SPSO Individual Decisions

C complained that the practice failed to adequately investigate and/or diagnose the cause of their persistent cough. C was subsequently hospitalised and diagnosed with pneumonia while on holiday. The practice did not uphold C’s complaint. They said that they had taken reasonable action in light of C’s presenting symptoms and that C’s cough had been reasonably treated. They said that C’s final examination was normal and not in keeping with a diagnosis of pneumonia and that, therefore, there was no missed diagnosis. C remained unhappy and asked us to investigate. We took independent advice from a GP. We found that there had been a failure to adequately investigate the cause of C’s cough. In light of C’s presenting symptoms, a persistent cough and infection, we found that an in person appointment and an urgent referral for a chest x-ray should have been considered after their initial telephone presentation. We also considered that C should have been referred for an urgent chest x-ray following a second presentation, in accordance with the Scottish Referral Guidelines for Suspected Cancer. Therefore, we upheld C’s complaint.

C complained that the medical practice failed to provide their late parent (A) with reasonable care and treatment after A fell and hit their head. A had sustained a subdural haematoma (where blood collects between the skull and the brain). A was cared for in their home and later admitted to hospital. A died a few months after their fall. We took independent advice on this complaint from a GP. We found that the head injury assessment was unreasonable and not in line with NICE guidance. We were critical that the practice did not acknowledge this failing in their complaint response, the significant adverse event review (SAER) or in response to our enquiries. We found that it was unreasonable that concerns raised by C, after A’s fall, did not prompt further action by the practice. We also noted that the clinical notes did not adequately describe the head injury and there was no evidence that the practice understood the significance of the head injury and communicated that to the medical service they referred A onto. Therefore, we upheld this part of C’s complaint. C also complained that the practice unreasonably failed to carry out a SAER in line with the relevant Healthcare Improvement Scotland Guidance. We found that the initial SAER was of poor quality. The enhanced SAER was in line with the guidance, but we were again critical of the quality. Therefore, we upheld this part of C’s complaint. We also found that the practice’s complaint handling did not mirror the current Model Complaints Handling Procedure. Therefore, we made a recommendation to address this.

C complained that the partnership had not provided the correct care and treatment for their ear infection in their right ear. C did not consider that the ongoing ear infection had been correctly diagnosed or treated, noting that the antibiotics which were prescribed had not been effective. C was concerned that although a referral to ENT had been made, the referral was not correctly prioritised, which had caused a significant delay. It was only when C saw a doctor, who phoned ENT, did C receive specialist input. We took independent advice from a GP adviser. We found that C had not been seen face to face for a six month period, the first was a routine referral and the second expedited referral did not reflect the clinical situation because C had not been examined. We also found that the overuse of antibiotics had likely aggravated the situation. Overall we considered that more could have been done to clinically assess and seek specialist input for C’s ear infection. We therefore upheld the complaint.

C, an MSP, complained on behalf of their constituent (B) about the standard of care B’s late spouse (A) received from their GP practice. A attended an appointment with a GP and received antibiotics and steroids for a possible chest infection. A’s health deteriorated a short time later and they suffered a cardiac arrest at their home. B complained that the practice failed to recognise that A was suffering from a serious cardiac condition. The practice said that a full examination and history had been taken from A. The GP concluded that the symptoms were from the chest wall rather than originating from the heart, with a suggestion of chest infection and narrowing of the airways. A received steroids and an antibiotic in treatment of a chest infection, and given advice on what to do if their condition worsened. On learning of A’s death, a Significant Event Analysis was carried out by the GP, which identified learning points in relation to arranging ECGs (a test that records the electrical activity of the heart, including the rate and rhythm), and strengthening the advice given to a patient about phoning again should their condition worsen. We took independent advice from a GP. We found that it was reasonable for the GP to treat A on suspicion of a respiratory infection having taken a history and clinical examination. While A’s oxygen saturation levels were low, this can also be found in cases of acute or chronic lung disease, such as infection. A also displayed symptoms that were not typical of classic heart attack pain. We found that A’s blood pressure and heart rate were both normal which did not suggest a heart attack. We considered that the GP made a careful assessment and reached a reasonable working diagnosis at the time based on the information available and their clinical judgement. Therefore, we did not uphold C’s complaint. Related reading View Decision Report 202202721 as a PDF (24.8 KB) Updated: January 24, 2024

