SPSO Individual Decisions

C complained that the board failed to reasonably communicate with them about the care and treatment of their parent (A). C said that the board failed to inform them that a lump had been found on A’s breast while A was in hospital. A had been due to go into respite care in a care home but this was delayed. When staff found the lump on A’s breast, A told staff that they did not want it to be treated. This was communicated to A’s GP and respite care home but was not communicated to C. C subsequently learned of the breast lump when A was admitted to another hospital in another board area. We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). With regard to the breast lump, we found that an appropriate hand-over was made to the GP for follow-up in the circumstances. In a non-emergency situation, it was reasonable to take time to establish capacity and consent before informing family. Due to time constraints before A’s transfer, this was not fully explored, but the handover was deemed appropriate under the circumstances. Therefore, we did not uphold the complaint. However, we provided feedback to the board about the need for early assessments of decision-making capacity, re-assessment during admission, and improved engagement with family members where appropriate. We also provided complaints handling feedback. Related reading View Decision Report 202304648 as a PDF (24.51 KB) Updated: February 18, 2026

C complained about the care and treatment the board provided to their late spouse (A). A had a history of heart failure and severe left ventricular systolic dysfunction (LVSD, a severely weakened function in heart pumping) as well as other chronic health conditions. C complained about the cardiac (heart) care and treatment that A received prior to their death from cardiac failure. We took independent advice from a consultant cardiologist. We found that clinical aspects of A’s care were reasonable; however, the board’s communication was unreasonable in relation to a prescription for A’s heart medication, an echocardiogram (an image of the heart) and a possible referral to a specialist heart failure service. We upheld this part of C’s complaint on the basis of unreasonable communication. C also complained about how the board handled their complaint.We found that the board’s handling of the complaint was reasonable. We did not uphold this part of C’s complaint.

C complained about the medical care provided to their late parent (A) by the board when they were admitted to hospital. We took independent advice from a consultant in emergency medicine. We found that there should have been better communication between the medical, nursing, and other allied health professional staff in relation to bruising found on A. We found that medical staff failed to take note of the physiotherapy findings of bruising and to document the presence of any significant injury. We also found that medical staff should have prescribed a second antibiotic at the time of A’s admission, that an assessment using arterial blood gas analysis should have been carried out before A’s transfer to the critical care unit and that the mental health team failed to assess A’s delirium, or prompt medical staff to consider this. Finally, we noted that the cause(s) of A’s death should have been recorded in more detail on the death certificate. Therefore, we upheld this part of C's complaint. C also complained about the nursing care that the board provided to A. We took independent advice from a nurse. We found that nursing records, in particular, risk assessment and care planning documents, were not always completed to the required standard or frequency. We also found that A did not receive a reasonable standard of person centred care in relation to their fluid intake and nutritional support and there was poor and inadequate support provided to assist A with their personal hygiene. Nursing staff should also have identified earlier the bruising on A’s body and ensure A had timely access to their medications.Therefore, we upheld this part of C's complaint.

C’s adult child (A) had been referred to the board's Community Mental Health Team (CMHT). A had some contact with both psychiatry and psychology services over the next few weeks. A later died. The board commissioned a Significant Adverse Event Review (SAER) into the care provided to A. In the SAER it was concluded that, following an initial face-to-face assessment by Community Psychiatric Nurses (CPNs), a further face-to-face consultation should have been arranged and that not doing so compromised the care provided to A. C complained to the board about the care and treatment provided to A, and communication during the SAER process. We took independent advice from a psychiatry adviser. We found that the SAER conclusion regarding face-to-face consultation of A was reasonable. We also found that no evidence of a contemporaneous record of the examination carried out by a consultant psychiatrist had been provided and that the record that had been provided does not indicate a comprehensive Mental State Examination (MSE) was undertaken at this time. We found that this was unreasonable given the other evidence available of A’s presentation at this time. Given this, and the conclusion of the SAER that the care and treatment of A had been compromised, we upheld C’s complaint about the care and treatment provided to A. C’s concerns about the SAER process originated in the delays and lack of communication throughout the process, and the failure to provide a final copy of the SAER. We found that the SAER in itself was reasonably thorough but are concerned that no contemporaneous record of the MSE was identified by the SAER. We found that the extended timescale for completion of the SAER and the board’s communication with A’s family, which did not include regular or on-going communication and was subject to a lack of clarity around the status of the SAER report that continued for a period of years, was unreasonable. We also considered that during the SAER process, A's family were

