint. We also found that when Mrs C was admitted to hospital, there was an unreasonable delay in providing her with pain relief, particularly as she had been recorded as being in severe pain. We also upheld this part of Mrs C's complaint. With regards to her surgery we found that, based on Mrs C's symptoms, there was no unreasonable delay in her having surgery. We found that the time between Mrs C being admitted to hospital and undergoing surgery was unlikely to have had any negative impact on her outcome. We also found that the information passed from A&E to Mrs C's GP was reasonable and included all of the necessary information. We did not uphold these two aspects of Mrs C's complaint. Mrs C had also complained that the board did not answer her question regarding whether her current condition could have been avoided had she received emergency surgery at an earlier point. Whilst we recognised that this was an important matter to Mrs C, we did not consider this question to ha

Mrs C's mother (Mrs A) broke her ankle in a fall. Although Mrs A had a complex medical history, including cancer and diabetes, the decision was taken at Ninewells Hospital to fix the ankle surgically. After a period of care in the hospital, Mrs A was discharged to a nursing home. During an out-patient review, it was discovered that the ankle wounds had broken down and that the metal work used to fix the fracture had become exposed. Mrs A was admitted to hospital again and underwent further surgery to remove the metal work. Mrs A was discharged back to the nursing home a few weeks later. At a further out-patient follow up, it was found that Mrs A had an infection in the ankle wound and that the bone had not grown back together. She was admitted to hospital again for treatment with antibiotics and wound care. It was considered that amputation could be necessary to control Mrs A's pain and to improve her quality of life. Amputation surgery did not take place and Mrs A was later discharged back to the nursing home. Mrs C complained about the skin and pressure care that her mother received at the hospital across these admissions as Mrs A had developed pressure ulcers on her heel and lower back. Mrs C also complained about communication with the family in relation to amputation surgery. Mrs C and her siblings held power of attorney for Mrs A and they were concerned that the surgery was planned to go ahead without appropriate discussions with them. During their own consideration of this complaint, the board identified areas for improvement in relation to a number of areas, including pressure and skin care. After taking independent advice from a nursing adviser, we upheld Mrs C's complaint about skin and pressure care. We found that there was a lack of evidence to demonstrate appropriate skin and pressure care had been provided. The advice we received highlighted that pressure injury to Mrs A's foot could have been avoidable with different care and that pressu

Mr C complained about the care provided to his wife (Mrs A) during out-patient appointments at the cardiology department at Ninewells Hospital. Mrs A was referred to the cardiology department by her GP because of drop attacks (sudden episodes of collapse). Over the following 18 months, Mrs A attended consultations in the department and a number of investigations into her symptoms were carried out. During the period that Mrs A was waiting to be fitted with a cardiac event monitor device (a device to measure the heart's activity), she sustained a stroke and was admitted to hospital for treatment. Tests carried out during this admission indicated that Mrs A was in atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). Mr C complained that the board had failed to provide Mrs A with a appropriate treatment in view of her presenting symptoms and medical history. We took independent advice from a consultant cardiologist. We found that the board managed Mrs A's condition appropriately, with the exception of the way they handled a referral from her GP approximately five months prior to the date of the stroke. We found that this referral described a change in Mrs A's symptoms and their pattern and the adviser said that the referral should have been considered more promptly and carefully by the cardiologist. The adviser said that further tests could have been considered and that, had these been carried out promptly, atrial fibrillation might have been diagnosed sooner. The adviser said that if atrial fibrillation was diagnosed, then medication would have been started and the likelihood of the subsequent stroke would have reduced. We were unable to conclude that better management would have changed the eventual outcome in this case. However, we upheld the complaint and made recommendations.

Mrs C complained about the care and treatment that was provided to her following her admission to Ninewells Hospital for induction of labour. Mrs C complained that the midwifery care around her induction, labour and birth was unreasonable. She also complained about the way the board handled her complaints. During the birth, Mrs C's baby became stuck after delivery of the head due to shoulder dystocia (where one of the shoulders becomes trapped behind the mother's pubic bone) and additional help had to be called to assist the midwife who was attending to her. The baby was delivered following this, but died a few days after the birth. After Mrs C raised her complaints with the board, they carried out a local adverse event review and also had an external review conducted by a senior midwife from another NHS board area. These reviews identified some failings with regards to aspects of Mrs C's care. However, it was found that these failings did not affect the outcome, which was considered to be unavoidable. After taking independent advice from a midwife, we upheld Mrs C's complaint about the induction of her labour. We found that there had been delays which affected her access to pain relief and that there had been poor communication. We did not make any recommendations relating to this as these failings had already been addressed by the board. We also upheld Mrs C's complaint about her care during labour. We found that the board had already identified issues, including the way that examinations were carried out to monitor Mrs C's progress. The advice we received highlighted further concerns about monitoring of blood pressure and listening to and recording Mrs C's preferences during labour. We made recommendations to address these matters. We did not uphold Mrs C's complaint about the care that was provided to her during the birth of her baby. The advice we received was that this care was timely and that the shoulder dystocia could not have been identified ear

