SPSO Individual Decisions

Mrs C complained about the care provided to her husband (Mr A) from Lochhead Day Hospital, which is a specialist assessment unit for people with known or suspected dementia. Mrs C complained that she was not adequately consulted about the decision to discharge Mr A. Mrs C also complained that no alternative day time care was offered to Mr A following his discharge. During our investigation we took independent medical advice from a psychiatric nursing adviser. The adviser considered that it was reasonable that Mr A was discharged from Lochhead Day Hospital, due to safety concerns. We did not uphold this aspect of Mrs C's complaint. However, the adviser considered that there was an unreasonable failure to involve Mrs C in agreeing a follow-up plan for Mr A's care before his formal discharge. Therefore, we upheld this aspect of Mrs C's complaint and we made recommendations in light of our findings.

Mr C complained on behalf of his wife (Mrs A) about the care provided by mental health services at Dr Gray's Hospital. Specifically, Mr C complained about the way in which a psychiatrist and a community psychiatric nurse (CPN) handled a request for a letter for Mrs A to be excused from attending court as a witness and that they had discharged her from the service without notifying her or offering alternative support. We took independent advice from a consultant psychiatrist and a mental health adviser. We were critical that the psychiatrist had not made a record of a phone conversation that took place with Mr C at the time to evidence the advice and support offered. This was contrary to national guidance in relation to record-keeping which we were critical of and we made recommendations in relation to this. We also found that the board had acknowledged and apologised that their psychiatrist and CPN had not properly communicated with Mrs A regarding her discharge from the service. The board said that they had taken action to remind staff to share all important communication with patients. We considered that the psychiatrist had not documented adequate reasons supporting why Mrs A was discharged, nor had they offered her the option of another consultation or seeing a different clinician. We also found that it would have been more appropriate for the CPN to have written to Mrs A and explained the options available to her in terms of continuing or not continuing the service. We upheld Mr C's complaints.

Mrs C complained about the care and treatment her husband (Mr A) received when he was admitted to prison. In particular, Mrs C complained that, on admission, the health centre's handling of Mr A's medication was unreasonable. She also complained that there was an unreasonable delay in treating Mr A's stomach condition. The board explained to Mrs C that Mr A was uncooperative and would not engage with the admission process when nursing staff tried to take his medical history. They advised that Mr A would have been asked to confirm his GP detail's so that his prescribed medications could be checked.

Ms C complained on behalf of her late mother (Mrs A) about the care and treatment she received from the board. Specifically, Ms C complained about a consultant geriatrician's assessment of Mrs A's condition, as well as their communication with Mrs A and her family about her condition and treatment options. Ms C also complained that an out-of-hours doctor failed to communicate appropriately about Mrs A's condition and treatment options. During our investigation we took independent medical advice from a consultant geriatrician and from a general practitioner. We found that the out-of-hours doctor's communication was reasonable. We also found that the consultant geriatrician's assessment of Mrs A's condition was reasonable. As a result, we did not uphold these aspects of Ms C's complaint. We did find that there were failings in how the consultant geriatrician communicated with Mrs A and her family. We, therefore, upheld this aspect of Ms C's complaint and made recommendations in light of our findings.

Mrs C complained about the care and treatment provided to her late husband (Mr A). Over the course of a number of years Mr A attended the practice with anxiety and depression. During this time, the practice treated Mr A in primary care, and did not refer him to mental health services. Subsequently, Mr A did not attend the practice with these problems for approximately 18 months. Mr A then contacted the practice and reported persistent thoughts about suicide to the GP who saw him. The GP developed a plan of management, including referring Mr A to psychiatric services. However, the referral was not processed. Mr A committed suicide approximately ten days after his attendance at the practice. Mrs C complained that the practice failed to appropriately refer Mr A to mental health services in view of his presenting symptoms. The practice said they provided appropriate treatment based on Mr A's symptoms during his earlier attendances. They did not consider a referral was appropriate at that stage. When Mr A returned and described persistent thoughts about suicide, they said a referral was appropriate. The practice acknowledged there was an error in processing the referral, although they noted that it was unlikely Mr A would have received an appointment before his death. After receiving independent advice from a GP, we upheld Mrs C's complaint. We found there was an administrative failing in not making the referral (as the practice acknowledged). We also found the practice should have scheduled an earlier review when Mr A re-attended the practice. However, we did not consider the practice should have made a referral at any of Mr A's earlier attendances, and we found that the care and treatment provided during this time had been reasonable.

