SPSO Individual Decisions

Ms C complained about the dental treatment she received on a tooth that was infected. The tooth had previously had root canal treatment and a crown. Ms C said the dentist had been clear that after two courses of antibiotics, they would take the tooth out and apply the antibiotic directly and replace the tooth temporarily to allow the infection to clear completely. Ms C understood that she would then be able to return in two months and that it would be refitted permanently. Ms C said that she was not made aware that the integrity of the tooth might be compromised or consented to the treatment that was carried out by the dentist. Subsequently, the dentist was unable to replace the root filling and later the tooth fell out. We took independent advice from a dental adviser. We found that the evidence from Ms C's dental records showed significant failings around the consent process and shortcomings in relation to the prescription of antibiotics and taking of x-rays. We also found that the dentist failed to offer and discuss alternative treatments with Ms C and so opportunities to save the tooth were missed. In view of the poor outlook of the tooth, we recommended that the dentist refund the cost of treatment available on the NHS to remedy the situation (a bridge), as well as the costs of the treatments Ms C received during this period.

Mrs C raised a number a number of concerns about the care and treatment given to her late mother (Mrs A) during an admission to Ninewells Hospital. Mrs C had complained to the board about the general clinical and nursing care that her mother had received. She had complained about the standard of communication and the delay in diagnosing and treating her mother, and she said that her mother had suffered unnecessary pain due to the non administration of medication. Mrs C was also unhappy with the board's handling of her complaint. During our investigation, we took independent advice from a consultant geriatrician and a nursing adviser. When responding to Mrs C's complaints the board accepted that there had been a number of failings and had taken action to address these. This included putting in place an improvement plan. However, notwithstanding the failings identified by the board, the advice we received and accepted from the geriatrician adviser was that there were failings in relation to the clinical treatment provided to Mrs A. These related to failings in communication within and between departments. We also found that the consent process for a procedure to fit a stent had not followed the relevant guidance. While the board had already accepted failings in relation to the nursing care provided to Mrs A, the advice we received from the nursing adviser was that there had been other failings by nursing staff. We found that there were gaps in nursing care, particularly around the use of the malnutrition universal screening tool (MUST - a way to screen patients to identify and treat adults at risk of malnutrition), and checking Mrs A's food, fluid and nutritional care. In relation to complaints handling, the board accepted that they had failed to deal with Mrs C's complaints in a timely and reasonable manner, so we upheld all aspects of Mrs C's complaint.

Mrs C learned that she had a gene mutation which increased the risk of breast and ovarian cancer. She decided to have surgery to remove both breasts to reduce the risk of developing breast cancer, and reconstruction surgery. Her surgery was cancelled on the morning she was due to be admitted. The board said that the cancellation was due to their failure to ensure the correct implants were available for the surgery to progress, and apologised. When she complained to us, Mrs C was concerned that she has not been given an alternative date for surgery. Whilst we were considering Mrs C's complaint she was given a date for surgery. Following Mrs C's surgery she decided not to proceed with her complaint because the quality of care she received from the board had been so good. Related reading View Decision Report 201508735 as a PDF (10.98 KB) Updated: March 13, 2018

Ms C complained that a member of staff at her GP practice had divulged confidential medical information about her to a mutual acquaintance and the practice did not thoroughly and appropriately investigate her complaint to them about this. Our investigation found that the practice had taken reasonable and appropriate action to investigate the matter, including taking statements from Ms C's friend (who had overheard a conversation between the staff member and the mutual acquaintance), the mutual acquaintance and the staff member. Despite this, it was not possible to determine exactly what had been said. In these circumstances, we were unable to uphold the complaint. Related reading View Decision Report 201504847 as a PDF (10.92 KB) Updated: March 13, 2018

Mrs C was removed from the treatment list of her GP practice following a difficult visit to the practice. Her husband (Mr C) complained about this and Mr and Mrs C were invited to a meeting to discuss the investigation. At the meeting they felt that no investigation had been undertaken and subsequently complained to us. The reasons the practice gave us for removing Mrs C from their treatment list did not meet the relevant criteria in legislation, policy or guidance for the immediate removal of a patient from a treatment list and we could see no other evidence that immediate removal was warranted. We saw no evidence that Mr C's complaints were dealt with in line with the NHS Scotland complaints procedure. As a result, we upheld both complaints.

