SPSO Individual Decisions

C, an independent advocate, complained on behalf of B, about the standard of medical and nursing care provided to B’s late spouse (A) by the board following a liver cancer diagnosis. B complained about A’s diagnosis, noting that A was initially seen to have one lesion and to be suitable for a liver transplant, however, three months later multiple lesions were found and A was no longer seen as a viable candidate. B also complained of subsequent delays in cancer treatment and that the nursing care provided to A was below a reasonable standard, including failures to prevent an unwitnessed fall. B said that communication from clinicians regarding A’s diagnosis, prognosis and treatment was lacking detail and infrequent, and that the board’s stage two complaints response was inaccurate. We took independent advice from a consultant hepatologist (specialist in diseases of theliver, gall bladder, bile ducts and pancreas) and a registered nurse adviser. We found that A’s diagnosis and treatment were reasonable and did not consider that multiple lesions had been unreasonably missed initially. We did not uphold this aspect of the complaint. However, we found that there had been failings with respect to communication, particularly when A’s care was transferred to a specialist transplant unit outwith the board. We also found that the nursing care provided was unreasonable, including failings to record comfort, pain, and personal care, and in relation to delirium, falls prevention and risk assessments. Lastly, we noted inaccuracies in the complaints responses provided to B. As such, we upheld these aspects of the complaint.

C complained about the care and treatment provided to their infant child (A) who was born with a terminal genetic condition. A's family had open access to the children's ward, allowing them to seek medical advice or assistance when needed. C brought A to the ward as they were unwell. After assessment, A was discharged with advice to return if their condition changed. A's condition deteriorated and they were taken to A&E the next day. When staff were unable to obtain intravenous access (when a needle is inserted into a vein), an intraosseous needle was used (a needle that goes directly into the bone). A complication occurred during the procedure and A was transferred to another health board for specialist care where there were further major complications. C felt that treatment would have started sooner if A had remained in hospital, avoiding the need for the intraosseous infusion and the subsequent complication. We took independent advice from a consultant paediatrician (specialist in children's medical care). We found that A received a reasonable standard of care and treatment and that the harm that occurred was a recognised complication of the procedure. We welcomed the board’s review of the case and noted that it had contributed to important learning in relation to the care of children with complex medical needs. We did not uphold C's complaint. Related reading View Decision Report 202405861 as a PDF (24.52 KB) Updated: February 18, 2026

C complained on behalf of their partner (A) about the care and treatment that A received from the board during their two admissions to hospital for suspected pulmonary embolus (when a blood clot blocks a blood vessel in the lungs). A had a stroke during their second admission. We took independent advice from a consultant in general medicine. For A’s first admission, we found that the triage nurse who took A’s bloods, clearly documented that a D-Dimer (a test to detect blood clots) had been done and the results were available on the board’s system before A was discharged but it was not noted or considered. We found that A’s D-Dimer result should have been considered and doing so could have led to an earlier diagnosis of A’s pulmonary embolus. We found this aspect of A’s care unreasonable and we upheld this aspect of the complaint. For A’s second admission, we found that the treatment of A’s blood clots with medication appeared to be in accordance with relevant guidance which was reasonable. We did not uphold this aspect of the complaint. We noted that the board advised C in their complaint response that they would take A’s case forward to their adverse events review group for further consideration and that 16 months later, there had been no indication that a significant adverse events review had taken place, which appeared unreasonable. In addition, we found that in their complaint response, the board should have provided C with an explanation of what happened when A was readmitted to hospital, and the nature of A’s stroke, as well as more detailed description of when the adverse events review group’s decision would be made and if this would be communicated to C.

C complained on behalf of their sibling (A) in relation to the care and treatment that the board provided to A after presenting at an out of hours service with symptoms including epigastric pain, vomiting and shaking. A was sent home with treatment for dyspepsia (indigestion) but died shortly afterwards from acute haemorrhagic pancreatitis. C complained that the board did not adequately take into account A’s full presentation and relevant background information in considering a treatment plan. We took independent advice from an experienced emergency medicine adviser. Overall, we found that the care and treatment that A received was unreasonable because A’s physiological observations showed a significant degree of abnormality, and the board did not have appropriate systems in place to identify the deteriorating patient in the acute community setting. We upheld the complaint.