Ms C, who works for an advocacy and support service, complained on behalf of Ms A about a health visitor's monitoring of her infant daughter (Miss A). Miss A was diagnosed with hydrocephalus (an abnormal build-up of fluid in the brain) at around four months old. Ms C complained that this should have been picked up sooner. We took independent medical advice from a health visitor, who considered that there were failures to appropriately record and interpret Miss A's head circumference, resulting in missed opportunities to identify the steep growth rate and make an appropriate referral for further investigation. In particular, it was noted that the measurement at Miss A's six to eight week assessment had crossed over the top centile and, in line with the board's policy, should have prompted referral. We concluded that the health visitor did not take appropriate action to monitor Miss A's development and we upheld the complaint.

Mr C made regular visits to his medical practice. He was concerned about symptoms of facial flushing and rash (for which he was seeing a dermatologist at a hospital). After six months, a blood test confirmed that Mr C had diabetes. Mr C complained that the practice failed unreasonably to recognise or suspect that he had diabetes given his symptoms. We took independent medical advice. We found that had the GPs been made aware that Mr C had symptoms including constant thirst and urination, they should have checked the levels of his blood sugar earlier. However, these symptoms were not noted in Mr C's clinical records. The evidence from the clinical records indicated that the GPs had been made aware of symptoms in relation to Mr C's facial flushing and rash and that it was reasonable they did not consider that diabetes could have been the underlying cause of this. We were therefore satisfied the standard of care and treatment provided was reasonable and did not uphold Mr C's complaint. Related reading View Decision Report 201603948 as a PDF (11.08 KB) Updated: March 13, 2018

Ms C complained about care and treatment her mother (Mrs A) received from her medical practice. Ms C was concerned that the practice missed opportunities to enable an earlier diagnosis of lung cancer. She felt that an earlier diagnosis could have helped prevent Mrs A's death. Ms C also raised concern about the way in which a GP handled a conversation about possible future resuscitation. We took independent medical advice from a GP. We found that the practice had provided a reasonable standard of care in response to the various symptoms Mrs A had presented with in the year leading up to her cancer diagnosis. We did not identify any clear evidence to show that the conversation about resuscitation was handled inappropriately, and considered that it was reasonable to have this conversation with Ms C and Mrs A. The practice reflected on Ms C's concerns in any case and took steps to improve the way in which their staff deal with such conversations with patients and their families. We did not uphold Ms C's complaints. Related reading View Decision Report 201603001 as a PDF (11.09 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment provided to her late father (Mr A). Mr A was admitted to Dr Gray's Hospital where staff identified that he had suffered a stroke. Over the course of approximately four months, he had three further admissions. During the course of the admissions, Mr A's condition deteriorated. Mrs C raised concerns about pain Mr A was experiencing in his abdomen and back, and swelling in his leg. During the fourth admission, a scan revealed cancer. Mr A died approximately one week later. Mrs C complained that the board unreasonably delayed reaching a diagnosis that Mr A was suffering from cancer. She also complained that the board failed to appropriately diagnose a deep vein thrombosis (DVT), which was identified during one of the admissions. The board apologised and acknowledged that they had been slow to investigate pain Mr A was experiencing in his back and abdomen. They did not consider that earlier identification of the cancer would likely have impacted on Mr A's outcome, and that treatment would have been palliative. The board considered there had not been a delay in identifying the DVT. After receiving independent advice from a consultant in acute medicine, we upheld Mrs C's complaints. We found that the symptoms Mr A had experienced were unusual, but should have alerted the board to the possibility of cancer at an earlier stage. We noted that the cancer was aggressive in nature and early detection would not have likely altered Mr A's outcome. We found that the board did fail to recognise the DVT in this case. We were critical of the limited records regarding checks for DVT. Finally, we had some concerns about delays in the board's handling of Mrs C's complaints.

Mr C complained about the care and treatment provided to his late father (Mr A) while he was a patient at Aberdeen Royal Infirmary. Mr A had a complex medical history and he was admitted to hospital with ischemia (inadequate blood supply to an organ or part of the body) and sepsis (a blood infection). Several weeks later, he was discharged to a community hospital from where he was discharged home. He died the following day. Mr C complained about aspects of Mr A's discharge to the community hospital including communication. We took independent medical advice. We found an unreasonable failure by staff to carry out comprehensive multi-disciplinary discharge planning. We also found that Mr A was transferred to a community hospital when he did not have capacity, which was against his family's wishes and without relevant documentation. We also found that there had been a breakdown in communication which meant that medical staff wrongly informed other staff about the family's wishes in relation to discharge. We upheld the complaint.

