SPSO Individual Decisions

C complained about the care and treatment provided to their late parent (A) by the board. A, who was diabetic, had been diagnosed with conditions including Myasthenia Gravis (an autoimmune disorder causing muscle weakness). A was admitted to University Hospital Crosshouse (UHC) as an in-patient four times, initially with a diabetic foot ulcer. This deteriorated over the course of time leading to infection, surgery and amputation. A died during their fourth admission. The board partly upheld C's complaint and identified failures in A’s care, particularly around the administration of medication for the treatment of Myasthenia Gravis and around communication with A’s family. They identified learning and improvements. C remained unhappy and asked us to investigate. C complained that A had been provided with inadequate care and treatment as a podiatry out-patient and as an in-patient at UHC. C also complained that the board had failed to adequately investigate their complaint. We took independent advice from a consultant vascular surgeon. We found that the out-patient podiatry care provided to A was reasonable and did not uphold this complaint. However, while we found that, overall, A’s care and treatment was reasonable during their in-patient admissions, there were failings in relation to A’s Myasthenia Gravis medication and in communication with A’s family. We upheld this complaint and recommended that the board provide us with evidence of the implementation of the learning and improvements they had previously identified. We found that the board’s investigation of C’s complaint was reasonable. However, we were critical of the time taken to respond to the complaint and of the board’s failure to keep C regularly updated on the progress of their investigation. We noted that the board had accepted this and identified learning and improvements. We made no further recommendation for action. Related reading View Decision Report 202309740 as a PDF (24.71 KB) Updated: March 18,

C complained on behalf of their adult child (A), who underwent septorhinoplasty surgery (to improve the function and appearance of the nose) after a rugby accident. C complained about the care and treatment provided to A following the procedure. C had all skin sutures and brace, seven days after surgery, as per the clinic letters. A developed a post-operative infection and was reviewed again 12 days after surgery, when a further suture was removed. More than a year later, A noted black suture material extruding from the scar line on their nose. They were commenced on antibiotics and further review arranged. C complained that the medical records did not support the board’s position that a suture was intentionally left in place and that the board had failed in their duty of candour. We took independent advice from a consultant otorhinolaryngologist (specialist in ear, nose, and throat medicine). We found the standard of care and treatment when A attended 12 days after surgery unreasonable. We also found that A was wrongly told that all remaining suture material had been removed at that time. With regard to the suture material which extruded from the scar line more than a year later, we found that the board’s explanation that this suture was intended to remain in place permanently was not supported by the records. Had it been intended to remain in place permanently, it should have been clearly recorded. We found the board had failed in their duty of candour and that it was unreasonable for the board not to have offered A a second opinion, even if that required referral outwith the board area. We therefore upheld the complaint.

C complained that the board failed to reasonably investigate and/or diagnose the cause of their symptoms of significant weight loss, intense abdominal pain, vomiting, altered bowel habit and nausea. C also complained that they were discharged from the board’s gastroenterology service (specialists in the diagnosis and treatment of disorders of the stomach and intestines) despite these ongoing symptoms. C said that they were left with no option but to obtain private care and treatment in England where they were diagnosed as suffering from mesenteric ischaemia (restricted blood flow to the intestines). C underwent surgery to correct this privately. While this resulted in significant improvements in C’s health, C complained that this course of action should not have been necessary and that there were cost implications. In their complaints response, the board acknowledged and apologised for issues with delays in providing investigations, and failings with respect to communication. However, they considered the clinical decisions made in relation to the investigation and management of C’s case were appropriate. We took independent advice from a consultant gastroenterologist and a consultant radiologist (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that the board should have considered a diagnosis of mesenteric ischaemia as a strong possibility based on C’s presenting symptoms. Furthermore, when a CT scan was undertaken there was a failure to report the narrowing of the blood vessels supplying the gut. We found that the decision to discharge C from the gastroenterology service was unreasonable given their ongoing persistent symptoms and, of particular concern, their ongoing weight loss. Therefore, we upheld C’s complaints.