Mrs C was referred to Perth Royal Infirmary due to a missing intrauterine system (IUS - a contraceptive device). A scan showed the IUS could be in her abdomen, but she was then found to be pregnant, so no x-ray could be done to confirm the exact location. The pregnancy was not viable and a medical miscarriage was performed. Mrs C was discharged after this without an x-ray to locate the missing IUS. Her GP arranged an x-ray, which showed the IUS was in her abdomen, and she was referred to gynaecology for surgery to locate and remove it. Mrs C raised concerns about the failure to x-ray her after the medical miscarriage, and about her surgery (which was more complex than expected). Mrs C said she was told an x-ray would be taken before the surgery to confirm the exact location of the IUS, and she queried why this did not happen. Mrs C also complained about delays in her gynaecology appointment and in the board's response to her complaint. The board agreed Mrs C should have been x-rayed after her medical miscarriage and they apologised for this. They said the delay in gynaecology appointments was due to increased demand, and they were taking action to improve this. However, they considered the surgery was carried out appropriately. After taking independent medical advice, we upheld Mrs C's complaints. We agreed the board should have x-rayed Mrs C earlier, and we found unreasonable delays in arranging the gynaecology appointment. However, we found that the surgery was carried out reasonably. The adviser explained that x-rays are not normally used to confirm the location of an IUS before surgery, as an x-ray cannot show the exact location (in three dimensions) and the position of the IUS can also change during the surgery as the patient is moved. We found the delay in responding to Mrs C's complaint was unreasonable, as the bulk of the delay (over five weeks) was caused by a delay in the draft response being signed off, rather than the investigation itself.

Mrs C complained that the practice failed to take her late husband (Mr C)'s symptoms seriously between January and March 2014, in particular his weight loss. She also said that they were given inaccurate information about the length of time Mr C would be admitted to a hospice. We took independent advice from a general practitioner and we found that Mr C had a history of back pain and diabetes, and in 2013 had been given advice about his diet. He lost weight as a consequence and, when he went to the GP a few months later suffering from leg pain, it was noted that he was still losing weight but this was considered to be because of his healthier diet. Nevertheless, Mr C's pain was investigated: blood tests were taken, he was referred for physiotherapy and an MRI (magnetic resonance imaging) scan of his back was carried out. Mr C's blood tests showed an abnormality, and he was, therefore, referred to hospital where he was later diagnosed with cancer. Mr C's pain was very difficult to control and he was admitted to a hospice on two occasions. On the second occasion, Mrs C felt that she had been misled as it was indicated his stay would only be short. However, because of the complexity of his needs, it took a considerable time to provide a solution to his pain. We acknowledged that Mrs C had coped with a very stressful situation but we did not uphold her complaint. However, as we found that Mr C's referral to hospital should have been an urgent one (because of the presence of weight loss), we made a recommendation for the practice to familiarise themselves with appropriate guidance.

Mrs C raised a number of issues about the care and treatment her late husband (Mr C) received during admissions to Ninewells Hospital and Royal Victoria Hospital. During our investigation, we took independent advice from a consultant geriatrician and a nursing adviser. We found no evidence that the clinical and nursing care was unreasonable. In particular, the consultant geriatrician noted that Mr C had been suffering from several conditions and had required significant medication to try and control his symptoms, and we found that there had been a number of discussions with Mrs C about her husband's condition. The consultant geriatrician was satisfied that the medication given to Mr C was always appropriately considered, prescribed and administered. While some of the medication caused side effects, the consultant geriatrician was satisfied that the board tried to avoid this medication as much as possible and that the side effects were unavoidable. The nursing adviser was satisfied that Mr C had been regularly assessed and care was planned for his mobility problems. We were satisfied that the care planning and assessment charts and nursing notes confirmed that Mr C's needs were fully assessed and managed. We did not uphold Mrs C's complaints. Related reading View Decision Report 201500037 as a PDF (11.18 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment given to her late husband (Mr A) at Ninewells Hospital where he was a patient from March to September 2014, when he died. She said that there was a delay in making his diagnosis and that information was given to him in an uncaring and uncompassionate way. She also complained that there was often confusion about her husband's medication and that his pain was not properly managed. We took independent advice from consultants in oncology and radiology and also from a senior nurse practitioner. We found that while Mr A's care and treatment had been appropriate and reasonable, his pain had been very difficult to control (due to his complex condition) and communication had not been as good as it could have been. He was given upsetting information at a time when support was not available to him, and was given his diagnosis over the phone. There was also confusion about his medication and treatment. In particular, there was confusion about Metformin (a drug Mr A was taking for diabetes) and whether he needed to stop taking it before his imaging test. When Mrs C later complained about these circumstances, the board delayed in providing her with a response. In view of this, we upheld Mrs C's complaint.