C complained about the care and treatment provided to their late spouse (A). C complained that A had an infected toe which remained unresolved despite undergoing several months of treatment. A was diagnosed with oesophageal cancer but was unable to start chemotherapy treatment because of the ongoing infection. C said that A experienced significant pain during this time and that there was a failure to reasonably coordinate A’s care needs. We took independent advice from a consultant orthopaedic surgeon (specialist in treatment of diseases and injuries of the musculoskeletal system) and a consultant clinical oncologist (specialist in the diagnosis and treatment of cancer). We found that the board had provided reasonable care and treatment to A over several admissions when each one was considered in isolation. However, on one occasion, we found that an MRI scan result was not correctly reported at the time. This resulted in A receiving lesser surgery than they would otherwise have received. We also found that the board had failed to report the incident in line with Duty of Candour legislation, or undertake an internal review process to learn from the event. We found that a more coordinated approach to A’s care may have provided a proper overview of their care needs (including pain) which were known to be complex given the number of specialties involved in A’s care. Therefore, we upheld this part of C’s complaint. C complained that the board’s handling of their complaint was unreasonable. We found that the board kept C reasonably informed of delays.However, they did not accurately describe the failing with the MRI scan or acknowledge the impact this had on A’s surgery and treatment plan. There was also a failure during the complaint process to initiate relevant reporting and investigation processes in relation to the MRI scan reporting when this became known. Therefore, we upheld this part of C’s complaint.

C complained about the medical and nursing care and treatment provided to their late parent (A). A was admitted to hospital after repeated falls at home. A’s behaviour changed significantly during their admission which suggested that their mental state was deteriorating. C said that they were not directly informed of this, and that A was not referred to the mental health team. A had also been refusing to eat and began to vomit blood. C was not contacted at this point, and was not informed of A’s deterioration until later that day. We took independent advice from a registered nurse and a consultant geriatrician (specialist in medicine of the elderly). We found that A had been prescribed medication, which combined with existing health conditions, should have required additional medication to protect their stomach. This was exacerbated by A’s refusal to eat. We found that nursing records of A’s nutritional intake were not completed. Additionally, A’s mental state was not properly assessed. We also found that the board had told C that they would make a change to improve the electronic prescription system. However, this change was not possible and the board had not informed C of this. We considered that A’s nursing and medical care fell below a reasonable standard and upheld these parts of C’s complaints. C also complained about the board’s complaint handling. We found that the board’s response to C was inaccurate. Therefore, we upheld this part of C’s complaint.

C complained about the actions of the board when carrying out a post-mortem examination of their adult child (A). C said that the board had failed to secure A’s admission blood samples, resulting in them being lost. C also believed that the board had failed to carry out the post-mortem properly, as no further blood samples had been taken. We found that A’s admission blood samples had been collected by Police Scotland and taken to another board for tests. There was no audit trail of paperwork other than the police statement of their actions. Once Police Scotland had collected the samples they ceased to be the responsibility of the board. While the board are not responsible for the misplacement of A’s admission blood samples, they should have ensured the samples were signed for and copies of the paperwork retained. Therefore, we upheld this part of C's complaint. The board had already apologised for this failing and taken appropriate action so we did not make any further recommendations In relation to the post-mortem, we found that the pathologist had followed the appropriate guidance. This recognised that admission samples were always preferable to post-mortem samples and at the time the post-mortem was carried out, there was no reason to suppose the admission samples were lost. Therefore, we did not uphold this part of C's complaint. C also complained about the board's communication. We found that the board's communication with C was reasonable. Therefore, we did not uphold this part of C's complaint. Related reading View Decision Report 202200046 as a PDF (24.45 KB) Updated: March 20, 2024