C complained about the standard of medical care and treatment provided by the practice and about the way that they handled C's complaint. C attended the practice with symptoms of rectal bleeding, a change in bowel habit and abdominal pain. The practice made a routine referral to hospital but did not carry out a rectal examination. C was later diagnosed with bowel cancer. C felt that there was an unreasonable delay in diagnosing and treating their cancer. We took independent advice from a GP. We found that C's referral to hospital should have been marked as urgent given their symptoms and a rectal examination undertaken. We also found that information about C’s family history was not recorded correctly. Therefore, we upheld this part of C's complaint. However, we noted that it was unlikely that these failings would have had any impact on the treatment options or outcome for C. C also complained that the practice failed to handle their complaint reasonably. We found that the practice failed to reflect on the failings in their response to C. We upheld this part of C's complaint.

C complained that nursing staff had failed to properly supervise their parent (A) resulting in a fall and that there was a lack of documented information about A's plan of care in the medical records. A was admitted to hospital for hip surgery following a fall at their home. A few weeks later, A fell and hit their head. This led to A sustaining a subdural haematoma (SDH, a brain injury) and A died as a result. C complained that following A’s fall there was a failure to treat A as a priority, and raised concerns that A was transferred from a trauma ward to an orthopaedic ward. C believed that A should have been transferred to another hospital, outwith the board, for surgery. In response, the board said that A’s care pre-fall had been in line with the relevant supervisory assessment. They apologised for a delay in A receiving a medical review following the fall, however, they said that nursing staff had carried out appropriate neurological observations. The board added that A was not considered suitable for surgery by surgeons and that the case had been considered at a local management team review (LMTR). We took independent advice from a consultant specialising in the care of the elderly, and an experienced nurse. We found that the documentation in A’s nursing records did not evidence that the care and interventions A received to keep them safe from harm and to support their mobility were to the standard required to prevent A falling. Additionally, we found that there were failings in relation to A’s neurological observations with a lack of proper assessment, implementation and evaluation and gaps in recording. We considered that while these measures may not have ultimately prevented A’s fall, there was unreasonable care and as such we upheld C’s complaint. We found that A’s post-fall care fell well below a reasonable level and did not meet the standards described in the board’s head injury protocol and the relevant NICE guidance for the management of head injuries.

C was Power of Attorney (POA) for the patient (A). C complained about the care and treatment that A received in hospital. A suffered two falls, resulting in five fractured ribs. A also acquired pressure sores, contracted pneumonia and died shortly after discharge. C that they were not timeously informed of the falls or A’s deteriorating health. C also complained about the board's handling of their complaint. The board advised that A was assessed by a doctor after both falls and pain medication was increased. Due to ongoing pain, x-rays and a CT scan were taken weeks later which showed the injury. The board advised that treatment would have been the same if they had known of the injury earlier. The board also noted that they had increased care rounding following the falls and provided a pressure relieving mattress. They acknowledged that on some occasions care rounding had been delayed due to clinical pressures. The board apologised that A had developed pressure sores and that they had not communicated effectively with C. They advised that staff had been reminded of falls guidance, pressure ulcer guidance and to contact POAs and next of kin. We took independent advice from a nurse. We found that the board had not regularly evaluated the risk of falls before A fell and did not appropriately review A after their falls. We found that they had not sufficiently managed the risk of pressure ulcers and did not appropriately manage the pressure ulcers once they had developed. We also considered that POA documentation was not correctly filled in on admission and that C had not been appropriately updated regarding important health matters or A’s falls. We found that the complaint response had taken too long, that C had not been regularly updated and that the complaint investigation could have been more thorough. We upheld all aspects of C's complaint.