C complained to the practice about the care and treatment provided to their relative (A). A began to experience abdominal pain and was reviewed by doctors at the practice a number of times before being admitted to hospital as an emergency. Following discharge, A was seen at the practice again with continuing symptoms and unintended weight loss. They were referred to hospital and again discharged. A colonoscopy performed suggested acute diverticulitis (where small pouches from the wall of the gut become inflamed or infected). A attended the practice again with worsening symptoms and was admitted to the hospital after an urgent request was submitted. A died in hospital a few weeks after. C was concerned about the standard of care provided to A by the practice. The practice met with A's family. The practice carried out a Significant Event Analysis (SEA). The practice responded to C's complaint and noted their frustration that A had been discharged from the hospital without progress in the management of their condition. However, they did not find that they should or could have done anything differently in A's care. C submitted a further complaint to the practice after they received a response from the health board regarding the care provided at the hospital. The practice responded confirming that an SEA had been carried out. The doctor who had seen A had discussed the case with colleagues in the practice and with their Educational Supervisor. These discussions had been informal and had not been documented in A's notes. C was dissatisfied with the complaint responses and brought the complaint to our office. We took independent advice from a GP. We found that most of A's care was of a reasonable standard. However, there was a delay in acting on concerns about A's condition following their second discharge from hospital. Given the significance of the failures identified, we considered that A's care fell below a reasonable standard and upheld this part of C's complaint. C a

C complained about how the practice had managed their lithium prescription (a medication used to treat mood disorders). We took independent advice from a GP. We found that the practice acted reasonably in requesting that C arrange blood tests every three months to monitor their medication levels. We were also satisfied that the practice had provided reasonable advice about how to ensure C did not run out of medication. We did not uphold C's complaint. Related reading View Decision Report 202201027 as a PDF (23.99 KB) Updated: May 24, 2023

C complained on behalf of their partner (A). A had a telephone consultation with the practice and reported haemoptysis (coughing up blood) and a fever. A also reported that they had taken a lateral flow test for COVID-19 which was negative. A did not take a PCR test for COVID-19 prior to contacting the practice. The practice considered it was likely that A had COVID-19 and advised that they self-isolate for ten days after symptoms started. A's condition deteriorated and several weeks later they were admitted to hospital and diagnosed with bacterial pneumonia. C complained that the practice did not offer A a face to face appointment and subsequently failed to correctly diagnose their condition of bacterial pneumonia, instead focussing on COVID-19 as being the cause of A's illness. The practice considered that they had been following the guidelines in place at the time and had correctly signposted A to the COVID-19 Hub for further assessment. We took independent advice from a GP. We found that there was no evidence in the clinical record that A had been signposted to the COVID-19 Hub and that haemoptysis was never listed as one of the common symptoms of COVID-19 infection. We found there was a failure to offer A a face to face appointment, particularly given they had reported haemoptysis. We welcomed that during our investigation the practice reflected further and accepted that A's complaint of haemoptysis merited further clinical consideration and assessment. Given that the practice have taken appropriate and sufficient action to learn and improve from this complaint, we did not recommended that they take any further action. However, we recommended that they apologise to C and A for not offering A a face to face appointment.

C complained that the medical practice failed to provide reasonable care and treatment to their spouse (A) after they presented with a lump in their right breast. We took independent advice from a GP. We found that the time taken to refer A to hospital when they first consulted the medical practice with the lump in their right breast was unreasonable. It was also unreasonable that the referral was not marked as urgent. The medical practice had carried out a detailed review of A’s care and had accepted that there was a complete systems failure in the care and treatment provided to A. They had made a number of changes which we welcomed and considered were appropriate. Nevertheless, we found that they had not fully acknowledged their specific role and responsibility in relation to the failings which had occurred given their responsibilities for the supervision, training and actions of their employed staff. We also identified additional issues not addressed by the medical practice in their consideration and response to the complaint. In particular, that the medical practice should have a system in place to ensure any outstanding referrals were identified when a colleague is unexpectedly absent due to sickness or ill-health and that it was unreasonable that A was not contacted by the medical practice after the cancer diagnosis given the significance of the diagnosis and their delay in sending the referral and marking it as urgent. We also found that the medical practice did not appear to have considered their duty of candour responsibilities in this case. Therefore, we upheld C’s complaint.

