SPSO Individual Decisions

Ms C attended an antenatal screening which tested for Down's syndrome before the birth of her child (Child A) and it was determined that she was at low risk to have a child with this condition. Following the birth, Child A was diagnosed with Down's syndrome. Ms C said that the board's communication with her about Down's syndrome, before and after the birth was unreasonable. During the pregnancy, an ultrasound scan confirmed Child A had a hole in their heart. Child A died a few months after birth and Ms C complained that the board had unreasonably failed to diagnose, discuss and treat Child A's heart condition and breathing problems. We took independent advice from a midwife and consultants in cardiology, emergency medicine and neonatology. We found that, before the birth of Child A, Ms C was given reasonable information about the Down's symdrome screening process but after their diagnosis there was little evidence of what had been said and discussed. There was no record of the conversation telling Ms C about Child A's diagnosis and the immediate plan for them. We upheld this aspect of Ms C's complaint. In relation to Child A's heart condition and breathing problems, we confirmed that there are limitations in the antenatal screening process, with screening identifying only half the number of heart defects. We found that Child A's heart and breathing problems had been reasonably diagnosed and treated but that there were also lung problems which could have not been predicted. We did not uphold this aspect of Ms C's complaint.

Mrs C complained about the care and treatment which she received during her pregnancy at the Royal Infirmary of Edinburgh. She had attended for a check-up where her baby's heartbeat was checked and blood tests were taken. Mrs C said that a nurse said that she might have an infection, but sent her home without medication. Mrs C then developed acute back pain and returned to hospital where she was admitted. Mrs C's condition deteriorated and she developed abdominal pain and was placed on a monitor. There were signs of fetal distress and it was decided to proceed to caesarean section (an operation to deliver a baby involving cutting the front of the abdomen and womb) where her baby was born. Mrs C then suffered a massive bleed and a hysterectomy (a surgery to remove the womb) had to be performed. Mrs C complained that there had been a delay in deciding to proceed to caesarean section and that antibiotics should have been prescribed earlier which would also have stopped her suffering from sepsis (a blood infection). We took independent advice from a consultant obstetrician (a doctor who specialises in pregnancy, childbirth and a woman's reproductive system) and we found that Mrs C had received a reasonable standard of care and treatment. We found that staff adopted a conservative approach initially to establish if Mrs C would be able to deliver naturally and they kept her under observation. When it became clear that there were signs of fetal distress then it was appropriate to move to a caesarean section. There was no evidence of any delay and the caesarean section was carried out to an acceptable timescale. There was also no evidence that antibiotics should have been administered to Mrs C at an earlier stage and they were provided when she showed symptoms of infection. We also found that, when it was realised that Mrs C had suffered a bleed, staff acted appropriately in accordance with the national guidance that in such cases staff should resort to hysterectomy sooner

Mr C complained about the care and treatment he received in relation to a suspected hernia (a condition where an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall) whilst he was in prison. In particular, that there were delays in being seen by his GP, being referred for an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body), being referred for surgery and concerns over his prescribed medication. Mr C also complained that he was not given a long-term sick line after an initial sick line expired. We took independent advice from a GP. We found that the time Mr C had to wait for appointments with his GP was reasonable. We also found that he was referred for an ultrasound scan and surgery within a reasonable amount of time and that his medication was reviewed appropriately. Therefore, we did not uphold this aspect of Mr C's complaint. In relation to Mr C's sick line, we found that it would be reasonable to expect that he would be able to attend classes and carry out light duties whilst waiting for surgery and, therefore, we considered that the GP's decision to refuse a sick line was appropriate. We did not uphold this aspect of Mr C's complaint. Related reading View Decision Report 201702309 as a PDF (11.19 KB) Updated: December 2, 2018