C complained that the practice failed to handle their telephone call reasonably. C called the practice while being discharged from hospital to speak to a GP about an urgent review of their GP prescribed medication. In particular, regarding the safe discontinuation of pregabalin (an anti-epileptic drug that can also be used to treat nerve pain and anxiety) following surgery. We found that the call did not address C’s concern that C needed advice about how to safely discontinue GP prescribed medication. C was also not told that further fit notes could be accessed by requesting one through the practice website or that they needed to wait until they had received a discharge letter so that the pharmacy team and the GP had the correct information. C was not informed that they could call for a same day triage appointment on their discharge from hospital. Although C was offered a routine appointment which is consistent with the practice’s policy on GP access, C was not given the chance to say whether they wanted to accept this before the call was terminated by the practice. We found that no offer was made to send a message to a GP informing them of the problem, to be actioned by the GP as and when appropriate. No explanation was provided to C about why their request to speak to the Practice Manager was refused and no consideration was given to requesting someone else (such as the Team Leader) to call C back. Therefore, we upheld this part of C’s complaint. C also complained that the practice failed to handle their complaint reasonably. We found that the complaint response did not address all the issues that C raised. The response also made statements about what C was told that were not supported by the recording of the telephone call to the reception team. We upheld this part of C’s complaint.

C complained about the care and treatment given to their partner (A) while in hospital, which they believe led to A's death. In response to the complaint, the board acknowledged and apologised that communication with C had not been effective. However, A had been aware of the severity of their diagnosis and prognosis and was able to make their own decisions and all communication had been with them. We took independent advice from a consultant in acute and general medicine. We found that, while significant parts of A’s care and treatment had been reasonable, there was a delay in the diagnosis and initiation of cancer treatment. In terms of the Scottish referral guidelines for suspected cancer, patients referred via the urgent suspected cancer pathway should receive their first treatment within 62 days of receipt of the referral, which did not happen in this case. We also found that there were unacceptable delays in relation to acting upon the results of the PET scan and a delay in A’s subsequent diagnosis. In addition, we found that at the time of A’s death a morbidity and mortality meeting (M&M) had not taken place. However, the board confirmed that a new M&M process had been implemented so that all deaths were reviewed through this process. We upheld the complaint. During our investigation, we identified issues with the board’s handling of the complaint. We made a recommendation to the board to support improvement of their complaint handling.

C complained about the nursing and medical care and treatment provided to their parent (A) when A was in hospital following a hip fracture. A had surgery for the fracture but was diagnosed with a number of illnesses while in hospital and died. We took independent advice from a nursing adviser and consultant geriatrician (specialist in medicine of the elderly). In relation to nursing care, we found failings with A's nutrition, pressure care, person centred care planning, and documentation. We upheld this part of C's complaint. In relation to medical care and treatment, we generally found this to have been reasonable and did not uphold this part of C’s complaint. However, we provided feedback to the board regarding starting oral nutrition supplements in line with Scottish Hip Fracture Guidance. Finally, we found that there were delays in the handling of C's complaint and the board failed to fully address of all C's concerns. The board had acknowledged these failings and taken action to address them. Therefore, we upheld this part of C's complaint but made no further recommendations in this regard.

C complained on behalf of their elderly parent (A). A had a known history of high blood pressure and white coat syndrome (when a patient’s blood pressure rises in response to a stressful situation, such as, a doctor’s appointment or visit to the hospital). A had been prescribed a combination of two diuretic medications (types of drug that cause the kidneys to make more urine) to treat this. During an appointment with a locum GP, it was noted that A’s blood pressure was high so they prescribed a third diuretic medication. A became unwell and attended the practice a few days later. They were then admitted to hospital and diagnosed with hyponatraemia (a lower than normal level of sodium in the blood). C was concerned that the practice prescribed an unnecessary third diuretic that led to A’s admission to hospital and that they did not perform checks on A’s bloods before prescribing this medication. The practice said that the medications were safe to be prescribed together with close blood monitoring. They explained that they have a system in place to monitor patients who are prescribed ‘triple whammy’ drugs (a combination of drugs of different types: non-steriodal inflammatories, diuretic, and ACE inhibitors). They also highlighted that they took bloods during the consultation before A’s admission to hospital. We took independent advice from a GP. We found that the decision to prescribe the third diuretic was unreasonable and unsafe. The consultation that took place before the admission to hospital was reasonable and bloods were gathered. However, the practice’s procedure to monitor triple whammy drugs does not apply in this case as A was prescribed three diuretics and none of the other drug types. Therefore, A’s case would not be picked up by this monitoring programme. We found that the practice should have carried out a Significant Adverse Event Review and did not acknowledge any failings in their complaint response. Therefore, we upheld C’s complaint.

