SPSO Individual Decisions

Ms C complained about the treatment she received from the practice in response to her symptoms of oedema (swollen tissue from retained fluid). Ms C said that she had reported symptoms to the practice on numerous occasions. Ms C said there was an unreasonable delay in responding to her symptoms. During an appointment with a GP Ms C was told to stop a certain medication. Ms C said that during the appointment she was not given proper instructions or after care, i.e. to get her blood pressure checked. A few weeks later, after a severe headache, it was found that Ms C's blood pressure was too high and she required hospital admission. We took independent medical advice from a GP. We found that Ms C's treatment by the practice was reasonable and found no failings in the treatment offered. The practice considered Ms C's symptoms, taking into account her overall medical hisotry and chronic illnesses when considering appropriate action to respond to Ms C's reports of oedema. Therefore, we did not uphold this part of Ms C's complaint. Ms C also complained that the board failed to provide reasonable after care, specifically that her blood pressure should be checked. There was no written record or evidence to support the practice's view that appropriate information was provided to Ms C regarding having her blood pressure checked. Therefore, we upheld this part of Ms C's complaint.

Mr C complained about the physiotherapy treatment (the treatment of disease, injury or deformity using physical methods such as massage, heat treatment, and exercise) given to his wife (Mrs A) after her hip operation at University Hospital Hairmyres. Mr C also complained that the board had failed to communicate reasonably with himself and Mrs A about Mrs A's rehabilitation potential. We took independent advice from a senior physiotherapist. We found that Mrs A had been provided with reasonable physiotherapy. The advice we received from the senior physiotherapist was that there were two treating physiotherapists which was excellent practice. We also found that the decision not to provide physiotherapy following discharge had been reasonable and that the communication about Mrs A's rehabilitation potential had been reasonable. Therefore, we did not uphold these aspects of Mr C's complaint. Mr C also complained about the pressure area care given to Mrs A. We took independent advice from a nursing adviser. We found that the pressure area care given to Mrs A was unreasonable. In particular, that there was a lack of risk prevention strategies implemented when Mrs A was admitted to reduce her risk of developing pressure damage; when the first damage to Mrs A's skin was identified no care plan was put in place to reduce further risk of damage; and when Mrs A's ulcer developed into a grade three pressure ulcer (grade four is the highest form of damage) the relevant guidance was not followed. We also found that the nursing communication with Mr C had been unreasonable and that there was no evidence of a care plan being initiated to address Mrs A's weight loss. We also noted that that the nursing records were unreasonable Therefore, we upheld this aspect of Mr C's complaint.

Ms C complained about the treatment she received from the dentist. Ms C was referred to the dentist as she required sedation during dental procedures. Ms C said she was told by the referring dentist that the tooth, which had a missing filling, was salvageable and could be crowned, however when the tooth was assessed, the dentist felt it was not salvageable. Ms C complained that the actions of the dentist led to an infection, cutting of the bone and was essentially unreasonable. We took independent advice from a dentist. We found that Ms C's treatment by the dentist was reasonable and found no failings in the treatment offered. When the planned treatment changed, Ms C was brought back from sedation so she would be in a position to consent to treatment. The treatment was carried out in a reasonable manner. Therefore, we did not uphold the complaint. Related reading View Decision Report 201805707 as a PDF (23.72 KB) Updated: May 22, 2019

Mrs C, an advocacy and support worker, complained on behalf of her client (Ms  B) about the care and treatment her elderly mother (Mrs A) received at Wishaw General Hospital and Kello Hospital. Mrs A had been in hospital after being diagnosed with lung cancer. Due to her frail condition, Mrs A was unsuitable for further care and could only be made comfortable. She was discharged home. Mrs A's condition deteriorated further and she was admitted to hospital for pain relief and palliative care. Mrs C complained that Mrs A was not fit for discharge and there was insufficient discussion with the family about this or about the medication Mrs A required to take at home. Mrs C also complained that the support provided by a nurse was unreasonable and on admission to Kello Hospital, staff failed to communicate reasonably with Mrs A family and delayed in providing appropriate pain relief. We took independent advice from a doctor and from a specialist registered nurse. We found that discharge planning for someone with a terminal illness was complicated and difficult. While it was acknowledged that Mrs A wanted to go home, the arrangements made for her discharge had been hasty with insufficient discussion with the family who were unprepared for the demands of looking after her; they had no clear understanding of the medication prescribed and needed by her. Therefore, we upheld these aspects of Mrs C's complaints. In relation to the nursing care, we found the support to be reasonable. We also considered the communication from staff at Kello Hospital to be appropriate and found no concerns with the pain relief given to Mrs A. Therefore, we did not uphold these aspects of Mrs C's complaints.