C complained about the care and treatment their late spouse (A) received for a bowel perforation. A died in hospital following a cardiac arrest. C complained that the conservative, non-surgical approach taken to A’s treatment led to a deterioration in their condition, leaving them unfit for surgery. C also complained about the standard of A’s medical records, which made it unclear whether clinical advice and treatments had been followed. Furthermore, C complained that the board’s complaint response contradicted information given at the time, particularly regarding the healing of the abdominal leak and plans for discharge. Instead, the board’s response stated that the treatment had failed, A’s condition was non-survivable, and the leak persisted. Given this, C questioned the board’s decision to attempt cardiopulmonary resuscitation and the lack of palliative care for A. We took independent advice from a consultant surgeon. We found that there were aspects of A’s care which were reasonably managed including timely administration of intravenous antibiotics and a CT scan on admission. However, we found that there was a lack of urgency and clarity following the CT scan, and an absence of documented clinical reasoning such as treatment purpose, an escalation plan, and consideration of palliative care. High dependency care was not provided early despite signs of deterioration. Communication with A and C was inadequate, with no documented discussions about the severity of A’s condition or care decisions. We also found failings in fluid resuscitation and monitoring, with delayed reviews of A’s response to treatment. We upheld C's complaint.

C complained that the board unreasonably failed to provide appropriate care and treatment to their late parent (A). A attended A&E with an injured arm after a fall at home. A was treated and sent home but was admitted to hospital a few days later with low sodium and anaemia. A was discharged after a short stay but re-attended A&E a few days later. An abdominal x-ray showed dilated loops of bowel and blood tests taken showed acute kidney injury. A’s condition deteriorated and they died later that day. We took independent advice from a consultant in emergency medicine and a consultant geriatrician (specialist in medicine of the elderly). In relation to A's first admission, we found that the management of A’s sodium levels was reasonable. However, there was a lack of accurate charting of A’s bowel movements. We also found that medications to address A’s constipation were not provided at discharge. Therefore, we concluded that the care and treatment with respect to A’s constipation was unreasonable and upheld this part of C's complaint. C also complained that the board failed to provide A with appropriate care and treatment during their second attendance at A&E. We found that there was an unreasonable delay in A being seen by a doctor on arrival. Therefore, we upheld this part of C's complaint.

C complained about the care and treatment provided to them in relation to their health in prison. C experienced difficulties in relation to their medical needs, including staff not attending when C requested, not receiving their medication, lack of communication and that the complaint response did not answer all of C’s concerns. We took independent advice from a qualified GP. We found that the board seemed to lack appreciation that without medication for stomach acid, C would be left very symptomatic and sore and that they failed to supply the alternative medication to C when it was due. Once the medication had been obtained, they failed to locate C within the prison to give them the medication and failed to follow protocol to store the medication for reissue. We found that the board failed to communicate the problem with their medication to C and failed to reach a solution about C’s missing medication. We also found that the board failed to attempt to reach a solution about the poor communication between them and the Scottish Prison Service (SPS). Therefore, we upheld this complaint. We acknowledged that the board had taken learning and improvement action in relation to a number of these failings. C also complained that the board unreasonably failed to respond to all of C’s concerns in their complaint response. We found that the board’s first complaint response was unreasonable, and while the second response was generally reasonable, the length of time it took for the board to issue this was unreasonable. On balance, we upheld this complaint. We also acknowledged that the board had taken some learning and improvement action in relation to these matters going forward.

C complained about the care and treatment that they received from the board. In particular, C complained that the board had failed to recognise or timeously act on the significance of the severity of their pain and abdominal symptoms. C later received emergency surgery in treatment of a ruptured caecum including formation of a stoma. We took independent advice from an obstetric adviser and a general surgery adviser. We found that C’s care had been reasonably managed in relation to their discharge from obstetrics and their re-admission when symptoms continued. We considered that the plan made for surgery was reasonable, noting the rare and rapidly progressing nature of the complication C experienced. We also considered the board’s own review of the episode of care was reasonable. We found that there were aspects of C’s care which were unreasonably managed, specifically, that there were incomplete medical records kept following a surgical review. On balance, we considered the standard of care provided to C was reasonable. We did not uphold this complaint. Related reading View Decision Report 202406679 as a PDF (24.29 KB) Updated: August 20, 2025