Ms C arranged an emergency appointment at the out-of-hours dental service as she was suffering from toothache. The dentist performed the first stage of a root canal treatment, however they experienced difficulty in accessing all the root canals. Ms C's tooth pain worsened and she had to return to the out-of-hours dental service the following day and she opted to have the tooth extracted. Ms  C complained that the dentist failed to properly explain the treatment options to enable her to give informed consent. She also complained the dentist failed to provide the appropriate treatment and that, had the dentist informed her of the difficulty they would have performing the treatment, she would have opted to have the tooth extracted. The board explained that the dentist had difficulty accessing all the root canals and this would explain why Ms C had significant post-operative pain, however, they did not consider that the dentist failed to provide the appropriate treatment or that they failed to appropriately explain the treatment options. We took independent advice from a dentist. We found that it was not possible to identify from scans taken of Ms C's mouth that the root canal treatment would be so difficult to perform, therefore the appropriate treatment was provided. We also found that the information provided to Ms C in terms of treatment options was reasonable in the context of an emergency service setting. We did not uphold Ms C's complaints. Related reading View Decision Report 201707641 as a PDF (11.22 KB) Updated: December 2, 2018

Mrs C complained on behalf of her child (Child A) about the care and treatment they received at the Royal Edinburgh Hospital. Child A was admitted to hospital and diagnosed with a severe depressive episode and suicidal thoughts. Child A remained in hospital some months, and mental health staff consulted with social work about alternative accommodation (as it was not appropriate for Child A to return to the family home at that time). However, Child A's behaviour became increasingly violent, and Child A was discharged with a few days' notice to social work staff, who arranged accommodation at a young people's centre. Child A ran away from the centre threatening to harm themselves on several occasions, and had to be detained by the police. Child A was then transferred to secure accommodation, where they remained for several months. Mrs C complained that the board inappropriately discharged Child A without ensuring adequate arrangements were in place for their safety and welfare. We took independent advice from a psychiatrist and found Child A's discharge to be unreasonable. We found that the discharge decision was made at short notice, without adequate planning for Child A's future accomodation and follow up care. We were also critical that a psychiatrist at the hospital instructed other staff not to detain Child A under the Mental Health Act if they returned to hospital. The adviser noted that detention under this Act is an important option to protect people who are a risk to themselves or others, and it was unreasonable for staff to try and remove the availability of this protection. Therefore, we upheld this aspect of Mrs C's complaint. Mrs C also complained that the board used different diagnostic labels at different times to influence the management of Child A's care. We found that a mixture of diagnostic labels were used during Child A's admission, and it was not clear that a structured approach was used to formulate a diagnosis. However, we did not find

Mr C complained about treatment he received at the Royal Infirmary Edinburgh after suffering a head injury. He raised concerns that the board had failed to identify a fracture to his skull on his first attendance, as they did not carry out a CT scan until he was referred back to hospital by his GP two days after being discharged. This case was very similar to a complaint we had recently upheld (201508264). In that case, we recommended that the board carry out an audit of similar head injury cases treated at the hospital. As the audit was still in progress at the time of Mr C's complaint, we asked the board to include his case in their consideration. They did so, and repeated what they had told Mr C in their response to his complaint - that they considered the treatment he received was appropriate. They also maintained this position in response to enquiries we made throughout our investigation. We took independent advice from a consultant in emergency medicine. The adviser told us that the board's failure to carry out a CT scan on Mr C's first admission was unreasonable as the board had recorded that Mr C had a severe and persisting headache and Mr C had suffered a fall from a height greater than one metre. Under guidance from the Scottish Intercollegiate Guidelines Network  (SIGN) and the board's protocol in place at that time, this should have led to a CT scan being arranged. We also found that the board had failed to carry out enough observations of Mr C's level of consciousness. In particular, the board had failed to record that Mr C was reviewed by an experienced doctor before being discharged. SIGN guidelines specify that an experienced doctor should review all head injury patients before they are discharged to ensure that six specific criteria are met. However, this failling had since been remedied by a new procedure implemented following case 201508264. We were also concerned that, despite a number of these failings being a repetition of those high

Mrs C complained about the respiratory care (care of the lungs and other organs) and treatment provided to her by the board. She said that she did not feel she was given appropriate follow-up care and that this resulted in her respiratory problems becoming worse. We took independent advice from a consultant in respiratory medicine. We found that Mrs C was appropriately investigated and that no follow-up was necessary. We also found that there was no evidence that her respiratory problems had been caused by, or became worse as a result of, lack of follow-up. We did not uphold Mrs C's complaint. Related reading View Decision Report 201706050 as a PDF (10.87 KB) Updated: December 2, 2018