C complained about the care and treatment provided to their late spouse (A) by the practice. A died due to invasive bladder cancer and urinary sepsis (blood infection). C complained that the practice unreasonably delayed referring A to secondary care for investigation despite presenting with recurrent urinary tract infections (UTIs) that did not respond to antibiotic treatment. C considered that A's bladder cancer may have been identified earlier, and that their death avoided, had the practice referred them for investigation much sooner. The practice's position was that A had a long history of intermittent UTIs, which were usually treated with antibiotics. At one point, all of A's urine samples showed pus cells but a normal range of red cells, which was suggestive of simple UTIs. The early signs of bladder cancer such as blood in the urine were not apparent in A's case until a relatively late stage. The practice considered that abnormalities in A's blood results (increased platelet and white cell count) were caused by A's unrelated medical conditions. We took independent advice from a general practitioner adviser. We noted that patients over a certain age with recurrent or persistent UTIs (i.e. three episodes in 12 months) associated with haematuria (blood in the urine) should be referred for urgent investigation in accordance with national guidelines. In A's case, they had attended the practice three times in four months with recurrent UTIs and haematuria found on dipstick testing. At this point, we found that A should have been referred on an urgent basis in line with the guidance but that the practice did not do so for a further ten months. We found that the practice had failed to identify that A's blood results showed signs of recognised malignancy and that they had repeatedly failed to record A's clinical history and review the results of investigations performed. As such, we upheld this complaint.

C complained to the practice about the treatment that they received when they contacted the practice with back problems. C spoke to a GP and an advanced nurse practitioner (ANP) by telephone during that period due to the COVID-19 restrictions and C was advised to make further contact should their situation worsen. C was taken by ambulance to hospital and after a CT scan was diagnosed as having cauda equine syndrome (a disorder that affects the nerves). C felt that the GP and the ANP should have seen them in person for an examination and that had this been the case, the correct diagnosis of cauda equine syndrome would have been reached sooner and would not have had such a drastic effect on their health. We took independent advice from a GP and an ANP. We found that C had a previous history of back problems over a number of years which were felt to be sciatica (back and leg pain caused by irritation or compression of the sciatic nerve) and musculo-skeletal in nature and that it was not unreasonable to attribute C's reported symptoms to those conditions. However, when C attended hospital their condition had deteriorated and they had reported new symptoms which were red flag signs of cauda equine syndrome. We did not uphold the complaint. Related reading View Decision Report 202004100 as a PDF (24.37 KB) Updated: June 23, 2021

C complained about the care and treatment they received from the practice after attending with concerns relating to swelling of the parotid gland (a salivary gland that lies immediately in front of the ear). C attended the practice several times and was eventually diagnosed with cancer. C later learned that it was terminal. C said that the practice had failed to treat their symptoms appropriately and that it took too long to refer them to the ear, nose and throat (ENT) department. We took independent advice from a GP. We found that the practice had provided reasonable care and treatment to C, that they treated their symptoms appropriately and made appropriate and timely referrals to ENT. Therefore, we did not uphold C's complaint. Related reading View Decision Report 201905692 as a PDF (24.06 KB) Updated: September 23, 2020

C attended the practice with a growth on their face. When after initially being prescribed antibiotics the growth remained, the practice referred C to the local NHS board's plastic surgery department as a routine referral. C contacted the practice some months later as the growth had enlarged and C was experiencing other symptoms. The referral was upgraded to urgent and C was seen by the plastic surgery department shortly after. C was subsequently diagnosed with a malignant tumour and underwent further treatment by the board after the diagnosis. C complained to the practice about the treatment that they received. C said that if the malignant tumour had been diagnosed sooner, then the treatment to remove the tumour would have been less invasive and impactful on their appearance. The practice responded via the local NHS board. Dissatisfied with the response, C brought the complaint to our office. We took independent advice from a GP. We found that the practice's working diagnosis of a sebaceous cyst (a common non-cancerous cyst of the skin) was reasonable, with appropriate treatment provided, initially with antibiotics and, when the cyst remained, with a referral to the local NHS board's plastic surgery department. We considered that the skin cancer had presented atypically, and it was therefore reasonable that the practice initially considered the lesion to be a benign lesion, rather than an atypically presenting cancerous lesion. When it was reported that the lesion had grown and C was experiencing other symptoms, the practice reasonably escalated C's referral to urgent. We did not uphold the complaint. Related reading View Decision Report 201906036 as a PDF (24.48 KB) Updated: July 22, 2020

