SPSO Individual Decisions

C complained about the care and treatment provided by the board in relation to a cancerous lesion (squamous cell carcinoma, SCC) on their middle finger. C received cryotherapy for eight months but at the end of the treatment, the lesion was worse. C said that they should have been reviewed by a consultant sooner when it became apparent the treatment was unsuccessful and they would have chosen surgery at the outset if they had been told of alternative treatment options. As a result of the failings, C said that they developed a more serious lesion. We took independent advice from a consultant in dermatology. We found that the standard of medical care provided was not reasonable in that the uncertainty of diagnosis was not communicated to C and treatment options were not fully considered and discussed. Additionally, cryotherapy treatment was continued without consultant review for an extended period and the GP’s re-referral of C was downgraded to ‘routine’. We upheld the complaint.

C complained on behalf of their spouse (A). The first of C’s complaints was that the board had failed to reasonably and accurately record and report an alleged incident between A and a member of staff. They also complained about the board’s investigation, and future references in records to the incident. We identified a number of failings including that the incident referred to was not reliably recorded on the board’s incident reporting system, that the board did not properly investigate C’s concerns, and that medical record correction notices issued were inaccurate and inconsistent. We upheld the complaint. C also complained about the care and treatment that A had received. We took independent advice from a psychiatrist. We found that the care and treatment was of a reasonable standard. We did not uphold this aspect of C’s complaint. Finally, C complained about the board’s handling of their complaints. While acknowledging that the complaints were numerous and complicated, we were of the view that the board could have taken action at an earlier point to define the complaints. They also could have investigated to a higher standard and responded more promptly. We therefore upheld this aspect of C’s complaint.

C complained that the board’s mental health services did not communicate information regarding C's adult child (A) reasonably. A, who had experienced various mental health issues, was taken to hospital after taking an unknown quantity of tablets. C and another family member were concerned about A's mental health. A did not wish to remain in the hospital and clinicians assessed that A had capacity to make this decision. A few days later, A agreed to go to the hospital for a mental health assessment. The board referred A to the community mental health team (CMHT) and did not admit them to hospital. A few weeks later, A took their own life. C complained about the board's actions in the lead up to A's death. The board’s complaint response indicated that they had no concerns about the actions taken in relation to A's care. A significant adverse event review (SAER) concluded that communication between agencies (including within the board) could have been improved and an action plan based on the SAER recommendations was developed. The board acknowledged that A had died while in their care and apologised for this. C remained dissatisfied and raised their complaints with SPSO. We took independent advice from a consultant psychiatrist. We found that, as the SAER concluded, there were failures in communication involving the mental health team, including failures to update risk assessments, failures to use the electronic case notes system and inconsistency in referral criteria across CMHTs. We concluded that the board did not take a partnership approach when communicating with Ass family and did not adequately take into account their concerns when assessing risk. Therefore, we upheld C's complaint. During our consideration of the complaint, we gave the board the opportunity to comment on the adviser's views on the SAER Action Plan. The board reviewed and rewrote the SAER Action Plan and the proposed actions now relate directly to the recommendations in the report. However, we a

C complained about the nursing care provided to their late parent (A) whilst in hospital. They complained about a lack of adherence to infection control, poor staff attitude and breaches of uniform policy. C also complained that A had been issued a zimmer frame without appropriate assessment and guidance, and that staff inappropriately handled A when transferring them to a hospital trolley. C also raised concerns about the management of A’s medicines. A did not receive their prescribed medications and were able to self-administer after medicine was left in their possession. Through the board’s own investigation of the complaint, they identified appropriate improvements to areas including staff behaviour, infection control, breaches in uniform policy, and moving and handling. C was unhappy with this response and brought their complaint to this office. We took independent advice from a senior nurse adviser. We found that the nursing care provided to A had been unreasonable. The board were unable to evidence basic nursing care in A’s case due to poor documentation. We identified significant failures highlighting that appropriate assessments did not appear to have been carried out for A or documented during the admissions. Therefore, we upheld C's complaint.

