SPSO Individual Decisions

C complained to us that the board failed to provide them with reasonable care and treatment during an appointment for a cataract procedure. We took independent advice on the complaint from a consultant ophthalmologist. We found that the scratch on the lens was not caused by the doctor but rather by the folding process of the lens in the lens introducer. However, it was unreasonable that a large scratch on the lens had not been identified after it had been inserted during the procedure. Had the issue been noticed at the time of the procedure, C would have been put into an informed position regarding the issue, of the symptoms that they would likely experience and the plan to remedy the issue. It could have been resolved much sooner, thereby lessening the pain and discomfort C endured over an extended period of time and the subsequent effect this had on their life. C also complained that the board failed to provide reasonable follow up care and treatment following the appointment. We found that early follow up and intervention by the board would have allowed for a relatively straightforward lens exchange. Better information and communication throughout this process would have allowed for smoother patient care. Therefore, we upheld both of C’s complaints.

C complained about the care and treatment that they received from the board when under the care of orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) for foot surgery. We took independent advice from an orthopaedic adviser. We found that the bones of C’s toe had been reset in the wrong position and the fixation was unreasonable. We also found that C was unreasonably managed at their first post-operative review, noting that C’s x-rays were described as satisfactory which was not the case. The decision to watch and wait was also unreasonable, as by this point a good outcome from the surgery would not have been possible based on the x-rays. We considered that it was unreasonable for the board to discharge C from orthopaedics at the next review appointment when the problem remained unresolved. There were aspect of C’s care and treatment which we found were reasonable, particularly in relation to the three further surgeries C received. However, we recognised that that these had only been necessary due to the failure which had occurred during the original surgery. On balance, we upheld this part of C’s complaint. C also complained about the board’s handling of their complaint. We found that the board’s response contained factually inaccurate information, that there had been delays in complaint handling and that there had been a failure to update C during this time. We upheld this part of C's complaint.

C complained about the care and treatment provided to their spouse (A). A stayed in critical care wards after surgery and acquired wounds to their back and shoulders. C complained that A’s wounds were not appropriately documented or treated. In response to C’s complaint, the board acknowledged that documentation of A’s wounds was not started in critical care wards, and A’s wounds were not initially logged on the board’s system for reporting adverse events. The board told us that after C’s complaint, the tissue viability service developed online learning for staff, and developed and promoted a wound management policy. The board apologised that A sustained wounds after surgery. We took independent advice from a nurse with a specialism in wound care. We agreed that the board did not reasonably document C’s wounds; however, we also found that they did not follow their guidelines in treating A’s wounds. We found that there was a delay in referral to a tissue viability specialist; a lack of skin inspection; inadequate repositioning to prevent pressure damage occurring or deteriorating; and inappropriate wound management. We also found that the board did not provide C with a full and informed complaint response. Therefore, we upheld C’s complaints.

C underwent a coronary artery bypass surgery (a surgical procedure that creates a new path for blood to flow around a blocked or partially blocked artery in the heart). C required three further surgical procedures on their chest wound over a period of seven years after their bypass surgery. C’s chest wound developed a sinus (a track that extends from the surface of an organ to an underlying area) and did not heal properly. C also developed osteomyelitis (a bone infection) in their chest wound. C raised concerns about the care and treatment that they received from the hospital. We took independent advice from a consultant cardiac surgeon. We found that the clinical treatment provided to C was reasonable. However, we found that the hospital failed to provide timely discharge information after C’s bypass surgery and after C’s surgery over a year later. We also found that the hospital failed to reasonably follow up C after discharge from two of their surgical procedures. Therefore, on balance, we upheld C’s complaint.

C complained about arterial surgery. The board accepted that there were issues related to the surgery and communication with C before the procedure. We took independent advice from a cardiology adviser. We found that there was nothing to suggest that there was poor clinical practice or decision making and found that, overall, the clinical treatment provided to C was reasonable. We did not uphold the complaint. Related reading View Decision Report 202202641 as a PDF (23.95 KB) Updated: January 24, 2024