Mr C underwent nasal surgery at St Johns Hospital and subsequently had ongoing issues with nasal obstruction, facial pain, breathing issues and sinus infections. Mr C complained that he was not warned of the recognised risks associated with the procedure and that the surgery itself was not performed to a reasonable standard. Mr C also complained that the board did not handle his complaint reasonably. We took independent advice from an ear, nose and throat consultant. We found that appropriate information was provided to Mr C regarding the recognised risks of the surgery. We also considered that the nasal surgery was performed to a reasonable standard. We did not uphold these aspects of Mr C's complaint. However, we noted that there was a delay in removing Mr C's nasal splints (temporary splints which are used to stabilise the nose after surgery) and made a recommendation in light of this. In relation to complaints handling, we found that there was a delay in issuing a response to Mr C and that there was insufficient detail about the surgery included in the letter. We considered that the board did not handle Mr C's complaint reasonably and upheld this aspect of his complaint.

Ms C complained about the care and treatment provided to her by the board. She complained that, when she suffered a slipped disc in her back, she was not given appropriate neurosurgical treatment during two periods of care. Ms C also complained that she was later not provided with reasonable treatment by the department for infectious diseases, cardiology, or rheumatology. We took advice from a neurosurgeon, a consultant in infectious diseases, a cardiologist and a rheumatologist. We found that, whilst overall the neurosurgical care given to Ms C was reasonable, there was a failure to properly document an appointment; that there was no evidence that the likely outcome of surgery was discussed with Ms C; and that there was a delay in follow-up after Ms C underwent surgery. We upheld this aspect of Ms C's complaint. We found that the care and treatment provided by the department for infectious diseases, cardiology, and rheumatology was of a reasonable standard and we did not uphold this aspect of Ms C's complaint.

Ms C complained to us about the care and treatment her mother (Mrs A) had received after she was admitted to St John's Hospital with bipolar disorder (a mental health condition marked by alternating periods of elation and depression). Ms C complained about a number of issues in relation to the nursing care provided to Mrs A. We took independent advice from a mental health nurse. We found that it had been unreasonable for nursing staff to allow Mrs A off the ward without an escort. Although Mrs A came to no harm, her safety and wellbeing were placed at undue risk as a result of this. We also found that, despite it being known that Mrs A had medication compliance issues, there was no evidence in the records of a coherent care plan designed to promote her compliance with oral medication. Neither her care needs nor her nursing care had been effectively planned or kept under review. Care plans in the records were dated four weeks after Mrs A had been admitted to hospital and we found that the manner in which the documentation had been used and completed was ineffective and unreasonable. In view of these failings, we upheld Ms C's complaint about the nursing care provided to Mrs A. Ms C also complained about a number of aspects of the psychiatric and medical treatment Mrs A received in the hospital. We took independent advice on these issues from a psychiatric consultant. We found that there had been a delay in actioning Mrs A's electrocardiograph (ECG - a test that records the electrical activity of the heart) results and that the consultant psychiatrist had failed to make themselves aware of these results. We also found that it was unreasonable that specialist cardiology advice was not sought and that anti-psychotic drugs were prescribed to Mrs A without attention being paid to the cardiac risks or guidance being given to staff that she should be closely monitored after taking these. In addition, Mrs A received two anti-psychotic drugs at the same time, when

Mr C, who is a solicitor, complained on behalf of his client (Mr A) about the treatment Mr A had received from the prison health centre. Mr A was assaulted and suffered a broken jaw. Some months after this, he started experiencing headaches. Mr A attended a number of GP consultations and his pain relief medication was adjusted at various points as a result. When Mr A suggested that the prescribed medication was not effective, he was referred to neurology (a branch of medicine that looks at the brain and nervous system) and had a scan. The results of this came back as normal and Mr A continued to be treated through adjustments to his pain relief medication. Mr C complained that the pain medication provided to Mr A was not reasonable or appropriate. We took independent advice from a GP adviser. We were satisfied that Mr A had been treated in line with General Medical Council and World Health Organisation best practice guidelines. We found that the medication prescribed had been appropriate. The board acknowledged that they did not pass on Mr A's scan results to him and apologised to him directly for this. They also outlined steps that they had taken to ensure this didn't happen again. We were satisfied that the fact that Mr A was not provided with his scan results had no impact on the treatment provided or medication prescribed. On balance, we did not uphold the complaint. Related reading View Decision Report 201704285 as a PDF (11.28 KB) Updated: December 2, 2018