C complained about the care and treatment provided by the board in relation to excision of a right sided neck lesion. C had been undergoing monitoring for a neck swelling thought to be a benign tumour. After a number of years of monitoring, C reported that they were experiencing pain and asked to have the mass removed. C underwent surgery to have the mass removed. The lesion had grown on the vagus nerve (the main nerve of the parasympathetic nervous system, which controls some body functions including digestion) and encased it, so the vagus nerve was cut in order to remove the lesion. Following surgery, C experienced gastroparesis (paralysis of the stomach, resulting in food and liquid remaining in the stomach for a prolonged period) and vocal cord palsy (where the vocal cords are unable to move properly). We took independent advice from an Ear, Nose and Throat (ENT) consultant. We found that the care and treatment that C received was unreasonable because there was a failure to recognise the lesion involved the vagus nerve and a failure to adequately discuss risks and consequences with C prior to listing them for surgery. We considered that it should have been made clearer to C that the surgery was likely to lead to injury or loss of function of the nerve. We also found that the events should have triggered the Duty of Candour process and that there was a failure to acknowledge the failings had occurred. Therefore, we upheld C's complaint.

C complained about the care and treatment that their sibling (A) received whilst in hospital following a fall. C also raised complaints about communication issues with the board. The board accepted that there had been poor communication with A’s family but did not indicate any concern regarding the care and treatment of A. C and their family were dissatisfied with the board’s responses and brought their complaints to the SPSO. We took independent advice from a nursing adviser. We found that A did not receive timely medical intervention due to documentation and assessment gaps, particularly in relation to A’s positioning, their need for increased oxygen support, falls prevention and support for hydration. We upheld this part of C's complaint. In relation to communication and complaints handling, we found that the board did not respond within reasonable timescales. We also found that it was unreasonable that the board did not apologise for the time taken to provide their response, that they did not take action to prevent any recurrence, that they included an inaccurate statement and that they did not respond to all of the complaints that they had clarified with C. We upheld these parts of C's complaint.

C complained about the care and treatment their parent (A) received during a hospital admission. C complained about the way episodes of agitation and aggression were managed by the board including in respect of administration of medicines; bruising to A during episodes of restraint and lack of dignity; a failure to manage their nutritional needs; and poor communication with A’s family. The board’s response to C’s complaint advised that medication had been used to settle A when other measures had been unsuccessful. The board said that A’s weight loss had been recognised and a referral had been made to the dietician, however, they had been discharged from hospital before a review could take place. It was recognised that documentation including fluid and food intake charts were incomplete and steps would be taken to ensure improved compliance. The board considered there had been good communication with A’s family, however, they apologised for the lack of empathy reported by C, which staff would be asked to reflect on for future learning. We took independent advice from a senior nurse adviser and a consultant geriatrician (specialist in medicine of the elderly). We found that there were aspects of A’s care which were reasonably managed particularly in relation to the way episodes of agitation and aggression had been managed on the ward. We found there were aspects of A’s care which were unreasonably managed particularly in relation to management of their nutritional needs, record keeping and communication. On balance, we considered the board failed to provide a reasonable standard of care and treatment to A and we upheld C’s complaint.

C complained that the board failed to provide their late relative (A) with reasonable nursing care whilst in hospital. C told us that they felt nursing staff did not take A seriously when they reported pain, that information given was not passed to medical staff as agreed, and that A was left feeling abandoned and ignored. The board said that A was admitted with a blockage in their bowel which was likely caused by bowels being stuck together after a previous operation. A underwent surgery to free the bowel and was cared for initially in the surgical high dependency unit. The board said that due to A’s co-morbidities, A began to experience worsening symptoms, including very advanced heart failure and respiratory issues. The correct diagnosis was made for heart failure and A was receiving correct treatment for this. We took independent clinical advice from a specialist nurse practitioner. We found that the nursing notes were completed to an acceptable standard with the exception of the infection control documentation. The board’s infection prevention control team identified and documented some issues with the documentation relating to a possible clostridium difficile infection (a type of bacteria that can cause a bowel infection). The nursing notes indicated a lack of recording and documentation of when A’s bowels had moved and there were no stool charts completed. There was a non-compliance of the completion of clostridium difficile infection paperwork. We considered that this indicated a lack of understanding in nursing staff of the importance of the infection control guidance and that the process was not followed or recorded appropriately. This indicates that the management of infection control in A’s care was unreasonable. We found that there was no evidence that matters raised by the family were recorded in the notes, or escalated to medical staff as the family thought. We also found that other documentation was incomplete, specifically, the ‘Getting to Know Me’