Mrs C complained that the board unreasonably failed to make appropriate arrangements to deliver her baby by cesarean section (c-section) in line with her birth plan. Mrs C's waters broke two days before she was due to have her c- section at Wishaw General Hospital and she contacted the hospital for advice. Mrs C was told to return that evening and confirmed she still wished to have a c- section. After her arrival at hospital, Mrs C waited almost three hours before being clinically assessed. By the time she was examined she was 8cm dilated, and although staff started to prepare her for a c-section there was no theatre available and she progressed through labour, with her child eventually being delivered by forceps. The board said that the department had been particularly busy, and that they had prioritised patients according to clinical need. Mrs C was unhappy with this response and brought her complaint to us. We took independent advice from a consultant obstetrician (a doctor who specialises in pregnancy and childbirth). We found that there was no medical need to open a second theatre and that Mrs C and her baby has been appropriately monitored throughout the labour. However, Mrs C was on the 'red pathway' for her maternity care which highlights significant/obstetric risks and we found that there had been a delay in assessing her after her arrival at hospital. We considered that Mrs C should not have been left without adequate triage on her arrival at hospital. We upheld this aspect of Mrs C's complaint. However, we noted that the outcome may not have been different even if Mrs C had been examined sooner. Mrs C also complained that the board's handling of her complaint was unreasonable. When Mrs C first raised her concerns with the board, she was offered a meeting with the consultant whose care she was under. At the end of the meeting the consultant suggested that Mrs C prepare a note setting out her account of what had happened. Mrs C understood she w

Mr C complained about the medical care and treatment his late mother (Mrs A) received at Hairmyres Hospital. In particular, Mr C complained that a biopsy was not carried out and that the board had failed to give Mrs A an appointment for a ring pessary (a device used to support the uterus, vagina, bladder or rectum) change. We took independent advice from a consultant gynaecologist (a doctor who specialises in the female reproductive system). We found that there had been no indication to carry out a biopsy when Mrs A attended the hospital following a referral from her GP. Therefore, we did not uphold this aspect of Mr C's complaint. In relation to Mr C's concern that Mrs A had not been given an appointment for a ring pessary change, we found that the board had initially advised Mr C that this was as a result of a system failure. However, they later clarified that this was not the case. We found that the failure to attend an appointment for a ring pessary change was not caused by a failing on the part of the board and we did not uphold this aspect of Mr C's complaint. However we were concerned that incorrect information had initially been given to Mr C about this matter and made a recommendation to the board.

Mrs C, an advice and support worker, complained on behalf of her client (Mrs A) regarding the treatment she received from the domiciliary podiatry service (area of medicine that treats disorders of the foot, ankle and lower limb). Mrs A complained that the podiatrists failed to review her on a regular basis and that they did not appropriately treat her foot blisters, cuts or check her foot pulses. We took independent advice from a podiatry manager. We found that the records indicated that the podiatrists reviewed Mrs A on a regular basis based on her presenting symptoms. When she requested an emergency appointment this was arranged within an appropriate timescale. We found that the podiatrists provided appropriate treatment in view of Mrs A's presenting symptoms and that her foot pulses were checked on an annual basis in line with national guidance. We did not uphold Mrs C's complaint. Related reading View Decision Report 201804213 as a PDF (23.77 KB) Updated: February 20, 2019