C complained about their adult child's (A) treatment in the months prior to their death. A completed suicide soon after they had been assessed by nurses from the Crisis Assessment and Treatment Service (CATS) and Specialist Drug and Alcohol Service (SDAS). C complained that the risk to A’s life wasn’t properly assessed, and that the family weren’t appropriately involved. C also complained that board staff failed to take follow-up action when A had communicated suicidal thoughts in previous months, and that there was no follow-up plan in place following discharge from a hospital admission. We took independent advice from a mental health nurse and a psychiatrist. We found that the assessment prior to A’s death did not explain how it was concluded that there was no immediate risk when A was exhibiting a number of risk factors. There was no evidence of these risk factors being effectively weighed against protective factors, and no evidence of hospital admission having been considered and ruled out. There was also no evidence of C and A's sibling (B) having been appropriately involved in the assessment. We found that the post-assessment care plan was not sufficiently robust, and that the notes were not clear as to the level of the family’s agreement with this. B contacted CATS out of hours service post-assessment to express concern about A and complained that no help was provided. We found that there was an unreasonable failure to arrange a follow-up telephone consultation. With regards to a lack of follow-up further to A’s previous report of suicidal thoughts, the board said that they could find no record of this having been reported to them. We found that there was evidence in the GP record of the GP having contacted SDAS about this. We found that there was a failure to record or act upon this communication from the GP. It was noted that this may not have had a material impact on the eventual outcome, as A was later admitted for assessment and stabilisation, though, we

C complained about the care and treatment that they received from the board for their right sided hearing loss. They complained that they had been misdiagnosed and wrongly advised that a hearing aid would improve their situation, and that no surgery would help them. C later accepted a second opinion and was referred to a hospital outwith the board area where they received a different diagnosis and treatment (a bone anchored hearing aid) which they said improved their quality of life. We took independent advice from an ear, nose and throat consultant. We found that C’s audiogram (hearing test results graph) had been unreasonably misinterpreted and C was misdiagnosed. We found that the treatment that was given (a standard hearing aid) was not suitable for C’s actual condition. We found that C should have been offered a Crosaid (a device worn behind the ear which routes sound from the affected ear to the unaffected ear), or the surgical option (a bone anchored hearing aid) which was eventually provided when C obtained a second opinion. We also considered that C was not provided with reasonable advice regarding the use of a hearing aid, that there was a failure to take a careful history for C and pick up on the clues in the referral letter from C’s GP as to the nature of the onset of C’s hearing loss, and a failure to arrange appropriate investigations for C. We also found that there had been failures in the way in which the board had communicated with C about their hearing loss, and we were critical of the way the board investigated and responded to C’s complaint. We therefore upheld the complaint.

C complained about the care and treatment provided by the board to their parent (A), who was admitted to hospital with severe back pain after suffering a suspected fall and later diagnosed with osteoporosis (a condition that affects the bones, causing become fragile and more likely to break). C complained about the physiotherapy and occupational therapy assessments carried out during A's admission, the communication by staff and a lack of recognition of A's cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember). C also complained about the lack of written information about osteoporosis/fragility fractures and how they should be managed after A's discharge, and A's follow up care, in particular, the failure to carry out a DEXA scan (a special type of x-ray that measures the density of bones). In order to investigate C's complaint, we took independent advice from a trauma and orthopaedics (conditions involving the musculoskeletal system) adviser. We found that it was reasonable, in light of cognitive assessments undertaken by A, for staff to have taken the information A provided at face value. It was also reasonable in light of current practice and guidance for the board not to have provided A with written information about the management of osteoporosis upon discharge. We also found that the decision not to offer a DEXA scan was appropriate given the diagnosis, and that the appropriate treatment for this type of injury (osteoporosis/fragility fractures) was conservative management and therefore follow up care was not a requirement. However, we identified a number of failings including that the board unreasonably delayed in starting A's osteoporosis treatment and that there were also failings in communication. In view of these specific failings, we upheld the complaint.