C complained about the care and treatment provided to their parent (A) over two admissions to hospital. A attended the emergency department following a fall at home and was treated with painkillers for a pain in their neck. They were admitted to the ward for further monitoring of their fast and irregular heartbeat. A was reviewed the next morning and discharged that day. However, A returned to hospital later that day after another fall. A was reviewed and admitted to the ward where they were later diagnosed with a fracture of a bone in their neck. C complained that the board failed to diagnose the fracture on the first admission to hospital and about the decision to discharge A. In response to the complaint, the board did not identify any failings with respect to assessment of A, but acknowledged that the communication of their diagnosis and discharge could have been better. With respect to the second admission, the board explained that symptoms of neck fracture are not straight forward and the examinations carried out within the emergency department were appropriate. C was dissatisfied with the response and brought their complaint to our office. We took independent advice from an emergency medicine consultant and a consultant geriatrician (specialist in medicine of the elderly). In relation to A’s first admission, we found that the initial assessment of A’s condition in the emergency department was reasonable, although there was a missed opportunity for further assessment before A went to the ward. However, the examination and assessment of A’s neck pain on the ward was unreasonable, as was the assessment of A’s suitability for discharge, given the failure to properly assess A’s neck injury, mobility, and cognitive function. We found that the board failed to provide A with appropriate care and treatment during their first admission and upheld this part of C's complaint. In relation to A's second admission, we found that A’s neurological examination did not include

C complained about a mis-diagnosis of their parent (A) at hospital. C noted that A was diagnosed with pancreatitis (inflammation of the pancreas) during their first admission. A CT scan was taken to confirm this diagnosis. During a later second admission, blood tests and an ultrasound were taken but no CT scan was taken and pancreatitis was again confirmed. A then attended a different hospital while away. A CT scan was taken and A was diagnosed with late stage pancreatic cancer and died shortly after. C complained that the pancreatic cancer had not been diagnosed at the original hospital. The board explained that the original scans confirmed pancreatitis and showed an abnormality which increased the risk of it recurring. During A's second admission, blood tests confirmed acute pancreatitis and there were no clinical signs to indicate that a further CT scan should be arranged. We took independent advice from a gastroenterology (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas) adviser. We found that the care and treatment was appropriate throughout the period and that there was no reason to suspect pancreatic cancer. In their second admission, A’s presentation was consistent with an attack of mild acute pancreatitis and immediate further CT scanning was not indicated at this time. As such the complaint was not upheld. Related reading View Decision Report 202300640 as a PDF (24.43 KB) Updated: February 21, 2024