Ms C complained that the treatment she received at Dumfries and Galloway Royal Infirmary was unreasonable. Ms C underwent a small bowel resection (removal of part of the small intestine) and since then had experienced significant pain. Ms C said that the treatment options were restricted for her and that her symptoms were being ignored. We took independent advice from a colorectal and general surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found that Ms  C's medical circumstances were very complex, and from the medical notes it was clear that treatment options were not straightforward and came with many risks. We found no evidence that appropriate treatment was withheld from Ms C. We also found that the medical care Ms C received was reasonable, appropriate investigations had been made and there was careful consideration of her care with appropriate discussions and follow-up appointments arranged for further treatment. Therefore, we did not uphold Ms C's complaint. Related reading View Decision Report 201801896 as a PDF (23.84 KB) Updated: February 20, 2019

Mr C complained about the care and treatment provided to his late father (Mr A) when he was admitted to Hairmyres Hospital with a suspected chest infection. Mr A was fed via a Percutaneous Endoscopic Gastrostomy (PEG, a tube into the patients's stomach through the abdominal wall) and early in the morning, on the day after his admission, Mr A's PEG became detached. While it appeared that nurses noticed this, it was not reported until a ward round later that day. By then, the entry tract had closed and the feeding tube was unable to be reinserted. Subsequently, there were difficulties in ensuring Mr A's nutrition and there were numerous failed attempts to re-establish his feeding. After ten days, Mr A's family requested that he be transferred to another hospital to have a PEG surgically inserted but the procedure had to be stopped. Mr A died shortly afterwards. Mr  C complained that staff failed to act when the PEG had become detached. We took independent advice from a consultant in general medicine. We found that the board's guidance stated that if a gastronomy feeding tube fell out, it should be replaced as soon as practicable, preferably within two hours. However, this did not happen and staff were initially unaware of the need to reinstate the PEG within a particular time frame. We also found that there was a lack of coordination and planning around the repeated failure to obtain a consistent route of feeding and there was a lack of communication about how unwell Mr A was. Although the outcome for Mr A may have been the same, we considered that his recovery was compromised by a level of care that fell below what could have been expected. Therefore, we upheld Mr C's complaint.

Ms C, an advocacy worker, complained on behalf of her client (Ms A) about the care and treatment provided by the board in relation to a respiratory (breathing) condition. Ms C complained that Ms A had been unreasonably discharged from the care of a lung specialist when the specialist left the board. She also raised concerns about the medical and nursing care provided when Ms A was admitted to Hairmyres Hospital. Finally, Ms C complained that the follow-up Ms A received at Monklands Hospital was unreasonable and that the board's response to the subsequent complaint was unreasonable. We took independent advice from a respiratory consultant. We found that as Ms  A's condition was stable, it was reasonable to discharge her when the lung specialist left the board. The discharge letter provided advice to Ms A's GP that if her symptoms progressed, she should be re-referred as a new patient. We also found no failings in the medical care and treatment that Ms A received either as an in-patient or in follow-up as an out-patient. Therefore, we did not uphold these parts of Ms C's complaint. We took independent advice from a nursing adviser in relation to Ms A's concerns about nursing staff. We found that the nursing care that was provided to Ms A was reasonable. We did not uphold this part of Ms C's complaint. Finally, we found that the response to Ms A's complaint was reasonable and considered that it addressed the points listed in her original complaint. Therefore, we did not uphold this part of Ms C's complaint. Related reading View Decision Report 201707184 as a PDF (23.97 KB) Updated: February 20, 2019