Mr C saw a podiatrist because of the deteriorating condition of his foot due to an ulcer. He then had several admissions to Ninewells Hospital as well as being seen as an out-patient. He underwent an artery bypass (a procedure to improve blood flow) from just below the knee to the foot with amputation of several toes and a skin graft. The bypass and the skin graft failed and Mr C may need further surgery in the future. We took independent advice from a podiatrist and a vascular surgeon. In relation to the podiatry treatment provided, we found that there were clear indications that Mr C had progressive foot disease when he saw the podiatrist on three occasions which the podiatrist failed to act on including referring Mr C to secondary care within a reasonable time. Clinical notes of Mr C's assessments were also inadequate. We found that the relevant guidelines (Scottish Intercollegiate Guidelines Network, SIGN) were not followed. We upheld this aspect of Mr C's complaint. With regard to the surgical care that Mr C received during his two admissions to hospital, we found that on the whole the board provided a reasonable standard of care and treatment but that there was an unreasonable delay in treating the foot initially when clinicians became aware that it was infected. We upheld this aspect of Mr C's complaint. In relation to Mr C's out-patient appointments following discharge from hospital, we were satisfied that there was evidence showing that assessment for each out-patient appointment was reasonable as was communication in relation to the management plan. We did not uphold this aspect of Mr C's complaint.

A GP was called to Mrs A's home when she was experiencing breathing difficulties. The GP examined Mrs A and prescribed medication. Two days later Mrs A was admitted to hospital with respiratory failure. Mrs A subsequently complained to the practice about the care and treatment she received at the home visit. The practice explained the reasons why the GP had made his decisions and indicated that they considered that these had been reasonable. Mrs A remained dissatisfied and Mrs C, who works for an advice agency, complained to us on behalf of Mrs A. Specifically, Mrs A wanted to see if there was a preventable delay in her care. We took independent advice from a GP adviser. The adviser reviewed the medical records for the home visit and considered that the symptoms and signs recorded were consistent with the diagnosis made, which was an acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD). The adviser told us that the GP had identified this appropriately and treated Mrs A in line with the National Institute for Health and Care Excellence (NICE) guidance relevant to COPD in Scotland. Overall, the adviser was satisfied that the practice's care and treatment of Mrs A was reasonable. We agreed with this advice, and did not uphold the complaint. Related reading View Decision Report 201502980 as a PDF (11.25 KB) Updated: March 13, 2018

Mr C complained about the care and treatment of his mother (Mrs A), who was admitted to Perth Royal Infirmary following some falls, and then transferred to Murray Royal Hospital for assessment. Mrs A remained in Murray Royal Hospital for about three months, although she was transferred back to Perth Royal Infirmary on several occasions. During Mrs A's time at Murray Royal Hospital, Mr C made allegations of abuse by nursing staff, and he complained that the board did not investigate this properly. Mr C also raised concerns about Mrs A's nursing and medical care at Murray Royal Hospital. These included concerns about her falls and physical safety, the numerous transfers between hospitals, the delay in replacing Mrs A's dentures, Mrs A's medications, and the decisions to detain Mrs A under the Mental Health Act and to use covert medication. Mr C also said the board failed to reimburse him for items lost during Mrs A's admission. The board apologised to Mr C for the time taken to replace Mrs A's dentures and for the lost items. They arranged several reviews of Mrs A's care in response to Mr C's complaint, but found her care was satisfactory. After taking independent advice from a mental health adviser and an adviser who is a consultant in general medicine, we upheld two of Mr C's complaints. We found there had been some failings in nursing care, including inadequate care planning (particularly in relation to falls risk) and inadequate nutrition monitoring. We also found the board failed to agree a clear communication plan with Mr C. However, we found that Mrs A's medical care was reasonable, and the decisions to detain Mrs A and use covert medication were made appropriately and in line with relevant guidance. We also found that, although the board had not yet reimbursed Mr C for all the missing items, they had handled his claim reasonably.