C complained about the care and treatment provided to their late spouse (A). A had a history of Parkinson’s Disease (a condition in which parts of the brain become progressively damaged over many years), dementia and cerebrovascular disease (a range of conditions that affect the flow of blood through the brain). A was admitted to hospital with a suspected urinary tract infection but their condition deteriorated and they died a few months later. C complained that the board failed to provide A with appropriate nutrition and hydration in the first few weeks following admission, that staff had not treated A with dignity and ascribed A’s symptoms to their pre-existing conditions rather than treating individual needs. C also complained about the personal care provided to A, particularly with respect to management of their skin during admission. The board considered that they provided A with reasonable care and treatment but acknowledged and apologised for a delay in inserting an nasogastric tube (NG tube, a tube that carries food and medicine to the stomach through the nose). We took independent advice from a consultant geriatrician (specialists in care of the elderly) and a registered nurse with experience in tissue viability care. We found that the management of A’s hydration was reasonable. However, there was a period of up to two weeks where A was Nil by Mouth without any other arrangements in place to ensure their nutritional needs were being met. We also found that staff were aware of A’s Parkinson’s Disease and it remained a priority during their admission. However, whilst specialist advice was sought, there was only limited input from relevant specialists and we found it unreasonable that there was not more direct involvement from relevant specialities. We also found that there was a failure to document the reasons for the provision of different medication and changes in delivery method. In relation to wound management, we considered that there were gaps between w

C’s parent (A) was receiving palliative chemotherapy, following a diagnosis of terminal cancer, which was suspended as the COVID-19 pandemic worsened. A was admitted to hospital following a prolonged period of vomiting that had not responded to treatment. A remained in the hospital for several weeks before passing away. C raised complaints with the board detailing C’s family’s concerns about A’s cancer diagnosis, decisions about A’s chemotherapy, aspects of the care and treatment of A, and communication with C and their family during A’s hospital admission. The board’s responses indicated that they considered A’s care and treatment had been reasonable overall, but accepted that there had been some aspects that could have been improved. They accepted that there were aspects of their communication that could have been improved, particularly that they should have contacted A’s next of kin when A’s condition deteriorated over a particular night. C was dissatisfied with the board’s responses and brought their complaint to us. We took independent advice from a specialist in palliative care. We found that A’s treatment had been reasonable overall and that while there were certain aspects of A’s care that could have been improved, overall the board provided reasonable care to A. In relation to the aspects of the complaint about the board’s failure to contact A’s next of kin when A’s condition deteriorated over a particular night and about the board’s responses to C’s complaints, we upheld these aspects of the complaint. In relation to the board’s handling of C’s complaints, we found that there were delays in responding, failure to address various clearly raised issues in responses, unreasonable action around the arrangement of a promised meeting within a reasonable timescale and the inclusion of statements that were not supported by evidence. We upheld these aspects of the complaint.

C complained that the practice failed to provide them with reasonable care and treatment. C suffered from inflammatory conditions of the skin and joints and was under the care of rheumatology (specialists in the diagnosis and management of chronic inflammatory conditions such as rheumatoid arthritis), dermatology (specialists in the in the diagnosis and treatment of skin disorders) and the practice. C was being prescribed an immunosuppressant and the practice was in a shared care agreement with the NHS board for monitoring bloods in regards to the prescription. C required a liver transplant due to liver cirrhosis induced by the treatment. C complained that the practice had not properly monitored their bloods, had not picked up on warning signs and had not communicated appropriately with the relevant specialists or with C. C noted that they had also been incorrectly prescribed an antibiotic containing penicillin. We took independent advice from a GP. We found that the practice had monitored bloods appropriately, and where there were gaps in monitoring, C's attendance had been requested. We also found that the practice had sought specialist advice and followed NICE guidelines appropriately. We noted that the practice had verbally apologised for the penicillin mistake. Therefore, we did not uphold this part of C's complaint but fed back to the practice that it would be appropriate to apologise in writing. C also complained that they were immediately removed from the practice register after making a comment on social media expressing concerns about their treatment. C noted that they were given no warning and that their poor health, vulnerability and their requirement for continuity of care were not taken into account. We found that the practice had not followed guidelines in respect of removing the patient from the register, without warning. Therefore, we upheld this part of C's complaint.