Mr C complained about the care and treatment he received at Monklands Hospital. Following an accident, Mr C presented to the emergency department on three occasions over a two day period. He raised concern that doctors did not listen to his concerns about his injury and that an x-ray was not performed until his third presentation. At the first presentation, Mr C was examined for a head injury and was discharged without an x-ray being performed. Mr C returned to the department the next day and was assessed by a different doctor who also discharged Mr C. A short time later, the doctor revised their decision to discharge Mr C and he returned to the department a short time later. An x-ray identified that he had suffered a spinal fracture. In response to Mr C's complaint, the board acknowledged that a scan should have been performed at the first presentation and an apology was offered to Mr  C. The board detailed a number of steps that would be taken to learn from the issues identified. We took independent advice from an emergency medicine consultant. We found that the board had appropriately identified all the failings in relation to this matter. We upheld this aspect of Mr C's complaint and asked the board to provide evidence of actions taken to prevent these failings reoccurring. Following the diagnosis of a spinal fracture, Mr C experienced an episode of urinary retention (inability to empty the bladder completely) during the admission. A number of attempts at urethral catheterisation (insertion of a thin tube into the urethra to drain and collect urine from the bladder) were made, yet these were unsuccessful. Urology doctors (a doctor who specialises in the male and female urinary tract, and the male reproductive organs) offered to perform suprapubic catheterisation (surgical insertion of a thin tube through the skin to drain and collect urine from the bladder), yet Mr C did not consent to this procedure. Mr C felt that doctors did not listen to him whe

Mr C complained that there was an unreasonable delay in being offered an ophthalmology (the branch of medicine concerned with the study and treatment of disorders and diseases of the eye) appointment at Hairmyres Hospital following a referral by his optician with possible glaucoma (a common eye condition where the optic nerve becomes damaged). We took independent advice from a consultant ophthalmologist. We found that it had been an unreasonable for Mr C to wait for seven months for the appointment. We noted that the board had apologised to Mr C for the unacceptable length of time he had had to wait for the appointment. We also found that there was a lack of documentation of the triaging process (a process in which things are ranked in terms of importance or priority) used by the board for referral to secondary ophthalmic care which made the auditing of the triage decisions impossible. We upheld Mr C's complaint.

Mr C complained about the care provided to his late mother (Mrs A) by staff at Wishaw General Hospital. Mrs A had attended the emergency department following a fall at home. She was observed for a few hours and discharged home. Mrs A fell again at home that evening and had to be readmitted to hospital where it was established that she had problems with the blood supply to her left leg. Mrs A was told that no further treatment could be given and she was commenced on palliative care. Mr C believed that the seriousness of his mother's condition should have been identified on the first attendance to hospital. We took independent advice from a consultant in emergency medicine. We found that on the first attendance the staff carried out a thorough assessment, made appropriate investigations and reasonably concluded that Mrs A could be discharged home with follow-up by the hospital at home team. When Mrs A re- attended hospital, her observations were mostly normal and it was only after a further period of review that issues were identified which revealed a lack of blood supply to her left leg. We found that the staff could not reasonably have predicted that Mrs A would go on to have subsequent problems. We did not uphold the complaint. Related reading View Decision Report 201803545 as a PDF (23.95 KB) Updated: December 19, 2018

Mr C complained about the care and treatment his late father (Mr A) received when he attended the emergency department at Monklands Hospital, after having been involved in a minor road traffic accident. The board concluded that Mr A had a soft tissue injury and he was prescribed paracetamol and ibuprofen. Mr A returned to the emergency department one week later reporting worsening symptoms. A further assessment was carried out and it was noted his international normalised ratio (INR - a measurement of how long it takes blood to form a clot) levels were high and fractures to his vertebrae and ribs were identified. Mr A's condition deteriorated significantly and he developed sepsis (a  blood infection) and discitis (inflammation between the discs of the spine). Mr  A died as a result of these complications. Mr C complained that the board failed to note that his father was taking warfarin (a drug used to prevent blood clots) and he should not have been prescribed ibuprofen. Mr C also complained that the fractured vertebrae and ribs were not identified during the first assessment. We took independent advice from a consultant in emergency medicine. We found that the assessment of Mr A's symptoms was reasonable and an x-ray to inspect for fractures was not warranted. However, we considered that the prescribing of ibuprofen was not reasonable and other forms of pain relief could have been considered. Therefore, we upheld the complaint. We did not make any recommendations as the board had already taken steps to address this failing. Related reading View Decision Report 201800001 as a PDF (24.12 KB) Updated: December 19, 2018