C, the parent of A, complained about a delay in diagnosing A's thyroid cancer. A had an emergency admission to Dumfries and Galloway Royal Infirmary with acute tonsillitis and a lump was found on their neck. This lump was subsequently excised four months later, and cancer was diagnosed the following month. C complained that no prior indication had been given that cancer was suspected, and that the delay in diagnosing this led to unnecessary operations. They also complained about a subsequent delay in informing them about identified nodules on A's lung that were being monitored. The board told us that they recognised that an earlier biopsy could have led directly to definitive surgery, without the need for further investigations or procedures and ultimately to a quicker resolution for A. They confirmed that they developed a new neck lump clinic as a result of this complaint. We took independent advice from a head and neck surgeon. We noted that A should have had an urgent needle biopsy at an earlier point in time. This would have led to an earlier diagnosis and less surgery. We noted that an excision should only have been considered if a diagnosis was not possible from the needle biopsy. Therefore, we upheld the complaint that there was an unreasonable delay in diagnosing A's cancer. We considered that the new neck lump clinic was the best way to avoid this happening again. While we were assured that the delay did not have an impact on A's prognosis, we noted that it will have added to the distress for A and the family. In relation to C's concerns about not being advised sooner that cancer was suspected, we noted that cancer did not appear to have been considered earlier. We were, therefore, unable to conclude that there was a failure to communicate a suspicion of cancer. We noted that the board had already acknowledged that they did not make A aware of the lung nodules when they were identified. Therefore, on balance, we upheld the complaint that comm

C complained that their late parent (A) was allowed to discharge themselves against medical advice. C considered that A was not fit to make this decision and that A's mental capacity had not been appropriately assessed. We took independent advice from a consultant geriatrician (a specialty that focuses on the health care of elderly people). We found that no formal assessment of A's capacity was carried out when they were noted to be agitated, confused or not-orientated during their admission. We found that a senior doctor did not review A's decision-making capacity at the time that A expressed the wish to discharge themselves. Therefore, we upheld C's complaint.

C complained about the care and treatment that they received in Accident & Emergency (A&E) following an accident. In particular, C was concerned that they were not kept in hospital for at least 24 hours following the accident, that they did not receive emergency surgery and that their x-rays were not looked at properly to identify the full extent of their injuries. We took independent advice from an emergency medical adviser and a radiology adviser (analyses images of the body). We found that it was appropriate to manage C's injuries conservatively and that there was not a need for emergency surgery, that it was appropriate to discharge C with a plan for follow-up with the orthopaedic (conditions involving the musculoskeletal system) surgeons and that the A&E staff correctly identified C's injuries from the x-rays. We, therefore, did not uphold C's complaint regarding the care received in A&E. C also complained about the orthopaedic care and treatment that they received. We took independent advice from a consultant orthopaedic surgeon and a radiology adviser. We found that assessments and examinations carried out by the orthopaedic department were reasonable. We, therefore, did not uphold C's complaint in this regard. Related reading View Decision Report 201908291 as a PDF (24.27 KB) Updated: June 23, 2021

Mr C was concerned about the care and treatment that his late wife (Ms A) received at Dumfries and Galloway Royal Infirmary. Mr C complained that his wife was misdiagnosed with pneumonia when she initially attended the Clinical Assessment Unit. We received independent advice from a consultant in acute medicine. We found that the investigations carried out during this attendance were reasonable. We also found it was reasonable to treat Ms A for a suspected infection based on the history, examination and investigations, while arranging a CT scan on an out-patient basis to investigate Ms A's symptoms further. We did not uphold Mr C's complaint regarding this point. Mr C complained about the delay in reporting an x-ray carried out during this attendance at the Clinical Assessment Unit. We took independent advice from a radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found an unreasonable delay in reporting a chest x-ray and we upheld Mr C's complaint in this regard. Ms A was subsequently diagnosed with lung cancer and a few months later was admitted to the hospital with worsening shortness of breath. Mr C complained about the care and treatment that his wife received during this third attendance at the Clinical Assessment Unit. We received independent advice from a consultant in acute medicine. We found that there should have been earlier consideration to administering IV fluids and IV antibiotics to Ms A given that her low blood pressure and high heart rate were indicative of sepsis (blood infection). We upheld Mr C's complaint about the care and treatment provided in the Clinical Assessment Unit on Ms A's third attendance. Mr C also complained about the care and treatment that Ms A received on the respiratory ward at Dumfries and Galloway Royal Infirmary. We took independent advice from a consultant physician in respiratory and general medic