C’s spouse (A) who had prostate cancer was admitted to the Clinical assessment unit (CAU) of the hospital following a few days of deteriorating health. During their admission, A remained in the CAU for three days before leaving the building without staff being aware of this. A contacted C in confusion and told C that they had not received food or hydration, had not been washed and had not been able to sleep. C returned A to the hospital on the condition that A was moved to a ward, which they were. The next day C was told that A had suffered an unwitnessed fall and was to be discharged to attend an oncology appointment. A also had lesions on their groin which had developed and not been cared for during their admission. A died within two weeks of being discharged. C complained to the board. The board accepted that there were a number of areas for improvement in the care and treatment that A had received, apologised and advised of actions that they would take or had taken to address these matters. C was dissatisfied with the board’s responses and raised their complaints with SPSO. The board identified further areas where the care they had provided to A had not been reasonable and advised of further actions that they would take to address these. Given this, we upheld C’s complaint that the board did not provide reasonable care to A, with specific reference to care of lesions on A’s groin and the discharge of A. We took independent advice from a nursing adviser. We found that the board, in considering how best to reflect on A’s care and treatment, had focussed too narrowly on A’s fall, that they should have considered the experience of A and their family more broadly and that relevant guidance indicates a Significant Adverse Event Review should have been carried out. We also found that there was a delay in providing a response to C’s complaints and that C had not been updated regularly while the complaints were being considered. We also found that the actions proposed an

C complained that there had been a lack of neurological (of the nervous system) support for their family member (A). A sustained a traumatic brain injury (TBI) that required emergency surgery, and was transferred to the board under the care of neurology. C said that staff dismissed their concerns about A’s worsening condition and that A was being managed for their epilepsy as opposed to someone with a TBI. They also complained that there had been an unreasonable delay in identifying the disconnected shunt (a thin tube implanted in the brain to direct excess cerebrospinal fluid (CSF) to another part of the body), despite A’s symptoms. The board said that the neurology team had been managing A’s epilepsy but in the absence of a consultant in neurological rehabilitation they had been seeking to provide general support and make appropriate referrals. It was acknowledged that there was a lack of NHS services for TBI rehabilitation generally throughout Scotland. The board also said that the disconnected shunt was not necessarily the cause of A’s symptoms. We took independent advice from consultant neurologist. We found that the management provided to A was appropriate with relevant referrals made. However, given the significant head injury suffered by A, we found that the consultant neurologist could have met with them at an earlier date. The information available indicates that the first meeting did not take place until some 14 months after A’s head injury. An earlier meeting would have assisted A in terms of general support and also in managing their expectations whilst providing confidence and reassurance that their condition was being managed in the best way possible. In relation to the time taken to identify the disconnected shunt, we considered that the evidence available indicated appropriate and timely steps were taken by clinical staff. We did not uphold C's complaints. However, we did provide feedback to the board in relation to the timing of the first meeting b

C complained about the care and treatment that they received from the board. C said that following gynaecological surgery, they were left with side effects including recurrent pain and the need for further treatment. C complained that the board failed to provide them with adequate care and treatment in relation to the operation. The board did not identify any failings in C’s care, but did apologise for communication failings relating to the operation. They said that C had experienced a rare complication, but that this had been recognised and treated appropriately. We took independent advice from a consultant gynaecologist. We found that C’s care and treatment during and after their operation was reasonable and noted that the complication that occurred was swiftly identified and managed. However, we also found that prior to their operation, C was not provided with adequate information about other possible treatment options, including a lack of discussion about the surgery. We also found that the surgical consent process was inadequate. The board accepted that discussions relating to informed consent and counselling to support patient decisions should be fully documented, and that this had not occurred in C’s case. The board also acknowledged the importance of discussing and documenting all potential post-operative complications with the patient, so that the patient has informed choice when agreeing to a management plan. We found that there were aspects of C’s care and treatment prior to their operation that fell below a reasonable standard. Therefore, we upheld C’s complaint.