Ms C, who works for an advocacy and support service, complained on behalf of Ms A about the practice's monitoring of her infant daughter (Miss A). Miss A was diagnosed with hydrocephalus (an abnormal build-up of fluid in the brain) at around four months old. Ms C complained that this should have been picked up sooner. We took independent medical advice. It was noted that, prior to her six to eight week assessment, the health visitor had measured Miss A's head circumference and the measurement had crossed over the top centile. This should have been a cause for concern and should have prompted a referral for further investigation. However, the health visitor had not taken action to alert the practice. The adviser considered, however, that the GP carrying out Miss A's six to eight week assessment should reasonably have looked at the growth charts and sought to satisfy themselves that Miss A was developing normally. They did not do so. We upheld the complaint. However, the GP had already apologised for not personally examining the growth charts and arranging further action. The practice had reflected on the case and confirmed that they were now checking measurements and centile charts at the six to eight week assessment. We considered this action to have appropriately addressed the identified failings and we had no further recommendations to make. Related reading View Decision Report 201508590 as a PDF (11.28 KB) Updated: March 13, 2018

Mr C complained to us that the medical practice had failed to provide appropriate care and treatment to his late teenage daughter (Miss A). He said that Miss A had a lump on the side of her head which, over a couple of years, the doctors had said was a cyst. This turned out to be cancer. Mr C felt that there had been a delay in reaching the diagnosis and that it was inappropriate that the practice had sent letters directly to his daughter about possibly removing the cyst at an earlier time. He said that he and his wife were not aware of the letters. The practice responded that the presumption was that Miss A had a cyst, and that the option of removal under local anaesthetic was discussed. Miss A was given the opportunity to consider the excision along with the offer of a second opinion. When the cyst was noted to be increasing in size, Miss A was referred to hospital and cancer was diagnosed. The practice explained that the diagnosis was unusual for a child of Miss A's age but that their investigation had identified a number of learning points. We took independent GP advice. We found that based on the recorded evidence, there were no concerns about the way the GPs managed the situation. Initially there were no signs that the lump was sinister and the offer to have it removed was made. Miss A was competent to make the decision whether to have the lump removed at an earlier stage for cosmetic reasons rather than for clinical reasons and she decided not to have it removed. That was a reasonable decision for her and her parents to consider as her parents were involved in Miss A attending the practice at times. It was also reasonable for the practice to write directly to Miss A directly. We did not uphold Mr C's complaint. Related reading View Decision Report 201605999 as a PDF (11.46 KB) Updated: March 13, 2018

Mr C complained about the board's management of healthcare appointments for his child, who suffers from allergies and diabetes. In particular, Mr C was concerned that the board cancelled an out-of-area appointment for a joint allergy and gastroenterology clinic, on the basis that equivalent local services were available. However, the board did not provide a gastroenterology appointment until about six months later. The board acknowledged that some of the appointments were outwith the 12-week waiting time target for new out-patient appointments, including a clinical genetics appointment (delayed due to a missed referral), an allergy appointment (provided out-of-area as the child's GP had requested this), and a gastroenterology appointment (which took longer to arrange as it was a joint appointment with gastroenterology and the head of the local allergy service, and was further delayed by a consultant gastroenterologist leaving the board). After taking independent medical advice, we found that it was reasonable for the board to take the position that an out-of-area referral for allergy and gastroenterology was not required, as there were equivalent services available within Scotland. We found that the delay in the clinical genetics appointment was unreasonable, and while the board had already acknowledged this and addressed the problem, we considered they should also apologise to Mr C. However, we were not critical of the timeframes for the gastroenterology and allergy appointments. While we acknowledged these were outwith the 12-week target, we noted that the target is for 95 percent of cases to meet these timeframes, and in this case we considered the timeframes were reasonable in view of the specific circumstances. Mr C also said the board gave inaccurate information in their complaint response about what kind of support it was agreed at a clinical meeting the health visitor should provide. We found there were conflicting accounts about exactly what was said