Following an x-ray of her spine, Mrs C's GP made a referral for a DEXA scan (dual-energy x-ray absorptiometry scan - a scan which is used to measure bone density). This referral, and a further referral, were rejected by the board as Mrs C did not meet the criteria. Mrs C was unhappy with this decision and complained to the board. The board said that because DEXA uses ionising radiation and they were required to assess whether the radiation detriment was outweighed by the benefit of receiving the scan. The board said that the referral criteria require a patient to have a predicated fracture risk of 10%, and since Mrs C's calculated risk was lower than this she did not meet the referral criteria. We took independent advice from a general medical adviser. We found that the board's referral criteria were based on appropriate national guidance, and we were satisfied that it was reasonable not to offer Mrs C a DEXA scan as she did not meet the criteria. We did not uphold the complaint. Related reading View Decision Report 201705605 as a PDF (11.1 KB) Updated: December 2, 2018

Mr C complained about the treatment he received form the prison health care service. He reported numerous health problems including persistent headaches, bodily twitching, and concerns about his testicles. We took independent advice from a GP adviser. We found that Mr C had received a reasonable standard of treatment. He had been referred to urology (the area of medicine specialising in the kidneys, bladder, urinary tract and men's sexual organs) and neurology (the area of medicine specialising in the brain and nervous system) on several occasions, and we considered that the referrals had been made appropriately and in line with clinical guidelines, without any delay. We found no evidence that Mr C's treatment was not of a reasonable standard. We, therefore, did not uphold his complaint. Related reading View Decision Report 201703559 as a PDF (10.98 KB) Updated: December 2, 2018

Miss C was referred for an endoscopy (a camera test into her stomach) by the practice to investigate stomach pain she was suffering from. She complained that this was not appropriately followed up and that further specialist investigation was not arranged. The practice said that all relevant investigations appropriate to Miss C's condition were undertaken by them. Miss C disputed this, noting that her psychiatrist had referred to anticipated follow-up investigation for her stomach issues, in a letter to the practice. Miss C said that this follow-up was not arranged by the practice. We took independent advice from a GP, who considered that the investigations arranged by the practice were appropriate. We found that the psychiatrist's letter was written in advance of the endoscopy appointment and that it referred to this investigation. It did not suggest that further investigation was expected. Therefore, we did not uphold this aspect of Miss C's complaint. Miss C also complained that some of her prescription requests were not appropriately responded to and that she had to go for long periods without her pain-killing and anti-anxiety/depression medication. The practice acknowledged that one monthly prescription for Miss C's anti-anxiety medication was missed and they apologised to her for this oversight. They also acknowledged some recording and communication issues, meaning some of Miss C's medication requests were not responded to appropriately. In particular, they recognised that an improved system was required for communicating with patients where medication requests have been declined. We upheld this aspect of Miss C's complaint, however, noted that the practice had appropriately reflected on the communication issues highlighted by this complaint and had instigated a reasonable plan to avoid similar future problems.

Mrs C complained about the care and treatment her late husband (Mr A) received at the Western General Hospital during two admissions. Mr A had been admitted to hospital with side effects of chemotherapy that he was receiving for plasmablastic lymphoma (a rare and aggressive form of blood cancer). During his first admission, Mr A had a couple of falls and was later discharged. Mr A was then readmitted and died a short time later. Mrs C complained that communication with the family about Mr A's condition was unreasonable and that nursing staff did not administer his medication properly. Mrs C also complained that the medical care and treatment Mr A received was unreasonable and that the board failed to handle her complaint appropriately. We took independent advice from a consultant haematologist (a doctor who specialises in medicine of the blood) and from a registered nurse. We found that there had been communication failings with the family during Mr A's hospital admissions, in particular towards the frailty of his condition. Therefore, we upheld this aspect of Mrs C's complaint. However, we noted that the board had acknowledged these failings and had apologised. In relation to Mr A's medication, we could not find any evidence to show that his medication had been administered inappropriately by nursing staff. Therefore, we did not uphold this aspect of Mrs C's complaint. Overall, we found that the care and treatment Mr A received was reasonable and we did not uphold this aspect of Mrs C's complaint. Finally, we found that the board's response to Mrs C's complaint was generally of a good standard. However, they had not kept her informed of delays in their response and they did not address a new issue that was raised. On balance, we upheld this aspect of Mrs C's complaint.