C complained about the care and treatment they received at Dumfries & Galloway Royal Infirmary, after they had fallen and hurt their leg. C raised various concerns about how their injury was diagnosed and their discharge home. We took independent advice from an adviser in emergency medicine. We found C was given appropriate care and treatment in relation to their injury. We also found it was reasonable C was discharged home. Therefore, we did not uphold the complaint. Related reading View Decision Report 201906781 as a PDF (23.92 KB) Updated: May 19, 2021

C complained about the care and treatment their late relative (A) received at Dumfries and Galloway Royal Infirmary. A reported that they did not feel well, had difficulty pronouncing words and were a little confused. A then had a fall at home before being taken to hospital. A was treated for a chest infection but died the next morning. C raised a number of concerns regarding the care that was provided and the staff's attitude towards A and C. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that A's initial assessment was reasonable; they were appropriately examined, their medical history taken and their existing medication noted. However, we noted that an x-ray taken to help with diagnosis showed appearances that were more consistent with heart failure than a chest infection. From the available evidence, it appeared that A was incorrectly diagnosed as having a chest infection, commenced on a suboptimal treatment pathway and left without being monitored effectively overnight. The true nature of A's condition was only identified when the consultant attended the next morning. A died shortly afterwards. Whilst clinically the outcome may not have changed for A, had C had accurate information about their condition, they may have been better placed to support A. We considered that the care and treatment fell below a reasonable standard and upheld C's complaint.

C's spouse (A) received care and treatment from the board for a recurrence of bowel cancer. C complained that the communication and actions by the board in relation to that were unreasonable. C complained that the board failed to provide reasonable treatment to A. We took independent advice from a senior clinical oncologist (a doctor who specialises in the diagnosis and treatment of cancer). We found that the treatment offered to A was reasonable and in line with guidance. We did not uphold the complaint. C complained that the board failed to provide reasonable care to A. We found that the board had acknowledged there were some failings relating to staff responding to care requests and there were challenges when a procedure was undertaken. Overall we found that while there were failings in specific instances, the care provided over the entire period was reasonable. On balance, we did not uphold the complaint. C complained that the board failed to reasonably communicate with A and C in relation to A's diagnosis and the potential risks of treatment. We found, based on the written records available, that the communication was reasonable, noting that the written records could not illustrate the level of empathy exhibited by clinicians. The written records did demonstrate that the risks relating to treatment were discussed. We did not uphold the complaint. Related reading View Decision Report 201908832 as a PDF (24.3 KB) Updated: March 24, 2021

C complained about the care and treatment of their late partner (A) who died from a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs), secondary to a deep vein thrombosis (DVT, a blood clot in a vein). The complaint related to a GP practice run by the board, which A attended feeling unwell. A was given antibiotics for a suspected infection and a sick note for their employer. A phoned the practice the following week, still feeling unwell, and the antibiotic prescription and sick note were extended. A’s condition deteriorated and they died the following day. C complained that the GP dismissed the recent history of A's long-haul travel and symptoms indicative of a DVT and misdiagnosed A with an infection. They considered that there was a failure to follow the National Institute for Health and Care Excellence (NICE) guidelines for assessing the possibility of a DVT. C also complained that arrangements were not made for A to be seen when they called the practice the following week. They considered A was denied appropriate follow-up care. We took independent medical advice from a GP. We found that the recorded symptoms that A presented with were consistent with a diagnosis of infection and not DVT. We considered that the GP’s recorded examination, history and working diagnosis were reasonable at that time. In terms of A’s follow-up phone call to the practice, we were unable to evidence what was said during the call and whether an appointment was requested. We noted that it is common practice for antibiotic prescriptions and sick notes to be extended without seeing the patient, and we considered that the practice’s actions were reasonable based upon the available evidence. We did not uphold C's complaints. Related reading View Decision Report 201908028 as a PDF (24.63 KB) Updated: February 17, 2021