C complained about the care and treatment provided to their parent (A) during their admission to hospital for a knee replacement. A said that they woke up during their surgery. The board responded to the complaint noting that there was no evidence A woke up during surgery. C and A were unhappy with this response and brought their complaint to our office. We took independent advice from a consultant anaesthetist (specialist doctors responsible for providing anaesthesia and pain management to patients before, during and after operations and surgical procedures) and asked the board to comment on issues we had identified. The board explained that A had been under a deep sedation during the procedure and provided further details about the management of A's sedation. They confirmed that A had to receive a 'top up' in medication during the procedure and had reflected on the manner of their complaint response and the detail they had originally provided and offered to make an apology to A. We found that the procedure was undertaken with a spinal anaesthesia and sedation rather than under general anaesthetic. We noted that the board's explanation with respect to managing A during the procedure was reasonable but confirmed that A did wake up. A did not appear to be aware this could be a possibility given they were not under general anaesthetic. We considered that while A did wake up, this was not due to inappropriate or unreasonable levels of care. Indeed, it was possible it could happen and it was handled appropriately. Therefore, we did not uphold C's complaint. However, we concluded that the board should have acknowledged that A woke up during the procedure and provided C and A with an explanation as to why this happened and how this was managed. Therefore, we found that the hospital failed to appropriately investigate and respond to C's complaint and made a recommendation to address this.

C complained about the treatment that they received from the Golden Jubilee National Hospital. C had surgery to address a non-union of the bones in their mid-foot. Just under a year after their surgery, C submitted a complaint to the hospital, noting that the surgery had failed and that they required a second operation due to the non-union of the affected joint in their foot. C said that they accepted that non-union was a known risk of this surgery. However, having reflected on their experience and having discussed their case with another orthopaedic specialist (a specialist in the treatment of diseases and injuries of the musculoskeletal system), C believed that the care provided by their consultant was inadequate and may have been a contributing factor in the failure of their surgery. We took independent advice from a consultant orthopaedic surgeon. We found that, whilst there was some confusing communication as to the type of surgery that C would undergo, the consultant's choice of procedure was reasonable and the reasoning behind it was valid. C's case was not straightforward due to a previous failed fusion surgery. We were satisfied that the clinical treatment provided was reasonable and that the actions of the board's staff did not contribute to the failure of the joint to fuse. However, we were critical of the board's decision to discharge C before it was clear that their surgery had been successful. Whilst the outcome would not have been any different for C surgically, ongoing monitoring and review would have allowed for potential issues to have been identified sooner and for the clinical team to have had discussions with C regarding the status of their fusion and their ongoing treatment options. Overall, whilst we found that the clinical care and treatment was reasonable, we were critical of C's early discharge and the quality of the communication from the clinical team. Therefore, we upheld C's complaint.

C complained on behalf of their sibling (A) about the treatment A had received from the Golden Jubilee National Hospital. A had emergency surgery to repair a dissected aorta (a tear in the heart) and a pacemaker fitted. Following A's surgery, they suffered a ventricular fibrillation (abnormal heart rhythm) resulting in cardiac arrest. It was later established that A's ventricular fibrillation had been caused by an incorrectly programmed pacemaker. C complained to the hospital about how this could have occurred. We took independent advice from a cardiologist (a doctor who can diagnose, assess and treat patients with diseases and defects of the heart and blood vessels). We found that A's external pacemaker had been incorrectly programmed and there was a failure to manage the resulting R on T event (when the temporary pacemaker delivers an electrical impulse to the heart at an inappropriate time causing an abnormal rhythm) leading to A's cardiac collapse. We found that the hospital had failed to provide A with a reasonable standard of treatment and upheld this aspect of C's complaint. C also complained that following A's cardiac arrest, A was discharged too early from hospital and had not been provided with clear information regarding their cardiology rehabilitation and aftercare, resulting in a delay in A receiving appropriate follow-up appointments. We found that A's post-surgical out-patient review had been delayed by seven weeks without explanation. We also found that the hospital's post discharge communication practice had contributed to the delay in A receiving appropriate cardiology follow-up and cardiac rehabilitation from their local health board. While we found that A's discharge was reasonable, the hospital had failed to provide A with appropriate cardiology aftercare. On balance, we upheld this aspect of C's complaint.