Mr C complained that his late mother (Mrs A) did not receive appropriate physiotherapy and rehabilitation whilst she was a patient at Tippithill Hospital. He was also concerned that the consultant in charge of Mrs A's care had unreasonably refused consent for another doctor to examine her. Mr C also complained that the board's response to his complaint was inadequate. We took independent advice from a consultant in old age psychiatry. We found that Mrs A had advanced dementia and that she did not have the potential for further rehabilitation as a result. We found that there had been appropriate referrals and assessments for physiotherapy, which took reasonable account of the risks involved in Mrs A's case. We did not uphold Mr C's complaint about physiotherapy and rehabilitation. We also did not uphold Mr C's complaint that consent had been refused to allow a further doctor to examine Mrs A. We found no evidence that consent had been refused, although it was confirmed that an examination by the further doctor did not take place. The advice we received was that, in the particular circumstances of Mrs A's case, it was reasonable that this examination was not carried out. We found that the doctor in question had previously reviewed Mrs A and did not consider this to have been of any assistance to the management of her care. Regarding the board's response to Mr C's concerns, we found that they had not directly addressed Mr C's complaint and that, when Mr C alerted them to this, they advised that they had nothing further to add. We considered this response to be inadequate and we upheld this aspect of Mr C's complaint.

Mr C complained about the care and treatment provided to his father (Mr A) at the Western General Hospital. Mr C complained that there was a delay in the board diagnosing Mr A's non-Hodgkin's lymphoma (a form of blood cancer), and that the board did not follow-up his complaint in a reasonable way. We took independent advice from a consultant radiologist (a doctor who specialises in x-rays and scans) and from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that there was an error in the reporting of a scan that Mr A had undergone for an unrelated condition, which resulted in a delay in the cancer diagnosis. We found that the board had acknowledged this delay and had taken some action to address this failing, however we made a further recommendation on this matter. We also found that, after a meeting had been held with Mr C regarding his complaint, there appeared to be some uncertainty within the board as to what action they had agreed to take. We found that they should have contacted Mr C to clarify what outcome he was seeking and the failure to do so meant there were perceived delays in complaint handling. We upheld both of Mr C's complaints.

Mrs C presented to the practice with weakness and pins & needles in her limbs and head. The practice reviewed her and arranged blood tests. She was informed that these came back normal and no further action was taken. Mrs C's symptoms began to improve over the following months and had resolved by the end of the year. However, her symptoms returned and she presented to the practice again, nearly two years after her initial appointment. She was referred to neurology and, following an MRI scan, was diagnosed with relapsing remitting multiple sclerosis (MS). Mrs C complained that this could have been diagnosed sooner, had she been referred for further tests following her first appointment at the practice. In responding to Mrs C's complaint, the practice said that the possibility of MS was considered but due to the fact that this was Mrs C's first presentation, that there was a lack of symptoms and that there was an absence of positive family history, they felt that the symptoms were unexplained. They said that the plan was to 'book bloods and review' and they apologised that they did not express clearly enough to Mrs C that she was expected to return for review. They observed that she was referred promptly at her second appointment as this was a second presentation of sensory symptoms, and that she was also exhibiting further symptoms. We took independent medical advice from a GP, who considered that an appropriate level of assessment and investigation took place for a first presentation of such symptoms. We found that it is generally accepted that MS is suspected if there are two or more episodes of suspicious symptoms. We noted that it would have been reasonable for the practice to have clearly explained to Mrs C that they wished to follow up her symptoms following the blood tests. The General Medical Council's Good Medical Practice (GMC GMP) guidance refers to this as 'safety netting'. However, the adviser did not consider this to be a serious oversight,