Ms C, an advocacy worker, complained on behalf of her client (Ms A) about the care and treatment provided to Ms A's late mother (Mrs B) by the practice following a home visit by a doctor from the out-of-hours (OOH) service. Mrs B was later admitted to hospital where she died. We took independent advice from a GP. We found that there was no indication, based on the report from the OOH doctor, for the practice to arrange an emergency home visit to Mrs B or that the OOH doctor had requested the practice carry out a home visit. There was also no evidence to suggest that Mrs B was deteriorating in the days following the visit of the OOH doctor. We found that the subsequent sudden deterioration in Mrs B's condition could not have been foreseen and the care provided by the practice following the visit from the OOH doctor, and the plan to visit Mrs B as a routine house visit, was reasonable and consistent with good medical practice. Therefore, we did not uphold the complaint. Related reading View Decision Report 201804029 as a PDF (24.23 KB) Updated: June 17, 2020

Mr C complained that the care and treatment given to his late wife (Mrs A) by her GP practice were unreasonable. Mrs A had a history of rheumatoid arthritis (an inflammatory disorder that mainly affects the flexible joints). Her health began to deteriorate further, but Mr C said that it took time to establish that Mrs A had heart problems for which she needed an operation. After surgery Mrs A was discharged home, but months later she required to be admitted to hospital again. Mrs A had developed a serious infection in her heart and died shortly afterwards. Mr C complained that it took too long to diagnose his wife's infection. We took independent advice from a GP. We found that in the early stages of her illness, Mrs A had been investigated and treated appropriately and it had been very unusual for a patient to have developed such severe heart disease in a short space of time. After her operation and return home, Mrs A became increasingly unwell and was regularly seen by members of the GP practice who treated her for a urinary tract infection. However, we found that the severe heart infection (endocarditis) had not been considered as a possible diagnosis, as it should have been, particularly as it was known that Mrs A had an artificial heart valve and persistent signs of infection. Her pre-existing heart condition could have predisposed Mrs A to developing endocarditis, and it was unreasonable not to consider this. This led to a delay in diagnosis and a delay in admitting Mrs A to hospital. Therefore, we upheld the complaint. During the course of our investigation, we also found the complaint handling to be unreasonable.

Mrs C complained to us about the care provided to her late husband (Mr A) by the practice prior to him suffering a fatal heart attack. In particular, Mr A had reported chest pains three times over a three month period to his GP. The GP had felt the problems were related to a stomach problem, prescribed Gaviscon (medication for heartburn or indigestion) to Mr A and said they had ruled out a cardiac cause for the chest pain. We took independent advice from a GP. We found that at the initial consultation it was reasonable that the GP had considered that Mr A's long standing stomach problem was responsible for his reported chest pain, and it was appropriate to prescribe medication. There was a question as to whether Mr A was taking the prescribed medication, which may have resolved the stomach problem, and that it was reasonable to pursue that line of enquiry in an effort to resolve the situation. We found that the GP had carried out an appropriate examination and did not uphold the complaint. We also noted that there was no evidence to suggest that had an earlier diagnosis been made, it would have prevented Mr A's sudden death. Related reading View Decision Report 201809722 as a PDF (23.9 KB) Updated: September 18, 2019

Mr C complained about the treatment his mother (Mrs A) received at the practice. Mrs A suffered from chest pain and breathlessness and had concerns she had angina (a heart condition). Mr C complained that appropriate treatment and investigations were not carried out in a reasonable time-frame. We took independent medical advice from a GP. We found that the practice unreasonably failed to carry out appropriate physical assessments during appointments. While the practice did not consider angina was a likely cause for Mrs A's health concerns, at the point where it was agreed to refer her, the practice used the incorrect referral pathway. They arranged for an electrocardiograph (ECG - test that records the electrical activity of the heart) followed by a routine referral to cardiology (the branch of medicine that deals with diseases and abnormalities of the heart), instead of the appropriate action of an urgent exercise tolerance test (or if the patient was not physically capable of doing this test then an urgent cardiology referral). We upheld this complaint.