C complained about the care and communication provided to their step-parent (A) before their discharge. A was diagnosed with lung cancer and then admitted to hospital with left leg weakness after falls at home. A was discharged home two weeks later, and re-admitted after three weeks with severe chest pain. A died two days later. C complained that the prognosis of ‘weeks to months’ was not shared with A or their spouse when the treatment plan was discussed. C also complained that A was discharged home without an Occupational Therapy (OT) assessment having been completed, and with no other offers of support for A who required end of life care at home. Finally, C complained to SPSO about complaint handling. We took independent advice from a medical director with specialism in palliative care and a qualified physiotherapist. The board acknowledged that A was not provided with an adequate supply of medication on discharge. We found that this could have had serious consequences, and would have caused anxiety and distress. The board apologised for not arranging an OT assessment before A was discharged, but said that no concerns were raised during A’s admission suggesting this was required. We found that the board should have considered a full assessment for A who was subject to falls and whose health would deteriorate. We also found that no consideration was given to home set up before discharge, and that A’s anticipatory needs were not considered when they should have been. Therefore we upheld this complaint. We found that the board failed to discuss with A and their family whether an OT assessment or OT screening assessment might be appropriate when planning A’s discharge home. Additionally, we found that the board should have shared that A was reaching end of life stage sooner, and provided appropriate support with adapting to this fact. The discharge letter should have been clear in alerting A’s GP to the seriousness of the situation. The board have acknowledged that t

C suffered with lower back and right hip pain. C complained about the care and treatment provided by the practice in relation to their diagnosis of Hip Osteoarthritis. C said that despite raising concerns with the practice, they failed to take appropriate action to ensure C’s symptoms were further investigated. We took independent advice from a qualified GP. We found that the management of C’s symptoms was reasonable and appropriate steps were taken to investigate C’s symptoms. We did not uphold this aspect of the complaint. With respect to the handling of C’s complaints, we found that the practice’s complaints handling procedure was not compliant with current requirements. We also found that, whilst their complaints response demonstrated that they had investigated the complaint, the practice unreasonably failed to provide further response to C’s subsequent communications or the communications from our office. We therefore upheld this aspect of the complaint.

C complained that the board failed to provide them with reasonable care and treatment when they attended the emergency department with pain and swelling in their leg. C was advised that their symptoms did not indicate a pulmonary embolism (a blood clot that blocks a blood vessel in the lungs) and that they were on appropriate medication. C was also referred to the deep vein thrombosis (DVT, a blood clot in a vein, usually in the leg) clinic for further investigation. We took independent advice from a consultant in emergency medicine. We found that the medical care and treatment provided to C in the emergency department was reasonable. Therefore, we did not uphold this part of C’s complaint. C also complained about the care and treatment that they received when they attended the DVT clinic several days later. C was advised at the clinic that it was highly unlikely that they had a DVT. However, around two weeks later, C attended the emergency department again due to worsening symptoms. C was diagnosed with a pulmonary embolism. We took independent advice from a consultant in general medicine. We found that an advanced nurse practitioner did not give sufficient consideration to C’s significantly high D-Dimer blood test result (a test used to check for blood clotting problems) and did not seek input from medical staff. In addition, the board’s DVT protocol at the time was too simplistic to take into account all of C’s risk factors. It did not mandate the recording of those risk factors and deviated from the national guidance at the time, which recommended a repeat scan six to eight days later. Therefore, we upheld this part of C’s complaint. C also complained about the Significant Adverse Event Review (SAER) the board had carried out. We found that the SAER fully recognised the omissions in the board’s protocol and changes were subsequently made to this. However, when carrying out the SAER, the review team did not seek input from C in line with national guidance. Theref

C complained that the board failed to reasonably respond to their complaint about the way a form was completed by the GP at their GP Practice. We found that while the board provided regular updates, apologised for the delay and reasonably managed C’s contact, the length of time responding to the complaint and the inaccuracies of the updates provided to C, were unreasonable. The response to the complaint was unclear and did not answer all of the points raised by C. As such, we upheld the complaint.