Miss C complained about the treatment which her late child (Child A) received at Wishaw General Hospital. Child A had recently had a vaccination and had developed a temperature and a rash. Miss C asked the staff if Child A could have Kawasaki Disease (heart disease) and was told that they did not meet the criteria. Instead Child A was treated for a viral infection and then discharged home after a period of observation. Although Child A showed some signs of improvement, over two weeks later they were admitted to hospital where they died. The post mortem report showed findings in keeping with Kawasaki Disease. Miss C felt that staff should have carried out additional investigations when Child A was originally at the hospital and the disease would have been identified sooner. We took independent advice from a consultant paediatrician. We found that the staff carried out appropriate assessments when Child A attended the hospital and that it was reasonable to have arrived at a working diagnosis of viral infection based on their reported symptoms. Child A did not meet the criteria for Kawasaki Disease at that time and there was no clinical indication that a hospital admission or referral to other hospital specialist was required. We did not uphold Miss C's complaint. Related reading View Decision Report 201802804 as a PDF (23.97 KB) Updated: December 19, 2018

Mr C complained about the decision to transfer his wife (Mrs A) from Wishaw General Hospital to a care home and the manner in which this was done. Mr C was concerned that he was not advised in advance about the transfer or that the decision was discussed with him. Mr C was also concerned about the lack of information given to him about the facilities available at the home and the handover provided by the hospital to the home. During our investigation the board issued an apology to Mr C for the errors made. They confirmed that the transfer took place during a time when there was an extreme pressure on beds and the information provided to Mr C was not adequate. They also accepted that staff on the ward were not aware of the type of services available at the home. They confirmed that there should have been a more adequate handover note. As the board apologised for the errors and confirmed steps they would take to improve the service, the complaint was resolved and we took no further action. Related reading View Decision Report 201800251 as a PDF (23.79 KB) Updated: December 19, 2018

Mr C complained that the practice had unreasonably stopped prescribing his Capasal (medicated shampoo) medication on NHS prescription. Mr C said that he had psoriasis (a skin condition) and had been prescribed Capasal for many years. He was suddenly told by the practice that in accordance with health board guidance, he would have to purchase Capasal over the counter at a chemist. We took independent advice from a general practitioner. We found that Mr C's medical records contained information that Mr C had been diagnosed with psoriasis in the past and as such he did satisfy the health board criteria which would allow the practice to prescribe the medication on NHS prescription. We upheld the complaint.

Mrs C received cataract surgery (surgery to correct clouding of the lens of the eye) and complained that the board did not provide her with reasonable follow- up care and treatment afterwards. Mrs C complained that board staff were not listening to her concerns about losing her sight. We took independent advice from a consultant ophthalmologist (eye doctor). We found that the care and treatment Mrs C received was reasonable. We found that Mrs C had appropriate tests and there was no obvious cause for her symptoms. Ongoing investigations were planned and no failings were identified in the care provided during the period covered by Mrs C's complaint. We did not uphold the complaint. Related reading View Decision Report 201705818 as a PDF (10.91 KB) Updated: December 2, 2018

Mr C, who is an MSP, complained on behalf of his constituent (Mr A). He said that the board had failed to provide Mr A with reasonable care and treatment in Monklands Hospital. We took independent advice from a general medical adviser, a nursing adviser and from a consultant orthopaedic and trauma surgeon. Firstly, Mr C complained that the board had unreasonably discharged Mr A with a bacterial infection and that he then had to be readmitted to hospital. We found that Mr A's discharge had been reasonable, as his symptoms appeared to be acceptably controlled at that time on oral medication; he had been appropriately reviewed; and no concerns about his discharge were raised. The blood tests results showing the infection did not become available until after he was discharged. We did not uphold this complaint. Mr C also complained that staff failed to prevent Mr A falling on two occasions when he was readmitted to hospital. We found that there had been a failure to complete and document a falls risk assessment when Mr A was admitted in line with standards of care for older people in hospital. There was also a failure to document communication with the family. We upheld this complaint. Mr A also complained that staff delayed in obtaining an X-ray after Mr A's falls. We found that an X-ray had not been clinically indicated after the first fall. An X- ray was then obtained after the second fall. On balance, we did not uphold this complaint. Mr C also complained that staff had given Mr A too much morphine (a medication for pain relief). We found that the approach to this and the doses prescribed had been reasonable. We did not uphold this complaint. Mr C also complained that staff failed to follow-up Mr A's care after his discharge from hospital. We found that, although an interim discharge letter was issued, a follow-up discharge summary was not issued. There was also insufficient information about how Mr A's hypertension (abnormally high blood pressure) was