Mrs C complained about the care and treatment provided to her late brother (Mr A), who had chronic obstructive pulmonary disease (COPD) (a disease of the lungs in which the airways become narrowed) and a mental health condition. Mrs C complained that the practice failed to admit Mr A to hospital in the months leading to his death. Mrs C had contacted the practice to raise concern about Mr A's physical health. Shortly following this, the GP attempted to carry out a home visit, but found no response on attendance at Mr A's property. A week later, Mr A was examined during a home visit by one of the board's out-of-hours doctors who initiated treatment for his COPD. At this time, Mr A had very low oxygen saturation and potential signs and symptoms of heart failure. A report of the out-of-hours consultation was sent to the practice. The practice arranged to visit Mr C again approximately ten days later, but when the GP attended Mr A refused an examination. The GP felt that the symptoms were likely due to COPD and treatment was commenced with a plan to review Mr A in ten days time. Mr A died on the date of the planned review, with the cause of death unknown. We took independent advice from a GP adviser. We were unable to conclude that the practice reviewed the details of the out-of-hours report, which contained details of concerning symptoms, and used this to determine a working diagnosis and management plan at the penultimate home visit attempt. We considered that the practice's decision that that there was no clinical indication for hospital admission following the home visit was unreasonable. We upheld this complaint.

Mr C complained about the care provided to his late mother (Mrs A) by the practice. In particular, Mr C said the practice knew that his mother had cancer and had had chemotherapy. However, the family had concerns that on one occasion there was a failure to admit Mrs A to hospital and, on another, a GP had refused to make a home visit. When Mrs A was seen by a different GP the same day, she was admitted to hospital. Mr C felt that given his mother's medical history, the practice could have provided more appropriate care. We took independent medical advice from a GP. We found that the GPs involved in Mrs A's care carried out appropriate assessments given the reported symptoms. On the first occasion, the GP had contacted the oncology (cancer) specialists for advice as Mrs A was experiencing the side effects of chemotherapy. At that time, it would not have been appropriate to have referred Mrs A to hospital due to the increased risk of her catching an infection from other patients who may have been unwell or from hospital acquired infections. On the second occasion, there was a change in Mrs A's symptoms from when the initial request for a home visit was made. As a result a home visit was arranged and Mrs A was appropriately admitted to hospital at that time. Therefore, we did not uphold Mr C's complaint. Related reading View Decision Report 201805241 as a PDF (24 KB) Updated: February 20, 2019

Mr C complained that the practice failed to discuss the risk of testosterone replacement when it was prescribed to him. We took independent advice from a GP. We found that at the start of his prescription, there was no evidence in Mr C's medical records to show that the risks and benefits of the treatment had been discussed with him as required by General Medical Council guidance. Therefore, we upheld Mr C's complaint.

Ms C complained about the care and treatment her mother (Mrs A) received at the practice. Mrs A had a history of a number of health issues and Ms C said that the practice failed to monitor her properly or to ensure that she saw a cardiologist (a doctor who specialises in diseases and abnormalities of the heart). She further complained that Mrs A's symptoms were not treated reasonably and the medication she was prescribed was inappropriate. We took independent advice from a GP. We found that Mrs A had been regularly seen, review appointments had been arranged and the medication prescribed was reasonable. At a previous surgery, Mrs A was managed in secondary care (in a hospital by a cardiologist) who had the responsibility for ensuring her ongoing cardiology follow-up and monitoring. We found that the practice had noted that Mrs A had not been to a follow-up and they contacted the hospital to advise them as was appropriate. Therefore, we did not uphold Ms C's complaint. Related reading View Decision Report 201801491 as a PDF (23.82 KB) Updated: February 20, 2019

Mr C complained about the practice’s management of his longstanding bladder and penile problems. He was diagnosed with an enlarged prostate (a gland in the male reproductive system) and underwent a surgical procedure. This was followed by further surgery to address a complication. After an initial improvement, his symptoms returned. He also began experiencing a lot of penile pain and irritation, for which he was referred to dermatology (the area of medicine concerned with the skin). Mr C complained that the practice failed to arrange appropriate investigations and treatment in response to his symptoms, including delays in referring him to urology (the area of medicine concerned with the male and female urinary-tractt, as well as the male reproductive organs) and prolonged ineffective treatment with antibiotics and creams. We took independent advice from a GP who considered that Mr C’s symptoms were appropriately managed by the practice. We identified two occasions where earlier referrals to urology might reasonably have been considered. However, we did not find that the delays in referring to urology materially impacted on Mr C’s ongoing issues or the outcome for him. We considered that the practice appropriately managed Mr C's bladder and penile symptoms and did not uphold his complaints. Related reading View Decision Report 201703286 as a PDF (11.24 KB) Updated: December 2, 2018