C complained about the nursing care provided to their late parent (A) in hospital. A had been transferred from another health board for rehabilitation having suffered a stroke. C said that there was infrequent care rounding and that the provision of and monitoring of A’s diet, nutrition and fluid intake was poor. C also complained about communication, catheter care and pain management. We took independent advice from a nurse. We found that record keeping was not to the standard required in areas such as care rounding, fluid balance and food charts, and pain assessment documentation. The lack of accurate records of A’s nutritional assessment and needs suggested that A’s nutritional intake was not delivered to a reasonable standard and that they were at risk of malnutrition. Additionally, the absence of pain assessments on A’s observation and care rounding charts indicated a failure to properly evaluate A’s pain levels, making it difficult to determine if the pain medication provided was effectively relieving their pain. We determined that there had been a lack of assessment, evaluation, and implementation of A’s care needs and lengthy gaps between care interventions. Therefore, we upheld C’s complaint.

C’s spouse (A) was admitted to hospital following a stroke. A remained in hospital for several weeks before transferring to another hospital. A later died. C complained to the board about A’s hospital stay and raised concerns about wound management, fall pain management and the identification of hip and shoulder injuries. The board’s response highlighted several areas for improvement. Firstly, there should have been a referral for A’s wounds, with more robust documentation. Staff training has been conducted to address these issues. Secondly, A fell twice in the ward, prompting a thorough medical review after each fall. Staff training regarding falls has been provided. Thirdly, although A was on regular pain medication, there should have been a pain recording chart in place. Staff will receive training on this aspect. Lastly, A’s hip dislocation likely stemmed from their stroke rather than a fall, with no evidence of shoulder dislocation occurring the ward. C was dissatisfied with the board’s response and brought their complaint to us. We took independent advice from a nurse with a speciality in wound care and a consultant geriatrician (a specialist in medicine of the elderly). We found that staff failed to follow the board’s policy on wound management. We also found that whilst the medical care of A’s falls was reasonable, the nursing documentation about A’s falls was unreasonable, because documentation was incomplete and at times inaccurate. A’s care plan was also poor, making it difficult to manage A’s pain, and there was a delay in A receiving a medical review over the weekend. Therefore, we upheld these parts of C’s complaint. We found that the board’s explanation of A’s injuries was reasonable. We did not uphold this part of C’s complaint. We also found that the board’s complaint response did not provide C with a timely, full and informed response to their complaints about the board’s management of A’s wounds and falls. Therefore, we made an additional recommen

C complained about the care and treatment that their late adult child (A) received from the board about symptoms of productive cough, breathlessness and occasional wheeze. A was referred by their GP to the board and received two outpatient chest x-rays. Separately, A also self-presented at the A&E owing to their symptoms, where they were discharged with a trial of steroids and inhaler. A’s first of the two outpatient chest x-rays was reported as normal and their GP routinely referred them to the respiratory department for further investigation of their symptoms. The second of the two outpatient chest x-rays was considered to show changes suggestive of pulmonary oedema (a condition in which too much fluid accumulates in the lungs, interfering with a person's ability to breathe normally). At this point, A’s GP upgraded the respiratory referral to urgent. On vetting by a respiratory consultant, A’s GP was contacted with advice to commence a diuretic (drugs that enable the body to get rid of excess fluids) straight away and urgently refer A to cardiology, on suspicion of heart failure. A was seen at the cardiac function clinic, with the plan being made to see them at the heart failure clinic. A’s condition deteriorated before being seen at the heart failure clinic and the GP arranged for their immediate admission to the coronary care unit (CCU). A suffered a cardiac arrest shortly after admission requiring resuscitation, and they were subsequently transferred to another health board for surgery where they died. C complained about the delays by the board to assess, diagnose and treat A’s condition, especially as A had presented to the A&E, and after the follow-up x-ray showed significant deterioration within a 4 week period. Having been referred to cardiology, C complained that the board failed to treat A’s condition with the urgency it required. C also complained that A had been transferred to another health board for surgery when it was known A’s condition was such tha