C complained that the board failed to provide reasonable care and treatment to their late parent (A). A was admitted and discharged from hospital on two separate occasions. A died shortly after their third admission to hospital. We took independent advice from a consultant in geriatric medicine and general medicine (a specialist in care of the elderly). We found that while some aspects of A’s care were reasonable, particularly in relation to cardiac (heart) care, given the complexity and combination of A’s conditions, age and frailty, A should not have been discharged the day after their first admission. A should have remained in hospital given that a deterioration in their condition was very likely to occur, and as they also required further detailed assessment of their mobility. It was determined that A’s combination of problems would have required inpatient care even for a previously healthy patient and the acute exacerbation of A’s conditions would have been profound and life threatening. We also found that there was a lack of detailed assessment of A’s mobility difficulties prior to being discharged. We found that the board failed to take account of the evidence in A’s records that they had struggled with their mobility and had needed supervision and support. We noted that an assessment of A’s mobility had been part of the medical plan at the time of their first admission. Given the severity of A’s illness, age, and the difficulty with walking, there should have been a specific and detailed assessment of A’s mobility prior to their discharge. We also found that the board failed to provide a full response to C’s complaint. Taking account of the evidence and the advice we received, we upheld C's complaint.

C had a history of multiple facial trauma and had undergone various procedures over the last decade in relation to their nose and face. C then received further injury which caused damage to their nose. C complained that the board refused to perform any further investigations or the reconstructive surgery they considered was required. This was despite numerous GP referrals to the ear, nose and throat (ENT) department. C stated that they continued to suffer ongoing pain and symptoms associated with their facial injuries. C complained that the board were acting on the basis of a psychological assessment from a number of years ago, which suggested investigation and treatment could be damaging to C. C strongly objected to the content of this assessment. We took independent advice from an ENT surgeon. We found that it was reasonable for the board to take into consideration the psychiatric assessment that warned against unnecessary investigations and treatment unless indicated on objective grounds. However, we considered that given the passage of time since that document was produced, and because C had recently been assaulted potentially causing new injury, it was reasonable for C to be reassessed. Therefore, we upheld C's complaint. We also noted failings in relation to complaint handling and made a recommendation to address this.

C complained about the care and treatment provided to their spouse (A) when they became unwell with severe lower abdominal pain and vomiting. A was visited and examined by an out-of-hours (OOH) GP, who administered an injection for vomiting and left some medication for A. A's condition worsened and a different OOH GP attended the same evening. A was taken to hospital by ambulance and was found to have a perforated bowel (hole in the large intestine) and kidney failure. Medical intervention was not considered appropriate and A's care was redirected to palliative care. A died in hospital two days later. C complained that the first OOH GP missed important aspects of A's condition during their home visit. C further complained that when A was admitted to hospital, A was left in pain and discomfort for many hours and it was only when C raised concerns that A was given stronger pain relief. We took independent advice from a GP adviser, as well as a registered nurse and a general physician in acute medicine. We found that overall, the assessment and examination carried out by the first OOH GP was reasonable and appropriate. It was determined that there was nothing suggestive of an acute abdomen (sudden, severe abdominal pain) which would have necessitated admission to hospital. We did not uphold this aspect of C's complaint. C also complained that A was given unreasonable care and treatment in the hospital, in relation to managing A's pain. We considered that overall, the approach to A's pain management by nursing staff was reasonable. Nursing staff identified A's level of pain from first admission and throughout and took appropriate action to try and address this. However, we found that given the very high doses of morphine administered, medical staff should have checked the medication prescribed to see if it was working, and review or prescribe something else. Furthermore, given that the medical team would have been aware that A was on the ward round for comfor