Mr C complained about the treatment he received from his GP practice after a fall in which he sustained a head and neck injury. He thought the practice should have referred him to A&E. We found the treatment Mr C received was reasonable. He attended the practice without an appointment and was seen by a triage nurse who assessed his injury. He was advised to take pain relief. Mr C later called the out-of-hours service and was given a pain-relieving injection and on-going pain relief. When the medication ran out he went back to the practice, was assessed, and was given more medication. Mr C returned to the practice and told them he wanted to go to A&E. He attended A&E the same day and had an x-ray, which was clear. He was given advice about lying flat and exercise. We found the treatment the practice provided was reasonable in the circumstances, given Mr C's presenting symptoms. Mr C's injury was assessed in the normal way by a triage nurse. No serious injury was evident. Mr C was, appropriately, advised to seek further advice should his condition deteriorate. When Mr C was assessed in A&E, no significant injury was found. We therefore did not uphold Mr C's complaint. Related reading View Decision Report 201601173 as a PDF (11.15 KB) Updated: March 13, 2018

Mrs C complained that when she phoned the medical practice for an appointment, she was given neither an appointment nor a phone consultation. We looked at the practice's records and took independent advice from a GP adviser. As there was no audio recording of the phone calls, we could not determine what was said. There was no evidence that Mrs C was not taken seriously when she was unwell, and we found that she saw a GP the day after she phoned the practice. We did not find that practice staff failed to respond to Mrs C's request for a medical consultation in a reasonable manner and therefore we did not uphold Mrs C's complaint. Related reading View Decision Report 201603468 as a PDF (10.91 KB) Updated: March 13, 2018

Mr C complained about a nurse in the substance misuse clinic within the prison. Specifically, that when he self-referred, the nurse did not provide him with adequate advice, care and treatment for his reported addiction and self-harm issues. Mr C had particular concerns that he had explained to the nurse that he did not wish to be prescribed methadone (a drug used medically as a heroin substitute) as he had had problems with taking it in the past, and that instead he needed a prescription for a different medication used to treat addiction. He said that the nurse had not passed this information to his psychiatrist. Mr C also said that the nurse had not passed on information about his self-harming to the psychiatrist. During our investigation, we took independent advice from a mental health nurse. We found that there was no evidence that the information Mr C said that the nurse had failed to pass on to the psychiatrist had ever been disclosed to the nurse. However, we found that no proper assessment and care plan had been completed by the nurse when Mr C attended the substance misuse clinic and considered this unreasonable. We also considered that the nurse's record-keeping was insufficient. In view of these failings, we upheld this aspect Mr C's complaint. Mr C also complained that the board's handling of his complaint had been unreasonable. We identified that, whilst the board's initial complaint response had been sufficient, they did not investigate Mr C's subsequent complaints. We found that this was unreasonable and not in accordance with national complaints handling guidance. Therefore we also upheld this aspect of Mr C's complaint.

Mrs C complained about the care and treatment her mother (Mrs A) received in the Glen O'Dee Hospital following a hip operation. The initial plan was for Mrs A to return to her own home following physiotherapy, but after a fall she said she wanted to be discharged into a care home. Mrs C complained that after the fall, staff at the hospital failed to recognise that a screw in Mrs A's hip had become displaced and that a further fall was not recorded in Mrs A's records. Mrs C also said that communication with her and her mother was inadequate and that the board failed to take her views into account when reaching a decision to discharge Mrs A into a care home. We took independent advice from a physiotherapist, a GP and a nursing adviser. We found that after her fall, Mrs A's physiotherapy treatment continued and she said she was not experiencing any pain. It was only when Mrs A began to feel pain that the situation was brought to the attention of a doctor who referred her to another hospital where she was x-rayed and the displaced screw was diagnosed. While Mrs C believed that there had been a subsequent fall, we found no evidence of this. However, we found that communication between the hospital and Mrs C had been poor as she had not been alerted to the fact that her mother had experienced a fall and we upheld this part of the complaint. However, we also found that Mrs A had been quite definite in wishing to be discharged to a care home despite her daughter's wishes. While the board took Mrs C's wishes into account, Mrs A had capacity to make her own decisions and the board had to acknowledge this. It was only later that Mrs A changed her mind and agreed to be discharged to Mrs C's home. We did not uphold this complaint.