C had a bilateral total knee replacement surgery, which was carried out by another organisation. Approximately three weeks after their surgery, C was admitted to a hospital within Forth Valley NHS Board following a fall. Approximately three weeks after C’s discharge, C had surgery to repair a tendon in their right quadriceps (thigh muscle), which was carried out by another organisation. C complained about the care and treatment that they received in hospital during their admission and the care and treatment that they received from the outpatient physiotherapy service over the next six months. The board said that the presentation of C during their hospital admission was a common presentation following knee replacement surgery and very similar to the presentation for an injury to the quadriceps. The board said that the outpatient physiotherapy guidance was followed when treating C. We took independent advice from a consultant orthopaedic surgeon (specialist in the treatment of diseases and injuries of the musculoskeletal system) and a physiotherapist. We found that the board failed to consider a right-sided quadriceps tendon injury when C was seen by a consultant in hospital, failed to reassess C during their admission and failed to escalate C when C did not progress when in hospital. On this basis, we upheld this part of C’s complaint. In relation to the physiotherapy service, we found that the exercises C received were in line with post-operative guidance and that physiotherapists followed protocols for treating C. We did not uphold this part of C’s complaint.

C complained about the care and treatment provided to their family member (A) during their admission to hospital, following a fall at their home. A was admitted to hospital after falling unwell, and for management of their underlying heath issues. A was discharged but had to be re-admitted to hospital two days later. C raised concerns that A did not receive appropriate care and treatment during their admission, that they should not have been discharged and that medical staff did not properly communicate A’s care plan during the admission. In response to the complaint, the board explained that staff were aware of, and managed, A’s pre-existing health conditions and that appropriate investigations were undertaken to investigate their symptoms. A’s weight loss during admission was noted and the board explained monitoring of this aspect of their care could have been better. The board explained that A was assessed as being medically fit for discharge and this was discussed with family. We took independent advice from a consultant in the care of the elderly and from a registered nurse. We found that whilst the general management of A’s underlying health conditions and symptoms was reasonable, in the initial days of their admission A was administered within correct medication and there was a missed opportunity to perform an x-ray to investigate A’s symptoms. For these reasons, we found that A’s care and treatment was unreasonable. We also found that medical staff failed to recognise the status of A’s family members as Power of Attorney, and did not appropriately communicate with A or their Power of Attorney with respect to their care. The communication with A and their family was unreasonable. We upheld this complaint. Finally, we found that appropriate assessments were carried out to determine A was fit for discharge and we did not uphold this complaint

C complained about the care and treatment provided to their parent (A). A was assessed by a junior doctor in A&E who ordered various tests and investigations. A was later moved to the acute assessment unit and diagnosed with a perforated bowel. A underwent emergency surgery and developed sepsis. C complained that there was a delay in identifying A’s condition. They said that the board focussed on potential cardiac issues rather than an abdominal cause. C considered that this delay resulted in a worse outcome for A. The board acknowledged that a more senior doctor may have identified the cause of A’s symptoms quicker. However, they said that the care provided was reasonable. They also noted that this this complaint had resulted in learning and ongoing development. We took independent advice from an emergency medicine consultant. We found that there were a number of red flags in A’s presentation that should have raised the possibility of significant abdominal pathology. It did not appear that A was reviewed by a senior clinician. We also found issues in the documentation. No intimate examination was recorded in the records and there was a lack of documentation around the interpretation of an x-ray. Overall, the initial assessment process led to a delay in the diagnosis of acute bowel perforation which is likely to have had a significant effect of the outcome for A. Therefore, we upheld C’s complaint