Mrs C complained on behalf of her client (Ms B) about the care and treatment provided to Ms B's late father (Mr A). Mr A suffered from heart problems and had a history of diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired) and a previous stroke. Over a period of about 18 months he had several hospital admissions and underwent two cardiac catheterisation procedures (where a tube is inserted into a blood vessel near the heart, to look at the condition of the blood vessels and/or insert a stent to widen them), but no stent was inserted. Doctors then referred Mr A for consideration of coronary bypass surgery (surgery to bypass a section of existing blood vessel that is narrowed with a graft). However, while he was waiting for review, Mr A suffered a further stroke and heart attack, and he died in hospital a few weeks after this. Mr A's family felt he should have been offered surgery earlier. They also raised concerns about the medical and nursing care during his admissions, and the board's response to their complaint. The board considered the medical care and communication was reasonable. However, they agreed there were some failings in the nursing care for Mr A's pressure ulcers and they apologised for this and took action to prevent a recurrence. We took independent medical, cardiology and nursing advice. We found that the overall management of Mr A's heart problems was reasonable, and it was appropriate that surgery was not offered earlier as this would have been a very high risk for Mr A (in view of his pre-existing conditions). We did not uphold this aspect of Mrs C's complaint. However, we found that there was no evidence Mr  A or his family were told about Mr A's heart attack for several days, and we made a recommendation in light of this finding. We upheld the complaint about nursing care, as we found failings in relation to fluid monitoring, pressure ulcers, falls monitoring and communication with

Mr C complained on behalf of his mother (Mrs A) regarding cataract surgery (surgery which involves replacing the cloudy lens inside the eye with an artificial one) she received at Hairmyres Hospital. Mr C stated that the board failed to give his mother the appropriate priority for surgery and failed to provide surgery within a reasonable period of time. We took independent advice from a consultant ophthalmologist (a specialist in the branch of medicine concerned with the study and treatment of disorders and diseases of the eye). We found that the categorisation of non-priority was reasonable according to nationwide practice. However, when Mr C notified the board that Mrs A's condition had deteriorated whilst she was on the waiting list for surgery, no further review of her condition was offered. This meant that there was no opportunity to assess if Mrs A required to move up the waiting list. Therefore, we upheld this aspect of Mr C's complaint. In relation to the surgery waiting time, we found that Mrs A was referred for an out-patient appointment outside the NHS target times. We noted that Mrs A could not be referred for surgery elsewhere in order to cut down on her waiting time due to her condition and the density of her cataract. However, Mrs A was given surgery 22 weeks after being listed for surgery which was outside the NHS treatment guarantee time of 12 weeks. We upheld this aspect of Mr C's complaint. However, we acknowledged that the board had apologised for this delay which reflects the current situation nationwide due to the demand on the NHS for eye surgery.

Miss C complained about the care and treatment provided to her late father (Mr  A) during admissions in Monklands Hospital and Coathill Hospital. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nurse with expertise in pressure ulcer prevention. Miss C raised concern that Mr A, who had diabetes, was discharged from Monklands Hospital with a large pressure ulcer on his left foot. In response to Miss C's complaint, the board acknowledged that there was little documentation of the care provided for Mr A's feet and they apologised for this. We found no evidence that medical staff reviewed Mr A's feet during this admission and considered that this was unreasonable in the circumstances. We also found a number of failings in the way nursing staff assessed, documented and managed Mr A's feet during the admission. We noted that there was a delay in referral to the podiatry team (the area of medicine which deals with the feet and ankles) and no evidence that Mr A was physically reviewed by podiatry. Finally, we were critical about the lack of information and equipment given to Mr A and his family before discharge and that the board did not ensure that arrangements for ongoing care were in place. We upheld this aspect of Miss C's complaint. During a subsequent admission in Coathill Hospital, Mr A was found to have fallen. Initially, no injuries were noted by either nursing or medical staff. When Mr A was reviewed by an occupational therapist the day following the fall, pain was noted yet this was not escalated to the medical team. The board apologised to Miss C for this failing. Two days following the fall, nursing staff found Mr A to be in pain and an x-ray was arranged. This identified that Mr A had a broken hip and he received treatment the following day. We found that the initial medical review did not appear to have included an examination to specifically assess if Mr A had suffered any injur