Mrs C's husband (Mr C) was admitted to Perth Royal Infirmary and treated for pneumonia. His condition did not improve whilst in hospital and he died seven days after being admitted. Mrs C raised a number of specific complaints about the medical and nursing treatment her husband received at the hospital. In particular, she felt that his medication was not managed appropriately and that she was left to take care of many of his basic personal care needs. We took independent advice from two advisers, one a consultant geriatrician and the other a nurse. Whilst we were critical of the board for failing to ensure Mr C's teeth were cleaned regularly and for initially denying Mrs C access to the ward outside of normal visiting times, we were generally satisfied that the medical and nursing care was of a good standard. Related reading View Decision Report 201405118 as a PDF (11.02 KB) Updated: March 13, 2018

Mr C complained about a misdiagnosis of cancer. He said staff at Ninewells Hospital told him about three years ago that he had six to nine months to live, but then told him about a year ago that he did not have cancer. Mr C was concerned about the misdiagnosis, and that the board did not follow up to determine the correct diagnosis for his symptoms. Mr C also raised concerns about the board's handling of his complaint, as they had still not responded to him four months after he complained. We asked the board when they would respond to his complaint, and they said they aimed to do so within three weeks. Mr C did not receive a response within this timeframe, and we began considering his complaint. However, the board then sent Mr C the final response from their investigation. We asked Mr C if he was satisfied with this response, or if he wished us to keep investigating. Mr C said he did not want us to keep investigating, and we closed our file on the complaint. Related reading View Decision Report 201503628 as a PDF (11.04 KB) Updated: March 13, 2018

Mr C complained because he said the board failed to respond appropriately to his complaint about scheduled appointments with the pain clinic. In particular, Mr C said the board had responded to his complaint saying that there was nothing documented about planned appointments with the pain clinic. However, before receiving the board's response, Mr C said a nurse gave him a written note. The note showed that his medical record had been checked and noted that he was due to attend pain clinic appointments. We made enquiries with the board but before finalising our investigation, Mr C was freed from prison. We tried contacting Mr C to confirm his new contact details but he did not respond to us. Therefore, we closed his complaint without reaching a finding. Related reading View Decision Report 201502164 as a PDF (10.93 KB) Updated: March 13, 2018

Ms C, an advice worker, complained on behalf of Miss A, who had had surgery to her jaw at Ninewells Hospital. Following this surgery, Miss A had been diagnosed with a serious injury to her neck, which had required a second operation to correct. Ms C suggested that the first operation had been inappropriate and that Miss A's injury had taken too long to diagnose. We received independent advice from a consultant maxillofacial (mouth, jaws, face and neck) surgeon and a consultant orthopaedic (concerning the musculoskeletal system) surgeon. The advice said that the injury was extremely rare and that it was not clear when the injury had occurred, although it was highly probable that it occurred during the operation. There were no signs before the surgery that Miss A was at risk of suffering this type of injury and the operation was the appropriate one for her condition. The advice said that the time taken to diagnose the injury was reasonable in the circumstances. We found that Miss A had suffered a very rare complication. Although this was highly unfortunate and understandably traumatic, it did not mean that the treatment she had received was unreasonable. Related reading View Decision Report 201407896 as a PDF (11.16 KB) Updated: March 13, 2018