C complained that the advice and treatment provided by the board following their positive COVID-19 test was unreasonable. C was a kidney transplant patient who tested positive for COVID-19 in early 2022. C said that they had contacted the renal unit who referred them on to the Covid Pathway (a central unit offering treatment advice and antiviral medication for high-risk patients). C received antiviral medication from a Covid Pathway nurse but was not referred to a renal clinician or advised to stop the immunosuppressant medication they were taking. C later contacted the renal unit with concerns about diarrhoea. C was advised to stop the immunosuppressant over the weekend and was given advice on what to do if their condition worsened. C felt that they were given wrong advice about their medication and that their disease progression was more severe because of this. The board advised that they had no record of C’s contact with the renal unit about COVID-19. Their first record was 11 days later, when they spoke to a renal nurse with concerns about diarrhoea. We took independent advice from a pharmacist and a consultant nephrologist (specialist in the diagnosis, treatment, and management of kidney conditions). We found that if C had indeed phoned the renal unit initially, C should have been escalated to a clinician for medication advice. We were also critical that the nurse at the Covid Pathway had not sought advice from or referred C to the renal unit. However, we noted that the immunosuppression medication was new and the situation was fluid at the time. We noted that improvements were made within two weeks, during which, guidance was published to ensure robust advice and treatment for COVID-19 positive, immunosuppressed patients and contact details for specialist clinical units were provided to the Covid Pathway. We also considered that the COVID-19 pandemic had since largely subsided. We considered that the advice and treatment that C received was reasonable as we co

C complained about their attendance at the A&E after their child (A) had a seizure. C said that A’s observations (to measure vital signs like heart rate, blood pressure, and temperature) had not been taken, but that the nurse had told C that they were. C also raised concerns about attitude and behaviour. The board’s complaint response said that the nurse had intended to reflect to C that observations had been taken by the ambulance crew, and that the nurse had triaged A and determined that A was able to wait for a doctor. C was dissatisfied with the explanations provided. The board told us that a further review of the records showed that the nurse had taken observations, but staff present concluded that there was no physical evidence of the nurse taking observations at any point at triage. We took independent advice from a qualified nurse. The evidence suggested that observations were not carried out, and that there were failings during the triage of A to act on their abnormal heart and pulse rate promptly. Appropriate repeat observations and a Glasgow Coma Scale score were not taken. There was also a lack of clarity as to whether A was assessed as an adult or paediatric patient. We upheld this complaint. We found that there had been record keeping failings, including records which did not match the accounts provided by the nurse, paediatric assessment tools not being completed, incorrect oxygen saturation levels having been recorded, and nursing and medical entries not being time stamped. There was also a lack of explanation for the discrepancies in the board’s accounts of observations being taken. We upheld this complaint. We found that C and SPSO have, at times, been provided with inaccurate and inconsistent information in relation to whether A’s observations were taken. We therefore upheld this complaint.

C complained that the board failed to reasonably assess their mental health condition. C had been receiving treatment for a number of years in England, before returning to Scotland. C said that the board’s assessment questioned C’s existing diagnosis and sought to remove this. C asked for a second opinion and a different consultant reviewed their notes. C felt that they should have been seen face-to-face and complained that the board failed to offer an independent second opinion. We took independent advice from a consultant psychiatrist. We initially upheld the complaint. However, in response to our provisional decision, the board provided evidence showing that they had not sought to remove C’s diagnosis. We found that if C’s existing diagnosis was not being removed, then there was no need for a second opinion. Rather the board should offer C an opportunity to work with a different clinician to repair the therapeutic relationship. As C’s diagnosis was not being removed, the basis for C’s complaints no longer applied. Therefore, we did not uphold C’s complaints. However, we recommended that the board apologise to C given the extent of the misunderstanding, which was not clarified early enough by the board.

C complained that the practice failed to provide them with reasonable care and treatment. C was involved in a road traffic accident after they momentarily lost consciousness while driving. C had a phone and then a face-to-face consultation with a physician associate (PA, a healthcare professional who support doctors in the diagnosis and management of patients) who referred them to respiratory medicine to investigate possible sleep apnoea caused by hypersomnia (excessive daytime sleepiness). Another telephone consultation was held, during which the PA indicated their intention to refer C to the DVLA due to concerns that C was continuing to drive despite their advice to stop. C was unhappy with their level of care. C disputed having been told that they must not drive, and complained that the referral was made on the basis of a suspected rather than confirmed diagnosis. They also said that they had not received fair warning of the consequences. C complained that it had not been made apparent that they were being seen by a PA rather than a GP. Lastly, C complained about the practice’s complaints handling, and the accuracy of their responses. We took independent advice from a GP. We found that the questionnaire used to assess hypersomnia had been incorrectly completed by the PA which provided misleading results. C’s prescribed medication had not been followed up as a contributing factor in the accident and C’s significantly low pulse rate had not been identified or acted upon. We found that the PA appeared to have been acting without sufficient supervision from a GP, particularly once the complex nature of C’s situation became apparent. It would have been reasonable for C’s case to be transferred to a GP. We also found that the referral to the DVLA had not been made in line with either DVLA or GMC guidance. Furthermore, the practice had failed to take appropriate steps to ensure that it was clear to C that they were receiving care from a PA and not a GP. Lastly, we found