C complained on behalf of their spouse (A) about the care and treatment provided by the board before they died. A was an end of life patient having been diagnosed with incurable lung cancer. A developed symptoms likely caused by an obstruction of one of the major blood vessels attached to the heart and was scheduled to have a stent inserted through the blockage. C complained about their experience on the ward on the day of the procedure which, they said, caused great pain and distress. We took independent advice from a registered senior nurse. We found that A lacked person centred information to prepare them for admission which caused distress, that there was a failure to provide a clear pathway for a patient diagnosed with end stage lung cancer the Peripheral Vascular Cannula (PVC)(insertion of a plastic conduit across the skin into a vein) process was not followed. We found that a pressure ulcer risk assessment was not undertaken and a plan of care not developed or implemented to prevent pressure damage. We also found that there was a failure to provide A with their prescribed steroids, despite requesting this. We noted record keeping failures during A’s admission and found failings in the board’s handling of the complaint, with the complaint not addressing all the issues raised by C and failings to fully investigate and respond to C about the PVC process. We upheld the complaint.

C complained that the board had unreasonably failed to follow the care plan put in place to support them with their mental health. In particular, C complained that the board had failed to arrange their admission to hospital during an episode of crisis. The board’s response to C’s complaint advised that they had been appropriately assessed at the time, with it being the view of the mental health service that further support in the community would help to reduce the need for an inpatient admission. The board also advised that, in keeping with the care plan, C’s request for admission had been discussed with a consultant psychiatrist, with the decision not to arrange admission on this occasion being based on clinical opinion. We took independent advice from a consultant psychiatrist. We found that C’s care plan included provision for a five day admission to hospital when required, however, the need for this would be discussed with a consultant at the time. When C reported feeling low in mood to the mental health service during their episode of crisis, they had responded reasonably, noting that C had been supported by increased phone and face to face contacts. On receiving C’s requests to be admitted to hospital, this had been assessed by the consultant psychiatrist in keeping with the care plan. Overall, we considered that the board had reasonably followed C’s care plan. We did not uphold this complaint. Related reading View Decision Report 202302960 as a PDF (24.43 KB) Updated: February 21, 2024

C complained that the board failed to provide reasonable care and treatment to their late parent (A). A was admitted to hospital but was discharged later that month. Two days after discharge, A was readmitted and died a short time later. We took independent advice from a consultant in geriatric and general medicine. We found that some aspects of A’s care were reasonable particularly in relation to COVID-19, A’s diabetes, and detailed assessments from physiotherapists and occupational therapists prior to discharge. However, we found that while A’s last blood tests were normal, A was then unwell for several days which could have developed into kidney impairment if levels of hydration in the body became low. A’s blood tests were not repeated prior to discharge. Had A received blood tests prior to discharge, taking into account A’s blood tests on readmission, it is likely that the test would have been abnormal which would have resulted in A remaining in hospital. We considered that the board failed to provide A with reasonable care and treatment. Therefore, we upheld this part of C’s complaint. C also complained that the board unreasonably failed to consider their concerns in sufficient detail when responding to their complaint. We found that the board’s complaint response did not reasonably address C’s specific concern in relation to the comments of a nurse. We also found that when investigating the complaint there was a lack of attention given to the reasons for readmission and a lack of reflection by the medical team to ensure lessons were learned. Therefore, we upheld this part of C’s complaint.