Mr C complained about the care and treatment provided to him at one of the board's addiction clinics. In particular, he felt that he did not receive appropriate support in order to help him withdraw from his diazepam medication (medication to help anxiety or withdrawal symptoms) in a safe and controlled manner. He said that he had been discharged back to the community mental health team without any assistance to reduce his medication. We took independent advice from a psychiatrist. We found that Mr C's consultant psychiatrist had referred him to the addiction unit for advice and support to assist in his withdrawal from diazepam. The referral to the addiction team was on a time limited basis, with further care and treatment to be provided by the community mental health team. The addiction team made appropriate slight amendments to the dosage of Mr C's medication. We also found that Mr C received appropriate advice on psychological support services which were available in the community. We found that it was also appropriate that a long term treatment plan to enable Mr C to reduce his diazepam dosage was managed by the community mental health team as Mr C had a number of other health issues which would have been outwith the scope of the addiction unit. We did not uphold the complaint. Related reading View Decision Report 201800547 as a PDF (11.17 KB) Updated: December 2, 2018

Mr C complained about the care and treatment his late father (Mr A) received during his two admission to Wishaw General Hospital. Mr A was diagnosed with bowel cancer and Mr C complained that the board failed to provide Mr A with appropriate medical and nursing care and treatment. We took independent advice from a consultant in acute medicine, a consultant in colorectal surgery (a specialist in disorders of the rectum, anus and colon) and a nurse. In respect of Mr A's first admission, we considered that Mr A's underlying issues were all reasonably investigated, treated and resolved. In respect of Mr  A's second admission, we found that all appropriate investigations were carried out and that, overall, Mr A received appropriate medical treatment. However, we noted that there was an unreasonable delay before Mr A was seen by the speech and language therapy service (SALT) given that there was concerns regarding his ability to swallow. Therefore, we upheld this aspect of Mr  C's complaint. In relation to the nursing care, we found that there was no evidence to indicate any failings in nursing care and that the nursing records were of a reasonable standard. We did not uphold this aspect of Mr C's complaint. Mr C also complained that the board failed to communicate appropriately with Mr  A's family regarding his condition at a meeting. In particular, that only two family members were allowed to attend the meeting when there were twice as many hospital staff in attendance and that he was not allowed to record the meeting. We considered it was unreasonable that Mr C had been restricted to two family members while double the number of hospital staff attended the meeting. Mr C also appeared to have been open with hospital staff that he wanted to record the meeting and the reason for this. Therefore, we considered it would have been reasonable to have allowed him to record the meeting. We upheld this aspect of Mr C's complaint. We also noted that that these issues

Mr C, a solicitor, complained on behalf of his client (Ms B) regarding the way the board managed her daughter's (Ms A) transition from paediatric services to adult services. In particular, Ms B was concerned about the co-ordination of Ms A's care and her ability to access services when she needed to. We took independent advice from a consultant paediatrician. While we found evidence of good practice in relation to a number of areas of transition care, we found little evidence of co-ordinated planning to support transition. In particular, we considered that a healthcare professional responsible for managing and co-ordinating transition should have been identified, as indicated by the board's transition guidance. We further noted that the board's guidance did not appear to have been reviewed in line with the planned timescales for review. We found that the board had appropriately met with Ms A's family and listened to their concerns, however, there was also evidence that the board and Ms A's GP had differing views on who was leading clinically. On balance, we upheld Mr C's complaint.