C complained to the board about the treatment provided to their late relative (A) who died of a ruptured bowel. A had been in University Hospital Ayr two weeks previously with symptoms of severe pain. Staff had carried out tests and a scan, and discharged A home without follow-up. C believed that the board should have carried out more intensive investigations, which may have discovered A was still having bowel problems and provided additional treatment. The board believed that appropriate treatment had been provided. We took independent advice from a consultant in acute medicine (a specialist in the immediate and early management of adult patients with a wide range of medical conditions who present in hospital as emergencies) and a consultant radiologist (a specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that staff at the hospital provided a reasonable standard of treatment based on A's reported symptoms. We also found that it was not unreasonable to discharge A home with antibiotics based on the diagnosis of pyelonephritis (kidney infection) following a CT scan. Although a subsequent CT scan carried out on readmission showed evidence of infarct (a small localised area of dead tissue resulting from failure of blood supply) which might have been evident on the original scan, it was not unreasonable to have diagnosed pyelonephritis following the original scan. We therefore did not uphold the complaint. Related reading View Decision Report 202102504 as a PDF (24.5 KB) Updated: July 20, 2022

C complained to the board about an incident during which they were restrained by staff to receive emergency treatment when they experienced a life-threatening complication of their health condition. At the time, C was being detained under a Compulsory Treatment Order by the board when the complication arose necessitating their transfer to the acute hospital site for further treatment. C complained about several aspects of this episode including the conduct of the staff when restraining them, the failure by the board to contact or seek appropriate consent for the treatment from their court appointed welfare guardians, failure to maintain their privacy and dignity, and failure to tend to their comfort or basic hygiene needs. C also complained about the board’s suggestion that a pattern was emerging of them making unfounded complaints due to them previously complaining about a separate episode of care. We sought independent advice from a senior mental health nurse on the care and treatment provided by the board to C. We found that C's treatment was of a reasonable standard. We noted that the emergency nature of C's condition allowed treatment without their guardians’ consent, and the steps taken to ensure their privacy, dignity and comfort had been reasonable in the circumstances. On considering the conduct of staff during the episode of care, the likelihood of having to restrain C for treatment had been anticipated in advance and plans were made to do so in line with board-approved techniques. We did not uphold this aspect of C's complaint. In respect of the board suggesting that there was a pattern emerging of C making unfounded complaints, we referred to the rights of patients outlined within The Patient Rights (Scotland) Act 2011 and the Charter of Patient Rights and Responsibilities. As this legislation ensures the rights of patients to complain or give feedback about their healthcare encounters, we considered the board's response to C to be unreasonable and

C complained about the treatment a family member (A) had received from the board. A was admitted to hospital three times over a short period with severe stomach and back pain. Following A's third admission, they were diagnosed with kidney failure and discharged to receive palliative care. A died a short time later. C complained that the board had missed opportunities during A's earlier admissions to identify their deteriorating kidney function. C said that an earlier diagnosis could have prolonged A's life expectancy as treatment could have commenced sooner. C also complained that on A's second admission, their discharge had been unreasonably managed by the board. C complained that A was left all day in the discharge lounge in their nightwear and that staff failed to properly communicate A's discharge arrangements to the family. A was later returned to their nursing home in a taxi instead of an ambulance. C said that this was extremely distressing and undignified for A, and had been unacceptable given A's age and poor health. We took independent clinical advice from a consultant geriatrician (a specialist in the care of the elderly). Whilst there had been a reasonable approach to investigating A's symptoms on their first admission, we found that there were missed opportunities by the board to diagnose A's kidney failure and infection, and the family's concerns had not been given appropriate consideration during the second admission. On the third admission, there was a delay in the clinical consideration of A's abnormal blood results, and in recognising the severity of their condition. We also noted from the board's own investigations that there had been a failure to move A's personal belongings between wards. Therefore on balance, we upheld this aspect of the complaint. We also found that A was not clinically fit to be discharged from hospital following their second admission, and given their age, fragility and poor health, that their discharge arrangeme

C complained to the practice about the lack of treatment when they attended two consultations reporting a breast lump. C felt that the GPs they saw gave them false reassurance that there was nothing to worry about. C then attended the hospital specialists for an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body), biopsy (tissue sample) and mammogram (an x-ray of the breast) and received results which showed evidence of a cancerous lump which required chemotherapy (a treatment where medicine is used to kill cancerous cells) and surgery. We took independent advice from a GP. We found that the GPs involved carried out appropriate examinations and that it was appropriate to refer C to the hospital specialists for further examination. We did not uphold the complaint although some feedback was provided to the practice in an effort to improve learning. Related reading View Decision Report 202009052 as a PDF (24.2 KB) Updated: April 20, 2022