Mr C complained about the way in which his pain relief medication was handled by the prison health centre. Mr C has osteoporosis (a condition causing weakness of the bones) and had been prescribed tramadol (a strong opioid painkiller). He was unhappy that there was little discussion or information about why it was being stopped. He was also unhappy that the board failed to provide relevant information in their response to his complaint. We took independent advice from a medical adviser who is a GP. We found that, when reviewing Mr C's medication, the health centre acted in line with Scottish national guidelines on the management of chronic pain and on prescribing. Tramadol was not the only type of painkiller that could be used to treat Mr C's pain, and there is a lack of evidence for the long-term use of opioids for chronic pain. We considered it reasonable that the health centre tried alternative painkillers on the basis that further review took place. We concluded that reasonable attempts were made by the health centre, and in the board's complaint response, to explain why the medication was being reduced and then stopped. Related reading View Decision Report 201405328 as a PDF (11.16 KB) Updated: March 13, 2018

Mr C has had contact with mental health services in the board area since 1997, and his complaint concerned the care and treatment he received from 2004 until 2014. Mr C said it was clear he had suffered from post-traumatic stress disorder throughout his contact with mental health services during this period, but that the board failed to diagnose him with this or provide appropriate treatment, such as trauma-focussed cognitive behavioural therapy (CBT). Mr C complained this meant that he was unable to return to work and effectively 'lost' ten years of his life. We took independent advice from one of our medical advisers who specialises in psychiatry. We found that the action taken by each mental health practitioner following contact was reasonable, and there had been no indication that trauma-focussed CBT should have been preferred to the treatment given. Related reading View Decision Report 201403324 as a PDF (11.02 KB) Updated: March 13, 2018

Mrs C and her husband were participants in an egg-sharing programme (as donor) in the Assisted Conception Unit at Ninewells Hospital. As part of the programme, after fertility treatment, Mrs C retained some of her eggs and some were donated to a recipient. Mrs C complained that the care and treatment given to her was unreasonable, and that staff were primarily concerned with the recipient. She said that communication with the staff was also unacceptable, and that she was given information despite saying that she did not want it. She believed she had been looked down upon. We obtained independent advice from a consultant obstetrician and gynaecologist (a doctor specialising in pregnancy, childbirth and the female genital tract) who was a reproductive medicine specialist. We found that all of Mrs C's treatment had been conducted in terms of the Human Fertilisation and Embryology Act code of practice. While there had been a slight delay in providing part of the treatment, this had been because the recipient's and Mrs C's menstrual cycles had to be synchronised. The delay was unavoidable. Similarly, the code of practice had been followed with regard to communication with Mrs C, but it seemed that she had not fully understood. We noted that the board had since made changes to prevent a similar occurrence. Mrs C's complaint was not upheld.

Mr C's daughter (Ms A) was admitted to Ninewells Hospital three times with severe abdominal pain and swelling accompanied by nausea. Investigations and tests were negative. Mr C complained that Ms A was discharged from hospital unreasonably, and that doctors failed to reach a diagnosis, which led to a great deal of anxiety for Ms A and her family. As a result, Mr C said that Ms A’s health deteriorated. We took independent advice from a medical adviser who is a specialist in gastroenterology (medicine of the digestive system and its disorders). We found that the board properly investigated Ms A's symptoms, and that the decision to discharge her on each occasion was reasonable because no abnormalities were found. The adviser said that a diagnosis had been reached by doctors. However, we found that this was not clearly relayed to Ms A so we understood Mr C's position that doctors had failed to reach a diagnosis. We therefore made a recommendation to put this right.

Mrs C complained to us on behalf of Mrs A, in relation to an incident of potential contamination due to the use of unclean equipment. Mrs A attended Dundee Dental Hospital for treatment, and during the course of her treatment a microscope was put close to her mouth. She could see dirty marks on the microscope which looked like dried blood. After her treatment she raised concerns with staff. One nurse immediately wiped the microscope. Mrs A said that she was told it would be sent for analysis. Later that day staff contacted Mrs A to provide further information and advice. Following Mrs A’s complaint to the board, they took further steps to investigate the situation, and identified failures in the board’s cleaning protocols, which were rectified. We took independent advice from one of our nursing advisers, which indicated that, while it was not appropriate for dirty equipment to be in use, the board had identified gaps in their protocols and had made appropriate changes. She also considered that the information and advice provided to Mrs A and her husband were reasonable. The adviser was also satisfied that appropriate action was taken in cleaning the equipment, and did not express concerns that the wipe used to clean it had not been analysed. We concluded that Mrs A was understandably upset by what had happened. However, we found that it had been appropriate to clean the equipment as soon as possible, and not taking a sample for analysis was in line with national policy. We also considered that the information and advice Mrs A was given were appropriate. We found that the board’s response to the complaints made and the action taken were reasonable. Related reading View Decision Report 201406517 as a PDF (11.42 KB) Updated: March 13, 2018