Mrs C complained that the practice failed to provide appropriate care and treatment to her late husband (Mr A). Mr A, who had type 2 diabetes, had thought he was suffering from a urine infection but the practice dismissed the suggestion and did not provide medication. Mr A subsequently developed chest and back pain over the next week. A house visit was then requested early in the morning but it took until early evening for a GP to visit. The GP felt that Mr A required a hospital admission and an ambulance was called to take Mr A to hospital. He died the following day. Mrs C complained that the practice failed to diagnose that Mr A had a urine infection and that, on the day he was taken to hospital, there was an unreasonable delay in a GP making a home visit. We took independent advice from an adviser in general practice medicine and found that the practice provided Mr A with reasonable treatment regarding his perceived urine infection. The practice carried out an appropriate assessment, including testing for a urine infection, which was reported as negative. Therefore, we did not uphold this aspect of Mrs C's complaint. In relation to the home visit, we found that there was an unreasonable delay in arranging the home visit to Mr A as there was a breakdown in communication when the request for a home visit was considered. Initially, it was felt that an advanced nurse practitioner should visit but they felt that it was outwith their remit and there was a delay in the request being picked up by the GP. Therefore, we upheld this aspect of Mrs C's complaint.

Mr C complained that the board unreasonably refused to support an out of area referral for a specialist neurosurgical assessment of his chronic migraines. Mr C suffered from chronic migraines for a number of years and had explored non-surgical treatment options but they did not help his situation. He wished to receive a professional opinion on surgical treatment options including occipital nerve stimulation (a procedure where a surgical implant is inserted near the occipital nerve - a nerve in the brain - which can be controlled by the patient to deliver electrical impulses with the aim of masking pain). However, this treatment is not available in Scotland. Mr C saw a consultant neurologist (a doctor who specialises in the brain and nervous system) in another Scottish health board area, who wrote a referral to a specialist centre in England. However, Mr C's consultant neurologist at his local board refused to support such a referral and funding was not approved. The board's view was that there was not a good evidence base for such interventions for patients with migraine. Mr C was unhappy with this response and brought his complaint to us. We took independent advice from a professor of neurology with specialist expertise in headache disorders. We found that the board's decision was reasonable and was consistent with relevant guidance. Therefore, we did not uphold this complaint. Related reading View Decision Report 201700584 as a PDF (11.28 KB) Updated: December 2, 2018

Miss C complained that the plans made for her labour at the Royal Infirmary of Edinburgh were unreasonable. Specifically, that she was refused a caesarean section and induction of labour, and that she was advised not to call an ambulance when going into labour. Miss C also complained that staff included inaccurate information, about a consultation, in correspondence to her GP. We took independent medical advice from a consultant obstetrician and found that there was no evidence to show that Miss C was refused a caesarean section or induction of labour. We considered that it was reasonable of board staff to recommend against a caesarean section in this case, given the complications associated with the operation. We also considered that advice given not to call for an ambulance outside an emergency situation was appropriate. Therefore, we did not uphold this complaint. We were also satisfied that a member of staff had not unreasonably included inaccurate information to Miss C's GP and, therefore, did not uphold this complaint. However, we provided feedback to the board that there appeared to have been some miscommunication regarding the matter. Related reading View Decision Report 201702565 as a PDF (11.13 KB) Updated: December 2, 2018

Ms C attended a dental practice for emergency treatment as she was experiencing tooth pain. Ms C complained that the dentist treated the wrong tooth and failed to identify an infection in her wisdom tooth. The practice confirmed that the dentist performed the first stage of a root canal treatment in the tooth that they identified as causing Ms C's pain. They also confirmed that there was no infection present in Ms C's wisdom tooth on the day of her appointment. Ms C was unhappy with this response and brought her complaint to us. We took independent advice from a dentist and found that Ms C's dentist carried out a thorough assessment of her symptoms. We noted that the dentist treated the tooth that was identified as causing the pain following a series of tests, including an x-ray. We also found no evidence of an infection in the wisdom tooth and, therefore, it was likely that the infection developed after the appointment. We considered that the treatment Ms C received was reasonable and, therefore, we did not uphold her complaint. Related reading View Decision Report 201706088 as a PDF (11.04 KB) Updated: December 2, 2018