C complained to us on behalf of their child (A) about the care and treatment A received from child and adolescent mental health services (CAMHS). Specifically, C complained that A was unreasonably discharged from CAMHS. We took independent advice from a child and adolescent psychologist and also from a mental health nurse. We found that there was a delay in CAMHS offering A video appointments following the COVID-19 lockdown but we found that the delay was not unreasonable, as they needed time to set up the necessary IT systems. We also found that all relevant information was taken into account about A's condition before CAMHS decided to discharge A. Therefore, we did not uphold the complaint. Related reading View Decision Report 202005289 as a PDF (24.04 KB) Updated: April 20, 2022

C complained that the practice failed to provide appropriate care and treatment to their late child (A). A had a lump removed from their eye lid which was subsequently diagnosed to be cancerous. A went to see their doctor with severe pain in their left arm, which moved to their right arm and neck. A was prescribed painkillers and referred to physiotherapy. A returned from a family holiday and, still suffering from severe pain which had worsened, saw another doctor. A's painkillers were changed and they were referred to physiotherapy. After a further consultation, A was referred for an x-ray which identified that A's C6 vertebrae had collapsed and that there was a cancerous tumour. A died a few months later. C complained that doctors at the practice failed to respond to A's symptoms in a reasonable manner given A's history of cancer. C complained that it took A to attend the practice on a number of occasions before appropriate treatment/investigations were undertaken. C believed that had doctors taken account of A's previous history, A would have received appropriate treatment sooner. A considered that the practice failed to investigate and respond to their complaint appropriately. We took independent advice from a medical adviser. We found that the practice's consultations with C were reasonable. There was no unreasonable delay in the decision to refer C for an x-ray. We did not uphold this aspect of the complaint. With respect to the complaints handling, we found that there was a misapprehension on the practice's part about the handling of the complaint which resulted in a failure to communicate with C in accordance with their complaints handling procedure. However, the practice had investigated the complaint and provided an accurate and detailed response within a reasonable timeframe and, on balance we did not uphold this aspect of the complaint. We provided feedback to the practice on their obligations with respect to complaints handling. Related re

C complained that the practice did not take reasonable action in response to their late spouse (A)'s symptoms and condition. A had a long history of degenerative disc disease affecting their spine (when normal changes that take place in the discs of your spine cause pain) and a history of stomach cancer. A visited or contacted the practice several times over three months regarding pain in the neck and shoulder, numbness in the right hand and jerking of the right leg. Tests were undertaken, medication and therapies prescribed and a referral to an orthopaedic specialist (a specialist in the treatment of diseases and injuries of the musculoskeletal system) was made. Following a fall at home, A was admitted to hospital where a spread of cancer to A's spine was diagnosed. A died shortly after C submitted a complaint to the practice about their response to A's symptoms and condition over the previous few months. In response, the practice recounted the actions they had taken in response to A's visits and contacts in their final months, highlighted blood tests whose results did not indicate any significant abnormality or spread of cancer and explained that A's symptoms were relatable to their ongoing diagnosis of degenerative cervical disc and spinal stenosis (a condition where the space around the spinal cord narrows, compressing a section of nerve tissue). The practice advised that a significant case review had been carried out. This had highlighted that A's orthopaedic referral could have been upgraded to urgent when it was clear A's symptoms were not being controlled, but stated that it was doubtful this would have had any impact on the outcome. C was unhappy with this response and brought their complaint to this office. We took independent advice from a GP. We found that the practice took reasonable action in response to A's symptoms and condition until a point. However, when it was clear that A's symptoms were not being controlled and began to worsen, the pr