C attended Dumfries and Galloway Royal Infirmary (DGRI) for a colonoscopy (a procedure where a camera on the end of a flexible tube is inserted into the rectum). During this procedure, polyps (tissue growths) were found and biopsies (a sample of tissue) were taken. C was told that a polyp showed possible signs of cancer. A second colonoscopy was carried out and the doctor attempted to remove the polyp, however the procedure was painful and was stopped. C was discharged home the next day. Soon after, C had a bloody bowel movement and went to Galloway Community Hospital where they were then transferred to DGRI. C collapsed and was resuscitated, given a blood transfusion and moved to critical care. C complained that the colonoscopy was not carried out properly, that it was painful and asked whether it should have been done in the first place. C also complained about the decision to transfer them from Galloway Community Hospital to DGRI and about the care they received on arrival at hospital. We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines). We considered that the colonoscopy procedure was required as there was evidence C might have cancer. We noted that pain is subjective and the amount of pain relief given to C may not have been sufficient, although it was the recommended dosage. We found that the procedure appeared to have been carried out appropriately. We also considered that the decision to transfer C from Galloway Community Hospital to DGRI was reasonable. It was possible that C would need surgical intervention which was only available at DGRI. We found that C was promptly assessed and was treated appropriately following their collapse. We did not uphold C's complaints. Related reading View Decision Report 201908284 as a PDF (24.64 KB) Updated: February 17, 2021

C complained about the care and treatment their late partner (A) received during two consecutive admissions to Dumfries and Galloway Royal Infirmary. A had a number of existing medical problems and spent around four weeks in hospital, including 18 days in critical care, before being discharged. C complained that A was inappropriately discharged with pneumonia, and required readmission 12 hours later. A spent almost a further three weeks in hospital before being discharged again, and died two months later. Whilst in hospital, A developed a severe pressure ulcer. C complained that nursing staff failed to take reasonable measures to prevent the pressure ulcer from developing. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that A’s suitability for the first discharge was assessed over a number of days and blood tests and basic observations did not indicate an underlying pneumonia at that time. We considered that it was reasonable for A to be discharged and we did not uphold this aspect of C's complaint. We also took advice from a tissue viability nursing specialist (a nurse who provides advice and care to patients with, or at risk of, developing wounds). We found that, while the risk of pressure damage was identified and care prescribed to mitigate this, this was not adhered to. Risk assessment, skin inspections and repositioning were not carried out as often as required, and the pressure ulcer was initially graded incorrectly. Inappropriate dressings were also used and there was a delay in providing a pressure relieving mattress. We upheld this aspect of C's complaint.

C brought a complaint to us about the care and treatment given to their late parent (A) at Dumfries and Galloway Royal Infirmary. C complained that there was a lack of communication between staff and the family throughout A’s treatment. In particular, they said that the severity of A’s illness was not explained to A or the family. C stated that the family remained unclear about the specifics of the cancer A had, that there had been no reaction to A’s early symptoms and that A was advised about their diagnosis by phone with no offer of support provided. C also complained that the administration of A’s medication was unreasonable; in particular, that there was inadequate pain control and that no one took overall control of A’s care and treatment. During the board’s own investigation of the complaint, they accepted that A should not have been advised of their diagnosis by phone, and an apology had been given for that. The board had also indicated this was an area for reflection and learning. We took independent advice from a consultant hepatologist and gastroenterologist (a doctor who cares for patients with benign or malignant disorders of the gastrointestinal tract, liver, pancreas and gallbladder). We found that while there was some learning for the board in relation to aspects of communication, the overall care and treatment given to A was reasonable. While we did not uphold the complaint, we asked the board to provide evidence of the action taken to ensure alternative methods of communicating a diagnosis to a patient had been considered. Related reading View Decision Report 201902073 as a PDF (24.47 KB) Updated: February 17, 2021