Mr A had lung cancer and was receiving end of life care at home. Mr A's wife (Mrs C) complained to us about the care he received from district nursing staff, about the standard of communication, and about the board's response to her complaints. Mrs C was concerned about a dose of medication given to Mr A by the nurses and about record-keeping. We took independent advice from a nursing adviser and a medical adviser. They found that there was no evidence that the standard of record-keeping affected the management of Mr A's symptoms. They also found no error in the prescription or administration of the medicine. We did not uphold these aspects of Mrs C's complaint. Mrs C also complained about a decision to move Mr A in bed. She said that this caused him pain and was concerned that a bathroom towel was used. We found that moving Mr A in bed was a good way of assessing pain control and that both the decision to move Mr A and the way he was moved were reasonable. Mrs C complained that she had not received a good standard of communication from the nurses. The nursing adviser said that Mrs C had not been offered support and there was no evidence that staff had listened to Mrs C's concerns. However, given the available evidence, it was not possible to reach a judgement on other aspects of Mrs C's complaint about communication. Mrs C also said that the board failed to respond reasonably to her complaints and that their response was accusatory. We found that while the board's response addressed every clinical issue, there was no evidence of compassion or empathy. We therefore upheld this aspect of Mrs C's complaint.

Ms C, who works for an advocacy and support agency, complained on behalf of Ms A that during a surgical procedure at Aberdeen Royal Infirmary to address a condition affecting her spine, Ms A's spinal-cord was injured which led to a significant deterioration of her condition. Ms C complained that staff failed to investigate her new symptoms following the procedure and that they failed to recognise that they were a result of an injury from the surgery. We took independent medical advice from a specialist in neurosurgery. We found that while the evidence indicated the operation itself was carried out to a reasonable standard and that the cord injury Ms A suffered from was a recognised complication (and one which she had been made aware of prior to the operation), there were shortcomings. Firstly, there was no evidence that clinicians had discussed all treatment options with Ms A during the consent process. Secondly, clinicians unreasonably failed to investigate Ms A's new symptoms before discharge home. Therefore, we upheld Ms C's complaint.

Mrs C complained to us about the treatment her mother (Mrs A) received from her medical practice. In particular, she was unhappy with the treatment Mrs A received for pain in her left arm and in relation to choking episodes. She also made a number of complaints about the medication prescribed to Mrs A. We took independent advice from a GP adviser. We found that, in general, the treatment provided to Mrs A by the practice had been of a reasonable standard. However, although Mrs A had angina, she had been prescribed an anti-inflammatory medication by a GP that is contraindicated in (should not be given to) patients with angina. In addition, Mrs A had incorrectly been prescribed a double prescription of heart medication and iron tablets. Although there was no evidence that Mrs A suffered harm as a result of these prescribing errors, in view of these failings we upheld the complaint. The practice had already apologised for this. Mrs C also complained that a GP had told Mrs A that she had cancer when she attended a consultation at the practice on her own. We found that the specialist clinician who had previously arranged tests for Mrs A should have previously informed her of the diagnosis. It was reasonable for the GP to assume that Mrs A had already been informed of her diagnosis. We did not uphold this aspect of Mrs C's complaint. Finally, Mrs C complained about the practice's handling of her complaint. We upheld this, as we found that the practice had delayed in responding and had not advised Mrs C that she could contact SPSO.

Mr C, who suffers from chronic back pain, raised a number of concerns about surgery performed on his spine at Aberdeen Royal Infirmary. Mr C complained that he suffered significant blood loss during the operation and that the surgeon failed to record on the operation note that he required blood transfusion. Mr C also complained that the surgeon operated on him using old scan images and that the operation caused nerve damage. We took independent advice from a consultant neurosurgeon (a surgeon specialising in surgery of the brain and nervous system). They did not find evidence that the surgeon unreasonably failed to record a blood transfusion on the operation note and noted that it was only after the conclusion of the operation that the requirement for transfusion became apparent. The adviser was satisfied that it was reasonable for the surgeon to operate on Mr C using an old scan, and considered that there was no evidence that the operation caused nerve damage. Although we did not uphold this complaint, the adviser was critical about the level of detail in the medical records and we made a recommendation to address this. Mr C also underwent operations to replace his hips. He complained that the board unreasonably failed to diagnose his hip condition for five years. The adviser noted the extended process involved in diagnosing the cause of Mr C's pain but found that it was reasonable of the board to have focused their investigations on his back given that he had a known back condition. The adviser did not consider that successive consultant neurosurgeons failed to diagnose Mr C's hip condition and said that it was the responsibility of a patient's GP to first investigate the potential of a hip pathology. We did not uphold this complaint. Mr C also complained about the way the board communicated with him during their investigation into his chronic pain. Mr C felt that a consultant neurophysiologist (a doctor specialising in disorders of the central and perip