Ms C complained about a number of consultations, for different medical complaints, that she had at her GP practice. Ms C also complained that she had been unreasonably removed from the practice list, and she complained about how the practice had responded to her complaint. We took independent advice from a GP adviser. We found that Ms C had received a reasonable standard of care and treatment, and so we did not uphold this aspect of the complaint. However, we did find a consultation which had happened had not been noted in the clinical records. We made a recommendation to address this. We found that the practice had followed the correct procedure when removing Ms C from their patient list and that they had responded thoroughly to her complaint. We did not uphold these complaints.

Ms C complained about the care and treatment provided to her late father (Mr A), who had bowel cancer. She complained that there was an unreasonable delay between a referral being made by Mr A's GP and his treatment starting at Ninewells Hospital. Ms C also complained that the care and treatment provided to Mr A in Ninewells Hospital was unreasonable. She raised further concerns that the standard of communication between the board and Mr A and his family was poor. Finally, Ms C complained that the board's handling of her complaint was unreasonable. We took independent advice from a consultant gastroenterologist and a consultant colorectal surgeon. We found that there was an unreasonable delay between the referral by Mr A's GP and his treatment starting at the hospital. Mr A's GP had made a routine referral to the board's colorectal service and we found that this referral should have been reprioritised by the board as urgent because Mr A had high risk symptoms. In view of this, we upheld this aspect of Ms C's complaint. Mr A had elective right hemicolectomy (removal of the right side of the large bowel through keyhole surgery). Four days after this, he returned to theatre for emergency surgery. Following this surgery Mr A was transferred to the intensive care unit (ICU), where he died the following day. We found that the surgery and the care Mr A received in the ICU had been reasonable. However, we found that there was an unreasonable delay in starting Mr A on antibiotics when his condition deteriorated in the ICU. We were also concerned that the frequency of consultant review following Mr A's surgery was not in line with published good surgical practice standards. We also found that the standard of record-keeping was unreasonable, particularly as there were gaps in the medical records. In light of this, we upheld this aspect of Ms C's complaint. We found that the communication with Ms C, Mr A and the wider family about Mr A's care and treatment had bee

Mrs C complained about the orthopaedic care and treatment provided to her by the board. She complained that she was given facet joint injections (injections of anaesthetic to relieve pain) into her spine without being examined by the consultant first, and that at her review appointment she again was not physically examined despite having ongoing pain. Mrs C was also concerned that she was not referred for an MRI scan or CT scan by the orthopaedic consultant. She also complained that the orthopaedic consultant failed to communicate reasonably with her after her review appointment, and that they did not refer her to the pain clinic when they said they would. We took independent advice from an orthopaedic consultant. We found that it was reasonable that Mrs C was not referred for an MRI or CT scan, as this was in line with national guidance. However, we found that it was unreasonable that Mrs C was not physically examined before the anaesthetic injections were administered, or when she was reviewed at a later appointment. On balance, we upheld Mrs C's complaint about care and treatment. We found that the communication from the orthopaedic adviser to Mrs C after her review appointment was reasonable and did not uphold this aspect of the complaint. However, we found that there was an unreasonable delay in referring her to the pain clinic and we upheld this aspect of the complaint. Mrs C also complained about the board's response to her complaint. We found that when Mrs C initially made her complaint, she made it to the complaints department as well as to the individual clinician. Therefore, we considered there had been some confusion regarding who would respond to her complaint. We also found that there had been delays in the response being issued and that Mrs C had not been kept reasonably aware of these delays. The board confirmed that they had already taken action to address this failing. We upheld this complaint.