Mr C complained that the practice refused to register himself and other members of his family as new patients. He also said that the practice failed to make reasonable adjustments to accommodate the needs of disabled family members. We found that the practice had followed their policy in relation to Mr C's registration. The practice declined to register Mr C on the basis of being unable to form a doctor / patient relationship with him because of his conduct which they are entitled to do. Therefore, we did not uphold this part of Mr C's complaint. Mr C also wanted to register other members of his family as new patients. The practice said that they could not do so unless they came to the practice so that their identification could be verified. This was in line with the practice policy. The practice made this clear to Mr C, however, we found that some later communication was not appropriate. The practice appeared to link the decision to not register Mr C's family to Mr C's behaviour in their communication. However, we noted that the practice acknowledged this mistake and confirmed that members of Mr C's family could still register as new patients, provided that they comply with the registration policy. On balance, we did not uphold this part of Mr C's complaint. In relation to the practice failing to make reasonable adjustments, we found that Mr C had declined to provide sufficient information about the disabilities of members of his family. Therefore, we considered that the practice did not have enough information to assess whether the adjustment requested was reasonable, or not. We did not uphold this part of Mr C's complaint. Related reading View Decision Report 201704515 as a PDF (11.28 KB) Updated: December 2, 2018

Mrs C complained that the practice had failed to provide appropriate care and treatment to her husband (Mr A) when he reported mobility problems following a fall where he was hit by a car door. Mr A had a history of ankylosing spondylitis (a type of arthritis in the spine). Following the fall, a nurse practitioner made a home visit and, after speaking to a GP, a diagnosis of a dead leg syndrome was made. Mr A continued to deteriorate and a further call was made to the practice the following day. Mr A was then admitted to hospital where he was diagnosed as having two unstable fractured vertebrae (bones in the spinal column). We took independent advice from a GP adviser and from a nursing adviser. We found that, based on the symptoms first reported by Mr A, there was no indication of a serious illness and that he did not require a hospital admission that first day. We found that it was appropriate that it was only when his condition deteriorated and he reported some numbness that it was deemed necessary to contact the hospital specialists and arrange for Mr A to be admitted to hospital. We did not uphold the complaint. Related reading View Decision Report 201707783 as a PDF (11.16 KB) Updated: December 2, 2018

Ms C complained that the practice unreasonably removed her from the patient list. Ms C had had concerns about the treatment which she had received from the practice previously but these had been dealt with under the complaints procedure. Ms C was surprised to subsequently receive a letter from the NHS practitioners services advising her of the decision taken by the health board to remove her from the practice patient list due to a breakdown in the professional relationship. Ms C then learned that the instruction to remove her came from the practice and that she had not been given an explanation as to how the practice had come to their decision. We took into account the contractual regulations and relevant guidance regarding the removal of patients from the practice list. This sets out that, other than in cases involving violence or aggression, a patient whose behaviour is giving cause for concern should be given a written warning informing them that they will be removed from the practice list if they do not alter their behaviour. The warning should last for 12 months. While the practice did have concerns about Ms C's actions, and did discuss the issue with the health board, staff did not formally bring them to Ms C's attention in line with the regulations and guidance and therefore she was unaware of the practice's concerns. We upheld the complaint.

Mr C complained that the practice delayed in referring his late father (Mr A) for appropriate specialist investigation of his iron deficient anaemia (a condition where the blood lacks an adequate amount of healthy red blood cells). Mr C considered that an urgent colonoscopy should have been arranged, in line with cancer referral guidelines. He also raised concerns about the chosen referral pathway once a referral was eventually made, as the referral was to a vascular surgeon rather than directly for colonoscopy. Mr A was subsequently diagnosed with colorectal cancer which was not amenable to treatment and he later died. In responding to Mr C's concerns, the practice said they did not deem an earlier referral appropriate at the time in light of Mr A's other complex medical conditions. We took independent medical advice from a GP, who advised that there were no current complex medical conditions which could have explained the significant deterioration in Mr A's red blood count. As such, they advised that cancer referral guidelines should have been followed and Mr A should have been appropriately assessed and referred for urgent investigation. We found no evidence of an appropriate examination having occurred and a referral was not made until almost nine months after iron deficient anaemia was diagnosed. We found that the referral should have been sent to a gastroenterologist or surgical doctor, rather than a vascular surgeon. In addition, the adviser highlighted that Mr A was prescribed an inappropriate dosage of iron supplements and he was not adequately monitored to assess his response to these. We concluded that there was an unreasonable failure to appropriately assess, treat and monitor Mr A's iron deficient anaemia, and an unreasonable delay in arranging appropriate specialist investigation. We upheld the complaint.