Mrs C complained to us on behalf of her late mother (Mrs A) about the care and treatment she received in the Royal Victoria Hospital during the last three months of her life. Mrs A had fallen while in hospital. Over subsequent weeks her mobility deteriorated and she complained about pain in her hip. Mrs A was referred for a psychiatric review and then a pain assessment that highlighted concerns about her condition. She was referred for an x-ray, which identified a fractured hip. Mrs C complained that this should have been identified earlier, and that staff did not do enough to adequately manage Mrs A’s pain. She said that if the hip pain had been appropriately investigated, Mrs A would have had better pain control in the final weeks of her life. We sought independent advice from a nursing adviser and an adviser in elderly medicine. The nursing adviser highlighted significant concerns about the assessment and monitoring of Mrs A’s pain. They were also critical that nurses made negative remarks about Mrs A’s behaviour, without noting that the behaviour was a result of her pain. The adviser in elderly medicine found that doctors had appropriately assessed Mrs A after her falls. They noted that Mrs A had complex care needs, and her pain had a number of sources. However, they were critical that when Mrs A started to complain of pain in her hip about a month after her last fall, this was not further investigated. They said that if the fracture had been identified then, Mrs A could have received better pain management in the weeks before she died. We were critical that the nursing staff did not do enough to appropriately assess Mrs A’s pain as her condition deteriorated. This made it more difficult for doctors to assess her. However, medical staff also failed to identify significant signs of a potential hip fracture for several weeks, and this left Mrs A with poor pain management for longer than necessary.

Mr C complained that while his wife (Mrs C) was a patient in Murray Royal Hospital, she was assaulted by another patient and suffered a minor injury. The staff told him that Mrs C would be protected from the patient. Mrs C was then assaulted again by the patient and had to receive medical treatment for a severe injury to her eye. Mr C complained that the board staff had not taken appropriate action to prevent the second assault. The board maintained that the risk of the patient assaulting Mrs C on the second occasion was assessed as rare. We obtained independent advice from two of our nursing advisers. They considered that there was no indication that the patient would assault Mrs C on the second occasion. We found that the board had taken appropriate action following both assaults, which would have greatly reduced the likelihood of a further assault. Related reading View Decision Report 201501070 as a PDF (10.96 KB) Updated: March 13, 2018

Mrs C complained that the practice had not contacted her to tell her about the need for blood tests to be repeated. The practice responded to her complaint advising that they held a recording of a phone conversation in which she was told about the need for blood tests to be repeated. They offered Mrs C the chance to hear the recording. Mrs C brought her complaints to us. We received a transcript of the call from the practice, which supported their view. We decided we would not pursue the matter further in those circumstances. Related reading View Decision Report 201502371 as a PDF (10.84 KB) Updated: March 13, 2018

Miss C complained that her mother-in-law (Mrs A) had not been properly assessed by a GP following episodes of dizziness and elevated heart rate and blood pressure. Mrs A had suffered a fatal heart attack three days after visiting the GP. The GP said that Mrs A had suffered from a number of health problems. At the consultation in question she had been extremely anxious and had been prescribed medicine to counteract this. Her pulse and blood pressure had also been taken. We took independent advice on the care and treatment provided. Our adviser said the medical records did not show that a comprehensive examination of Mrs A had been carried out. Our adviser noted that Mrs A suffered from diabetes and that the appropriate Scottish guidance for management of patients with this condition had not been followed, which was unreasonable. We found that the GP had not carried out an adequate examination of Mrs A. However, our adviser also said that Mrs A's death had been impossible to predict and that even had a more thorough examination been carried out, it would not have been possible to prevent her fatal heart attack.