C complained about the care and treatment provided by the board to their partner (A). A had a seizure and was admitted to hospital for further assessment. C reported their concern to staff that A had dislocated their jaw during the seizure, and advised that this had happened to A before. A underwent x-rays and was referred to oral and maxillofacial surgery (OMFS, specialists in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) for review. OMFS concluded that no further treatment was required for A. C continued to report their concern about A's jaw and an urgent referral was made to ear nose and throat (ENT) for further assessment. This was later re-directed on vetting to OMFS, however no follow-up review by OMFS took place by the time of A's discharge some weeks later. On discharge, C contacted A's GP who arranged for A to be seen by another health board. A was diagnosed as having a dislocated jaw and underwent emergency surgery. The board said that there had been evidence of dislocation in the right jaw joint. They said that due to A's dementia and reduced mobility, they were unable to fully cooperate during their assessment and would not have been able to manage further x-ray procedures. They noted that A did not appear to be experiencing any pain and appeared to have a good range of movement of their jaw. We took independent advice from an oral and maxillofacial surgeon. We found that A's initial assessment on arrival at the hospital and the decision to wait until the x-rays had been reported before referring A to OMFS for further assessment was reasonable. However, we found that the assessment of A's jaw by OMFS failed to elicit the clinical features of the dislocation and failed to consider other types of scan after concluding the diagnosis was unclear. On the matter of the urgent referral to ENT which was later redirected to OMFS, we were critical that no follow-up review by OMFS took place prior to A's discharge. We considered

C complained about the care and treatment provided to their relative (A) by the practice. A attended the practice frequently within a year and was later diagnosed with an aggressive form of cancer. A died shortly after. C believed that A's concerns were not properly taken into account when they attended the practice and that A should have been referred sooner for investigations. The practice provided a detailed reply to C, stating their view that A's concerns had been investigated appropriately, and that there had been no indication for a cancer referral. We took independent advice from a GP. We found that there was no reason to suspect cancer as a possible cause of A's symptoms. However, as symptoms persisted, an urgent cancer referral should have been considered. We found that it was highly unlikely, given the aggressive nature of A's cancer, that the delay in A's diagnosis had any impact on the outcome of A's disease. Although A's initial treatment was reasonable, we found that there were failings in care in that the practice should have made an urgent referral for A sooner. We therefore upheld this complaint.

C complained about the care and treatment provided to their late parent (A) by the board. A had dementia and was experiencing worsening delirium following a urinary tract infection. A was admitted to hospital by an out-of-hours doctor who visited A at home. C's sibling accompanied A in the ambulance but was told that they were unable to stay with A in hospital due to COVID-19 visiting restrictions. A was transferred to a side ward and later that evening, fell from the bed. A had a head laceration and complained of right hip pain. A head CT and hip x-ray were undertaken which confirmed a right hip fracture. A was transferred to an orthopaedic ward (specialists in the treatment of diseases and injuries of the musculoskeletal system) but it was decided A would not survive an operation due to the fall and hip fracture trauma. A died a few days later. We took independent advice from a consultant geriatrician (a specialist in the care of older adults) and a senior nurse in falls prevention. We found that a reasonable level of information from A's family was recorded and taken into account by medical staff, that the assessment of A's delirium was reasonable and that it is common practice for a doctor to try and speak directly with a patient with significant dementia or delirium to allow them to assess the individual's capacity. We also found that it was reasonable to transfer A to a side room, that the action taken by medical staff following the fall was reasonable, as was the communication with the family. Furthermore, that the pain relief was reasonable and was a priority of staff who saw A. However, we found that there were a number of failings in the nursing care and treatment provided to A. We found that it was unreasonable that no family members were allowed to stay with A, that there was a lack of information documented in the nursing records and a lack of completed paperwork in relation to assessments that should have been carried out on A. Whilst nursing staff's i

C complained about the care and treatment that their parent (A) received from the board. A was admitted to hospital and later discharged into a care home. C complained that during A's admission to hospital, communication with the family was very poor. Despite numerous requests for a call from clinical staff, no contact was made and the family were left with very little information as to A's condition or the treatment that they were receiving. C complained that as a result of this the family did not have sufficient information to make informed decisions about A's care. C said that they could see that A's health was declining. A died a few days later. A's discharge notes recorded that they had vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory), significant cognitive impairment, and lacked capacity for health and welfare decisions. C highlighted that A's hospital records made no mention of a dementia diagnosis and that this was never discussed with the family. C questioned whether A's capacity to consent to changes in their medication and about treatment was properly assessed. C complained about poor communication from the clinical team and about the assessment and treatment of A prior to the decision to transfer them to the care home. C said that, had the family known the extent of A's deterioration, they would have arranged for them to be cared for at home, rather than in the care home. In their response to C's complaint the board acknowledged C's concerns about not speaking with clinical staff. They said that attempts were made for A to be assessed by a Mental Health Liaison Nurse but that this was not possible due to A's level of distress. A was deemed medically stable for discharge to a care home. C was dissatisfied with the board's response and brought their complaint to our office. We took independent advice from a consultant geriat