C was admitted to hospital for an elective hernia repair. The procedure was said to have gone well and it was agreed that C could be discharged home. Before leaving hospital, C took a stroke (a serious medical condition that happens when the blood supply to part of the brain is cut off. Strokes are a medical emergency and urgent treatment is essential). In C's case, it was thought they had experienced a reaction to the medications they had been prescribed and it was deemed that they could be discharged from hospital. Once at home, C was reviewed by their GP, who arranged for them to return to hospital for further tests. Those tests confirmed that C had had a stroke prior to being discharged from hospital. We took independent advice from an appropriately qualified clinical adviser. We found that the board failed to document the assessment of C that was undertaken prior to them being allowed to return home. Without that evidence, we were unable to determine whether the assessment of C's symptoms was of a reasonable quality. We reached the view that the board unreasonably failed to diagnose that C had suffered a stroke and upheld the complaint. In addition, we found that the board's response to C's complaint was too brief, and lacked sufficient detail. There was little recognition that a significant diagnostic error had occurred, or the effect this may have had on C. The board's investigation and response did not note or disclose to C that there was no documentation in relation to this aspect of their care. The response also lacked appropriate detail in relation to the relevant discussions held as a result of C raising their complaint. We made recommendations to the board concerning these points.

C complained on behalf of their spouse (A) about the treatment provided to them. A had a history of cancer and attended the practice with urinary symptoms. A was later diagnosed with bowel cancer which had metastasised (spread to other parts of the body). C complained that the practice's response to A's symptoms, and the length of time it took for A's cancer to be diagnosed, were unreasonable. We took independent advice from a GP. We considered that A's symptoms were reasonably investigated, with appropriately prioritised referrals being actioned in a timely manner. A's history of cancer was considered when assessing their symptoms. A's symptoms initially aligned with a benign (non-cancerous) condition. When A's presentation changed, appropriate steps were taken, with further investigation and referrals to secondary care. A's pain was reasonably managed. Therefore, we did not uphold the complaint. Related reading View Decision Report 202002090 as a PDF (24.18 KB) Updated: January 20, 2021

Ms C complained about the care and treatment her mother (Mrs A) had received in Dumfries and Galloway Royal Infirmary and Castle Douglas Hospital. She was transferred to these hospitals after having surgery on her brain, which left her with quadriplegia (paralysis of all four limbs). We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nursing adviser. In relation to Ms C's complaint about the care provided to Mrs A, we did not uphold the complaint, as we found that: staff had assessed Mrs A in detail after her transfer and there was no evidence of a negative or palliative approach to her care; a detailed physiotherapy assessment was carried out promptly the day after her transfer and this was followed by regular sessions with physiotherapists; Mrs A's care in relation to alerting staff and consuming meals had been reasonable; it was reasonable that Mrs A did not receive counselling, as there was no clear indication for this in the observations of staff, or requests from Mrs A or her family; and the level of care provided to Mrs A in relation to massage, physiotherapy and bodily movement was reasonable. Ms C also complained that the board did not provide reasonable treatment to Mrs A following her admission. We found that there was evidence of a comprehensive assessment of Mrs A's needs and specific attempts to provide care and rehabilitation for her in both hospitals. The prescription of medication, based on the assessments carried out, was reasonable even if it did cause some sedation as a side-effect. We did not uphold this aspect of the complaint. Finally, Ms C complained that the board unreasonably instructed staff not to talk to her. We found that it had been reasonable for staff to propose a contact time for Ms C every day. This meant that rather than deal with a number of calls from Ms C, staff could give a focussed update. We did not uphold this complaint. Related reading View Decision

C complained about the care and treatment provided to their spouse (A) when A was an in-patient at Dumfries and Galloway Royal Infirmary after being transferred from another hospital. A had been commenced on Sando K (a medication used to treat and prevent low potassium levels). Three days later, A's potassium levels were found to be high. A's condition deteriorated and they were transferred to the critical care unit. C complained about the board's management of A's potassium levels and kidney function. We took independent advice from a consultant in acute medicine. We found that that there was a failure to note A's potassium levels were normal the day after being transferred and subsequent failures to check this on the following two days. Whilst we found that it was not A's potassium levels which resulted in their admission to the high dependency unit, we considered the failings to be unreasonable and we upheld the complaint.