C complained about delays in the care and treatment provided to their spouse (A) who was diagnosed with lung cancer following an abnormal chest X-ray. C said that there was a delay in A being provided with a CT scan result by the respiratory consultant, and a further wait to be seen by the oncologist (cancer specialist) following A’s biopsy (a medical procedure that involves taking a small sample of body tissue so it can be examined under a microscope). C asked whether A’s diagnostic pathway influenced their treatment, in that patients with more curable grades of cancer were treated sooner. We took independent advice from a consultant oncologist. We found that there was no formal pathway for lung cancer patients in place at the time. We also found that the diagnostic pathway being used, was inadequate for all patients, not just for A or other patients with high grade cancer. We found that due to a shortage of respiratory physicians at the time, there was a delay in arranging a review with the respiratory consultant. This resulted in delays to the biopsy which delayed a treatment plan. The board have accepted that the pathway for A was delayed and have made improvements to enable patients to follow the optimal lung cancer pathway. We found that there was an unreasonable delay in carrying out a respiratory review and that this, and a lack of formal pathway, had a significant impact on A’s overall treatment plan and experience. Therefore, we upheld C’s complaint.

C complained about the care and treatment that they received when they attended the board’s urgent care centre with sudden hearing loss in their right ear. C’s hearing loss became permanent and they felt that this could have been avoided. We took independent advice from a consultant in emergency medicine. We found that the board’s assessment of C was unreasonable. While a clinical assessment was undertaken, a clinical hearing assessment was not, which meant that the cause of C’s acute hearing loss was not ascertained. This could have led to alternate treatment options. The board also failed to provide reasonable advice on what to do if C’s symptoms should continue after five days. The board’s response did not reasonably reflect the records available, and their investigation did not identify the failings in C’s care. Therefore, we upheld C’s complaint.

C complained about the nursing care and treatment provided to their parent (A) who was admitted to hospital after a fall. We took independent advice from a registered nurse. We found that there were unreasonable time gaps between care and comfort checks, making it impossible for the board to provide assurance that appropriate checks were completed. We found that the necessary risk assessments and care documentation were not completed to the required standards, with no person-centred care plan in place for A. We also found that the standard of record-keeping was unreasonable. Therefore, we upheld this part of C’s complaint. C complained that the board had failed to provide them with timely updates on A’s care and treatment. The board accepted that C was not provided with appropriate updates regarding changes to A’s health. We upheld this part of C’s complaint. C also complained about the board’s communication in response to their complaint. C said that the board had not investigated their concerns about A’s dementia diagnosis and reduced capacity, and had referred in the complaint response to allegations by nursing staff about C’s behaviour which detracted from the complaint. We found that the board had shared the issues for investigation with C, inviting correction. We also found that it was reasonable for the board to take into account the experiences of the relevant nursing staff when responding to concerns C had raised. Therefore, we did not uphold this part of C’s complaint.

C complained on behalf of their spouse (A). A was taken into hospital with COVID-19 and low blood sugar and was discharged after two days. That night C was concerned that A’s condition had deteriorated. A was taken to ICU and died 4 days later. The cause of death was recorded as COVID-19, ketoacidosis (where a lack of insulin causes harmful substances called ketones to build up in the blood) and renal failure. C considered that A had been discharged inappropriately in the first instance. The board explained that A was frail. They came into hospital with chest pains from COVID-19 and were checked for pulmonary embolism. A was discharged appropriately but unfortunately deteriorated rapidly at home. Every effort was made to treat A on readmission. We took independent advice from a consultant physician, specialising in acute medicine. We found that A had a poor state of health prior to admission, that their discharge on the first occasion was reasonable and that there was no way the discharging team could have predicted A’s subsequent deterioration. Upon A’s second admission, medical teams and intensive care teams provided a reasonable standard of management and care. Overall, we considered that the care and treatment had been reasonable and that there was no requirement for a Severe Adverse Event Review or Duty of Candour to be initiated. Therefore, we did not uphold the complaints. Related reading View Decision Report 202303760 as a PDF (24.52 KB) Updated: October 23, 2024