Mr C complained to us about the decision to stop his medication in prison. He said that he had been wrongly accused of concealing it in his mouth when it was given to him under supervision by nurses. He complained to us about the way in which he was supervised when taking the medication. We took independent medical advice on Mr C's complaint. We found that the way in which he had been supervised was reasonable. The decision by medical staff to stop the medication was also reasonable given their concerns that Mr C was not using the medication in line with his needs. We did not uphold these aspects of Mr C's complaint. Mr C also complained to us about the response he had received from the board to his complaint. He said that this incorrectly stated that he had concealed medication four times in four months. Mr C's medical records showed that he had been caught concealing medication on three occasions. We upheld this aspect of his complaint. Finally, Mr C complained to us that the board had failed to treat his ongoing pain effectively. We found that the care provided to Mr C in relation to pain after the medication was stopped had been reasonable. We did not uphold this aspect of Mr C's complaint. Related reading View Decision Report 201507478 as a PDF (11.09 KB) Updated: March 13, 2018

Mr C complained about the medical practice after they removed his family from the practice list for being outwith the practice boundary. Following a home visit to Mr C's father-in-law, the practice had advised that they felt the distance they had to travel presented a potential safety risk. This had led them to audit the practice list and they had decided to remove all patients outwith their boundary. Mr C advised that, although his family was outwith the practice boundary, they had been registered there for many years following a complaint against their previous practice. He considered that this meant they should be allowed to remain on the practice list. We found that the practice had clearly explained the reasons for their decision and given reasonable notice of the removal of services. We sought independent advice from a GP adviser, who was satisfied that the practice had complied with the provisions set out in the General Medical Services Contract for the removal of patients from the practice list, and that it was within their discretion to remove patients who were outwith their practice boundary. We accepted this advice and did not uphold Mr C's complaint. Related reading View Decision Report 201600712 as a PDF (11.13 KB) Updated: March 13, 2018

Mr C complained about the care and treatment provided to him at Grampian Royal Infirmary following his diagnosis of prostate cancer. Mr C said that he had not been provided with all the information necessary for him to give informed consent for the prostate surgery he had undergone. Mr C said that the board had failed to provide him with a test result which showed that the indicator used to measure the cancer's activity had declined. The board said that Mr C had been managed and advised appropriately. They accepted that he had not been provided with the test result, but said this was not required for him to have given his informed consent. Additionally the board noted that Mr C had had a number of detailed discussions with his clinicians about his treatment options. We took independent medical advice on the treatment provided to Mr C. The adviser said that Mr C's management and treatment were in line with the appropriate clinical guidelines. It noted that Mr C had delayed his treatment as he had wished to travel abroad during it. During this trip, a test of his cancer indicators had shown a marked rise. The advice noted that the test Mr C was not informed about showed a lower level of this indicator. The medical decision to operate on Mr C was based on the assessment of a scan of his prostate, and a subsequent examination of the cancer showed it to be more serious than previously thought. The advice said this supported the decisions made by medical staff. We found that the test level was not the determining factor in deciding whether Mr C should have undergone surgery. We found that for informed consent, Mr C needed to be provided with sufficient information to understand the reason for his surgery, the risks and benefits of the proposed treatment and the alternatives available to him. The evidence showed that this had been done and that the treatment Mr C was provided with was the appropriate one. We did not uphold Mr C's complaint. Related reading Vie

Mr C complained that an incorrect entry had been placed in his GP records which he had asked the practice to remove or mark 'to be disregarded'. He also complained that the board did not deal with his subsequent complaint in a timely manner. Following investigation, we were of the view that the practice had taken reasonable action to try to establish the accuracy of the record which detailed a consultation alleged to have taken place between Mr C and a locum GP. As the locum no longer worked for the practice they were unable to speak to him. In order to establish if the record actually related to another patient the practice conducted a search of their records, including patients seen just before and after Mr C on the date in question. They also reviewed the records of patients with similar names and/or dates of birth. We considered that the practice had taken reasonable action to establish whether or not the record was inaccurate, but had been unable to do so. We did not uphold this complaint. On the matter of Mr C's complaint to the board, we found that there had been delays in dealing with Mr C's complaint. However, Mr C had been kept informed during the process. Although we upheld this complaint, we did not make any recommendations on this matter. Related reading View Decision Report 201508104 as a PDF (11.19 KB) Updated: March 13, 2018