Mr C complained that his GP practice unreasonably failed to arrange a scan of his shoulder and that they failed to refer him to an external psychology service. Mr C also had concerns that the practice failed to consult with him following a review of his medication, and that they failed to act on a letter sent to them by a consultant neurologist regarding changes to his medication. Mr C also complained that the practice failed to provide adequate responses to his letters and that they failed to apply the correct complaints handling procedure. Mr C required a cortisone injection in his shoulder and he requested that a scan be performed prior to receiving the injection. We took independent advice from a GP adviser and found that giving a scan prior to a cortisone injection is not standard practice in Scotland, therefore it was reasonable that the GP did not request this. We did not uphold this complaint. We found the standard procedure would be for a clinician to make a referral to external services, such as an external psychology service, and that a GP would not usually make such a referral. We, therefore, saw no evidence of failure on the part of the practice in this regard, and did not uphold this aspect of Mr C's complaint. We found that changes to Mr C's medication were discussed with him by his consultant, and that the GP correctly followed the consultant's instructions to amend the prescription. We found that when Mr C enquired with the practice about this change, they correctly advised him to make an appointment with his GP to discuss the review of his medication. We did not uphold this complaint. We found no evidence that the practice had failed to respond to Mr C's queries in a reasonable manner, and we did not uphold this complaint. However, we did find that the practice failed to follow the correct complaints procedure, and that they provided Mr C with the incorrect complaints procedure. The practice acknowledged this mistake, and we upheld this as

Mrs C complained about her medical practice, specifically that they failed to recognise or suspect she had whooping cough given her symptoms until a blood test confirmed the condition. Mrs C told us that as a result of the failings, her health needs were not met and she posed an unnecessary risk to her family and other members of the public. Mrs C also raised concerns about the way the board handled her complaint in that a complaints manager had been involved in both supporting her and investigating her complaint. We took independent advice from a medical adviser. We found that the standard of medical care and treatment provided was reasonable. We also found that, given the review of the investigation and report was undertaken by the head of services and not the complaints manager, the complaints handling was reasonable. Related reading View Decision Report 201607123 as a PDF (10.99 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment provided by her medical practice for her back pain. She said that she was not appropriately investigated or diagnosed, and that there was a delay in her being referred for a scan. We took independent advice from a GP. We found that when Mrs C presented with back pain, she was appropriately assessed and examined, and that appropriate action was taken as a result of these assessments. We also found that she was referred for a scan within two and a half weeks of presentation. We found that the care and treatment provided by the practice was reasonable and we did not uphold Mrs C's complaint. Related reading View Decision Report 201608069 as a PDF (10.86 KB) Updated: March 13, 2018

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs A). She complained that it was unreasonable for Mrs A's GP practice to fail to diagnose her with whooping cough until a blood test confirmed this. She also complained about communication with the GPs and the impact this had on the diagnostic process. We took independent advice from a medical adviser who specialises in general practice. We found that the standard of medical care and treatment provided to Mrs A was reasonable, and that there was no evidence of any failings. We did not uphold the complaint. Related reading View Decision Report 201606303 as a PDF (10.88 KB) Updated: March 13, 2018

Mr C complained about the care and treatment provided to him by his dentist. Mr C attended his dentist after experiencing pain in his teeth. After taking x-rays and performing an examination, the dentist considered there was an abscess around the roots of a tooth supporting the bridge in Mr C's mouth. When Mr C re-attended to discuss this, the dentist documented offering options including an extraction. Some weeks later, the extraction was performed. Mr C said he was persuaded to have the extraction and questioned whether this was appropriate treatment. He also said the dentures he was provided with were uncomfortable and ill-fitting. He said he told the dentist that he ground his teeth, and that the dentist offered a bite shield, which was not provided. After obtaining independent advice from a dentist, we did not uphold Mr C's complaints. We found that there was evidence of options being discussed in the dental records, and consent to treatment. We found the treatment option of an extraction was reasonable in the circumstances. We considered the dentist provided appropriate advice about the dentures and the need to have them re-fitted. We noted that a bite shield would not usually be provided until the condition of a patient's teeth was stable. Related reading View Decision Report 201604467 as a PDF (11.19 KB) Updated: March 13, 2018

Ms C complained about the care and treatment of her brother (Mr A). Mr A was diagnosed with liver disease and admitted to the acute medical unit at Ninewells Hospital a few weeks later. During the admission, he was also given medication for alcohol withdrawal. Mr A was diagnosed with acute kidney injury and treated with dialysis (a form of treatment that replicates many of the kidney's functions). Mr A's condition worsened suddenly, and he was transferred to intensive care, where he died. Ms C raised a number of concerns, including that Mr A was missed during the doctor's ward round the morning after his admission and that he was not referred to kidney specialists sooner. Ms C felt the hospital was under-staffed over the weekend, and she felt this meant that Mr A's condition was not taken seriously until it was too late. Ms C was also concerned that Mr A was given varying doses of medication, instead of commencing with a high dose which is slowly reduced. The board conducted an adverse event review of Mr A's admission. They acknowledged some failings, including that Mr A was missed on the ward round, that some of the nursing documentation was not fully completed, and that the family should have been told sooner how serious Mr A's condition was. The board apologised to Mr A's family, discussed the learning from the complaint with staff and agreed a new process for ward rounds to ensure that patients who are being moved are not missed. The board also met with Ms C to discuss the complaint, but Ms C found the meeting unhelpful and brought her complaint to us. After taking independent medical and nursing advice, we upheld Ms C's complaints about medical care and communication. While we found there were some omissions in nursing documentation, we found that the overall standard of nursing was reasonable. We found the administration of the medication was appropriate, as this was given as needed, using a scoring system to assess Mr A's symptoms. While we noted t