Mr C complained about the care and treatment his late wife (Mrs A) received during admissions to St John's Hospital, the Royal Infirmary of Edinburgh and the Western General Hospital. In particular, Mr C complained about an unreasonable delay in diagnosing Mrs A's lymphoma (a type of cancer) during those admissions. We took independent advice from a consultant upper-gastrointestinal surgeon and from a consultant physician. We found that appropriate investigations were carried out into Mrs A's condition. However, we found lymphoma is very difficult to diagnose and that it had presented in Mrs A in a very unusual way. We did find that Mrs A was unreasonably diagnosed with an autoimmune condition at St John's Hospital, based on blood test results that actually suggested inflammation. We found that an opinion from other relevant specialists may have avoided this misdiagnosis. We found that this error may have delayed her diagnosis of lymphoma by one month and we upheld Mr C's complaint.

Ms C, who is a patient adviser, complained on behalf of her client (Mrs A) about the care and treatment provided to Mrs A at the Royal Infirmary of Edinburgh. Mrs A attended hospital for a planned coronary artery bypass graft (a surgical procedure used to treat coronary heart disease). After a week of in-patient care, medical staff were satisfied that Mrs A had recovered well and was fit to be discharged. Mrs A became unwell shortly following discharge and was re-admitted to a different hospital with an infection. Ms C raised a number of concerns on behalf of Mrs A, who felt that the care provided by the board was inadequate. Firstly, Ms C complained that staff failed to monitor Mrs A's condition appropriately. We took advice from a cardiac surgery adviser and a nursing adviser. We found that appropriate monitoring did take place during Mrs A's recovery from surgery and that appropriate records of this were maintained. We did not uphold this part of the complaint. Ms C also raised concern that staff did not listen to and document concerns raised by Mrs A, and did not keep appropriate records of attempted blood tests. We found no evidence in the records that staff did not listen to and document Mrs A's concerns about her health. We were also satisfied that the medical and nursing records were maintained to a reasonable standard. We did not uphold this aspect of the complaint. Finally, Ms C complained that Mrs A was inappropriately discharged home with an infection. Ms C raised concern that Mrs A was left waiting for a number of hours in the discharge lounge whilst her condition deteriorated and that staff then failed to readmit her to the ward. We found no evidence from the records of the admission that Mrs A had an infection prior to discharge. However, the advice we received highlighted that Mrs A remained in atrial fibrillation (fast irregular heartbeat) on the day of discharge, and that medical staff should have discussed this, and any potential issu

Mr C complained that he was unreasonably discharged from the Royal Infirmary of Edinburgh following hip replacement surgery, as he was unable to pass urine and was constipated at the time of discharge. Mr C eventually had a catheter fitted and was advised by a consultant at the Western General Hospital that he would be put on a waiting list for transurethral resection of the prostate (a surgical procedure that involves cutting away a section of the prostate - a small gland in a man's pelvis located between the penis and bladder). Mr C complained that the board misled him about the date for his surgery and that they failed to carry out his operation within a reasonable time. We took independent advice from a nurse. They said that it was appropriate for Mr C to be discharged from hospital, as his notes indicated that he was not experiencing any issues with passing urine or that his bowels were not working. Therefore, we did not uphold this part of the complaint. However, we noted that the board recognised they should have provided Mr C with oral laxatives on discharge and will take action to address this issue in future. Based on the information available we did not consider that the board misled Mr C about the date for his surgery and we did not uphold this part of the complaint. However, we noted that the board had indicated that they had taken steps to try to ensure that in future, the medical team and their secretaries were kept notified of waiting times for procedures and we asked the board to provide evidence of this. The adviser said that Mr C's surgery was completed outwith the 12 week treatment time guarantee and as the procedure was classified as 'urgent', this appeared unreasonable. The board explained the steps that they had taken to try to reduce the waiting times for patients and identify alternative providers and we asked for further evidence of this. We also found that there was poor communication between the board and Mr C regarding the delay