C complained about the care and treatment their adult child (A) received from the board. A had a complex medical history including a diagnosis of Complex Regional Pain Syndrome (CRPS, a rare condition where persistent and severe pain occurs following an injury). A attended A&E complaining of an elevated heart rate and fatigue. A working diagnosis of sinus tachycardia (a faster than usual heart rhythm) secondary to medication was made. A was discharged home with no further treatment. A couple of months later, A was admitted to A&E following a collapse, racing heart and swelling of their hands and feet. A was admitted to hospital where their condition deteriorated overnight. A's condition continued to deteriorate and they were transferred to the Medical High Dependency Unit (HDU) and the Intensive Care Unit (ICU). Ultimately, it was decided that A should be transferred to a hospital in another health board area where cardiology and advanced cardiac (heart) support would be available. A's condition did not improve and they died a few days later. C raised a number of complaints with the board regarding the care and treatment A received. The board investigated C's concerns and undertook a Significant Adverse Event Review (SAER). However, C remained dissatisfied with some aspects of A's care. We took independent advice from an appropriately qualified adviser. We found that when A initially presented at A&E, the clinical staff were aware of their history of CRPS and existing medications, that a full examination was carried out along with blood tests which were normal and that there was no obvious reason to admit A to hospital at that time. We found that the treatment A received during this admission was reasonable and appropriate and that onward referral was unlikely to have changed the outcome for A. In relation to their second attendance, we noted that A was acutely unwell. We found that appropriate investigations were carried out in a timely manner and that, as A's cond

C complained about the care and treatment that their spouse (A) received from the board. A was diagnosed with colorectal cancer (bowel cancer) and underwent colon cancer surgery abroad, before returning to the UK. They were reviewed by the board’s oncology team (cancer specialist team) and it was determined that the cancer had spread and that chemotherapy was required. Although A initially responded well to chemotherapy, once the chemotherapy course ended, the cancer was found to have spread further. A was not considered fit enough to undergo further chemotherapy and died. C complained to the board that, following the positive indications, the board failed to communicate clearly with A and their family about their prognosis, treatment and next steps. C raised particular concerns that clinicians were unwilling to give information about the nature and extent of A’s deterioration, the sizes of tumours identified and information about the treatment that could be provided. C considered that the board failed to provide A with appropriate treatment during their time in hospital and that these failures could have resulted in A not being able to recover sufficiently to undergo further chemotherapy. C was concerned that A suffered a series of issues related to their stoma site (opening in the body) and C complained that these issues were not treated with sufficient urgency or concern. In response to the complaint, the board provided a detailed account of the care provided to A and their communication with A's family. The board acknowledged that A responded well to chemotherapy but once the first six cycles were complete, the cancer started to grow aggressively and A never regained the fitness required to restart treatment. The board explained that following further review of A, it was established that surgery was not an option for A and gave their view as regards the progression of A's illness and recurrent infections which necessitated admittance to hospital. Additio

C presented at A&E with a painful left foot. The diagnosis recorded in the medical records was a foot sprain. A few months later, C was diagnosed with a rare degenerative condition and a possible healing fracture in their foot was also noted. C complained that the doctor at A&E had not physically examined the foot, had not carried out an x-ray and had not taken a medical history. As such, a possible fracture may have been missed and a diagnosis of the degenerative condition was not considered. As a result, C felt that the correct treatment was not offered. We took independent advice from an emergency medicine adviser. We found that the condition in question is rare and unlikely to be diagnosed in an A&E setting. It was also not clear whether the possible healing fracture had been present at the time. However, it would have been appropriate to carry out a physical examination, to take a medical history and to carry out an x-ray. Overall, we upheld the complaint.