Mr C complained to us that the board had failed to properly assess his mother (Mrs A) before she was discharged from Perth Royal Infirmary. He said that, as a result of this, Mrs A had to go into a care home for full-time care, which had cost the family over £20,000 in charges. We took independent advice from a consultant geriatrician. We found that Mrs A had been discharged without being adequately assessed. There was no evidence of a multi-disciplinary team discussion or of adequate occupational therapy input in the discharge planning process. In addition, we found that that the physiotherapy and nursing notes indicated that she should have had further assessment. Mr C had also raised concerns several times to different members of staff about Mrs A's ability to return home. We found that Mrs A should not have been discharged on the day that she was. In view of this, we upheld the complaint. However, it was likely that she would have been reviewed again a week later and it was possible that a reasonable decision could have been made at that time that she could be discharged. This could have been either to her own home or to a nursing home. Mr C also complained that the board had not informed him of, or acted in accordance with, the relevant Scottish Government guidance on intermediary care following hospital discharge. The relevant guidance is normally used where care homes are being considered. In view of the fact that Mrs A had been discharged home, we found that there was no need to use the guidance. Although we found that staff had not taken sufficient account of Mr C's views at the time of Mrs A's discharge, on balance, we did not uphold this aspect of the complaint. Finally, Mr C complained to us about the board's handling of his complaint. We found that the board had delayed in responding to Mr C and that the communication with him about a meeting had not been clear. In addition, the board's response said that it had been reasonable to dischar

Mr C underwent an operation at Ninewells Hospital to remove a skin tag on his penis. He was concerned about the outcome of the operation and the appearance of the resulting scar, and he said that he was left with some disfigurement. Mr C complained that the consultant urological surgeon told him before the operation that the appearance of his penis would improve with surgery and that he was not warned that there was any risk of disfigurement. Mr C also had concerns about the standard of the operation itself, and follow-up care. We took independent advice from an adviser who specialises in urological surgery. We found failings in the consent process. We found that there was no evidence that Mr C had been warned of the risk of scarring and that the outcome of the surgery may not meet his expectations until the day of the operation. This meant that he had not been given enough time and appropriate information to make an informed decision, particularly in light of his additional needs. We found no evidence to suggest that the standard of the operation was not reasonable and while there were failings in relation to a follow-up appointment, this was addressed by the board.

Mr C complained that the prison health centre unreasonably decided to discontinue his medication when he failed a medication check. Mr C said the prison health centre failed to take account of the fact that he had reported to them that he was being bullied for his medication. The prison health centre considered that Mr C had not been taking the medication as prescribed and therefore the medication was stopped to maintain his safety. The decision was reviewed by a multi-disciplinary team who assessed that there was no significant clinical risk to Mr C ceasing to receive the medication. Before we reached a decision on Mr C's complaint, he requested to withdraw his complaint. Therefore, we closed the complaint without reaching a decision. Related reading View Decision Report 201604927 as a PDF (10.91 KB) Updated: March 13, 2018

Miss C said her mother (Mrs A) had a complex medical history and was admitted to the Royal Victoria Hospital with reduced mobility and delirium (a temporary state of mental confusion arising from, amongst other things, infection). Mrs A was discharged to a nursing home eight days later. Miss C complained that Mrs A was not medically fit to be discharged from the hospital. Mrs A died several weeks after her discharge. We took independent medical advice. We found that Mrs A was medically fit to be discharged and that the care package was reasonable. We therefore did not uphold Miss C's complaint. However, there were shortcomings in the way in which Mrs A was discharged. This included communication about Mrs A approaching the end of her life, meaning that Miss C was unprepared for Mrs A's death. We therefore made recommendations in relation to this.

Mr C complained about delays and communication in relation to his wife (Mrs A)'s hip-replacement surgery at Ninewells Hospital. After taking independent advice from a consultant orthopaedic surgeon, we did not uphold Mr C's complaints. The advice we received was that while Mrs A's patient journey had been a long one, there were no unreasonable delays in her orthopaedic treatment. After reviewing all the available evidence, no issues were found with the standard of communication. Related reading View Decision Report 201508596 as a PDF (10.84 KB) Updated: March 13, 2018