C complained about the care and treatment provided by the board during and after the birth of their child. Following the birth of their child, C received a perineal (space between the anus and vagina) repair. C complained that the stitching was incorrectly carried out and that this subsequently caused ongoing pain and tightening of the vagina. At a consultation with a gynaecologist (specialist in the female reproductive system) the following year, it was identified that C had a thick band of skin at the vaginal opening. There was also a concern about pelvic floor muscle tightness which indicted vaginismus (an involuntary tensing of the vagina when something is inserted into it). C was referred to physiotherapy. As this was not successful, an operation to remove the thick band of skin was undertaken with the explanation that it was unlikely to improve the tightness of the muscles. C was also referred for psychosexual counselling. C complained that they did not receive a follow-up after the operation and that they had not received an appointment for psychosexual counselling. The board reassured C that their perineal repair was performed correctly. However, they explained that unfortunately vaginismus can occur after any vaginal repair procedure. They noted that it was not always standard practice to follow up patients after gynaecology surgery but C had been added to the routine waiting list which was approximately one year. The waiting time for a psychosexual counselling appointment was 91 weeks. They apologised for C’s wait. We took independent advice from a consultant gynaecologist. We found that the perineal repair was reasonable and that the decision to offer physiotherapy, then the operation was reasonable. It was also reasonable to refer C for psychosexual counselling. Offering a follow-up review was not standard after elective gynaecological surgery. We considered that care and treatment, from the birth until the operation, was reasonable. We acknowledged that

C complained that the board failed to provide their sibling (A, a prisoner) with medication in a reasonable manner. C complained that the injection for A’s condition was not administered in line with the prescribing consultant’s instructions and that the board’s view that the acknowledged delays did not negatively impact A was unreasonable. C was also unhappy with the way that A’s other medications were managed. We took independent advice from a GP. We found that there was an unreasonable delay when one of the injections was administered and guidance did not support the board’s view that no detriment would have been caused by this delay. We also found that the record keeping for the other medications administered during that period did not indicate that other medications were provided at regular intervals. This was unreasonable. Therefore, we upheld this part of C's complaint. C also complained that the board unreasonably failed to arrange or rearrange hospital appointments for A. We found that some elements of this complaint were outwith the board’s control, in relation to third party organisations being involved in transportation. Whilst there were instances where A’s transport requests were not sent within the timeframes set out by guidance, overall we considered that the board’s efforts to schedule transport were reasonable. Where an appointment was cancelled due to transport issues, the board took quick action to reschedule the appointment and rearrange transport. This was reasonable. Therefore, we did not uphold this part of C's complaint.

C complained about the care and treatment that they received from the board. C attended hospital to have their gall bladder removed by laparoscopic cholecystectomy (keyhole surgery). The surgery was abandoned and C did not understand why. C also complained that communication was unreasonable. The board advised that C had a high body mass index which made the operation challenging. This was explained at C’s first consultation. Prior to the operation C was referred to the high risk clinic and the risks of the operation were fully discussed with an anaesthetist. The surgeon was also appropriately consulted by email. During the operation, C became wheezy and medication was administered to manage this. When C had stabilised, the operation had to be abandoned because the surgeon was unable to visualise the gall bladder and therefore could not safely complete the surgery laparoscopically. We took independent advice from a consultant general and colorectal surgeon (specialist in conditions of the colon, rectum or anus). We found that the decision making in surgery was appropriate and that the team had made a reasonable effort to explain why the surgery had been abandoned. However, we found that C could have been referred to weight management services when they were first put on the waiting list for surgery and that the high risk clinic was only six days before the operation, which was not enough time for C to fully consider the risks. We also considered that the surgeon should have been at the high risk clinic to discuss and assess the situation with C and that advice should have been sought from a regional specialist bariatric centre prior to proceeding with surgery. Therefore, we upheld both parts of C’s complaint.