C complained to us about the care and treatment their spouse (A) received at the Golden Jubilee National Hospital. A was referred to the hospital after being diagnosed with aortic stenosis (where a valve has narrowed and is restricting blood flow). We took independent advice from advisers both in cardiology (studies of diseases and abnormalities of the heart) and in cardiology nursing. C raised concern that A's angiogram (a type of x-ray that uses dye to look at blood vessels) was not carried out reasonably, including the aftercare. We found that A's angiogram was carried out in a reasonable manner and the aftercare was appropriate. We did not uphold this aspect of C's complaint. C also raised concern about an unreasonable delay in arranging A's heart surgery. We found that the hospital carried out appropriate tests to decide whether to list A for heart surgery. We also found that the hospital's decision not to proceed with heart surgery was reasonable, due to the risks involved from A's other health conditions. We did not uphold this aspect of the complaint. Related reading View Decision Report 201903410 as a PDF (24.22 KB) Updated: January 20, 2021

C complained about the care and treatment provided by the Golden Jubilee National Hospital. C underwent knee arthroscopy (a type of keyhole surgery used to diagnose and treat joint problems). Around two weeks later, C developed what was considered to be a surface infection, for which they were prescribed antibiotics and given another appointment for later in the week. Two days later, C attended another hospital's emergency department with pain and swelling. They required further surgery to wash out the joint. C complained that the decision to carry out the knee arthroscopy had been unreasonable, and that the care and treatment provided when they had an infection was unreasonable. We took independent advice from an orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the decision to carry out an arthroscopy on C's knee had been unreasonable, as C had severe arthritis and carrying out the surgery was contrary to British Medical Journal Clinical Practice Guidelines. We upheld this aspect of C's complaint. In relation to C's treatment when they had an infection, we found that it was reasonable for the surgeon to consider this to be a superficial wound infection rather than a deep wound infection, and the care and treatment provided for this was reasonable. We did not uphold this aspect of C's complaint.

C complained about the treatment which they received at the Golden Jubilee National Hospital. C had undergone a total right hip joint replacement but post operatively reported problems with right foot drop and loss of sensation in the right foot and leg. C was put on medication and referred to physiotherapy but still remained in pain with loss of sensation. C felt that something must have gone wrong during the surgery. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that there was no indication from the clinical records that complications had been encountered during C’s surgery in that the surgery was completed within normal timescales and that blood loss was within expected levels. It was possible that the sciatic nerve (nerve in the lower back area) could have been inadvertently damaged during the surgical procedure but there was no documentation to support such a view. While we did not uphold the complaint, we noted concerns about the standard of the record-keeping regarding the brevity of the actual operation notes and whether sufficient discussions about C’s high body mass index (BMI, a measure for estimating human body fat) level, which would increase risks of any surgery, were discussed with them prior to surgery. The concerns were highlighted as feedback to the hospital who have already amended their procedures in an effort to improve learning. Related reading View Decision Report 201906930 as a PDF (24.52 KB) Updated: November 18, 2020

C complained that their partner (A) was prematurely discharged from the Golden Jubilee National Hospital following cardiac surgery. The surgery was successfully performed with no reported complications. A was discharged home from hospital as staff deemed they were clinically fit for discharge. C was concerned that A had been discharged as they had severely swollen feet. A's health deteriorated, and days after discharge an ambulance was called as A had severe shortness of breath and a high temperature. A was then admitted to another hospital where they were an in-patient for several weeks. We took independent advice from a cardiology consultant (doctor who deals with diseases and abnormalities of the heart). We found that insufficient action was taken to establish the extent of A's heart failure and possible wound infection prior to their discharge from the Golden Jubilee National Hospital, which amounted to a failing in the standard of care and treatment required. We upheld the complaint.

Mr C complained about the care and treatment provided to him by the hospital when he had been admitted for a biopsy (a tissue sample taken for testing) and insertion of chest drain (a flexible plastic tube is inserted through the chest wall and into the affected area to drain it of fluid). He complained that pain relief had been inappropriate and caused urinary blockage; that there had been a failure to make a referral to his local hospital for urinary issues; and that his relatives had been informed there was a crash in his blood pressure, but that this was then denied. We took independent advice from a surgeon. We found that the referral to Mr C's local urinary team was made appropriately and there was no evidence that Mr C had a blood pressure crash. However, we found that there were failures in Mr C's care and treatment in relation to the management of his pain; his pain was not assessed regularly and in line with the pain assessment chart, and the pain relief that was given was not adequate for Mr C's needs and was not in line with the British National Formulary on prescribing. We also found that management and monitoring of Mr C's urinary output and retention was unreasonable. We therefore upheld Mr C's complaint.

Mr C complained about a number of concerns about the service and treatment he received while in the Golden Jubilee National Hospital. He was admitted to hospital in preparation for receiving a heart transplant. Firstly, Mr C complained about the behaviour and attitude of hospital staff towards him during a grand ward round. He stated that they spoke to him in an aggressive and threatening manner. Although there was no evidence of what members of staff the board spoke to as part of their complaint investigation, we noted that Mr C's medical records contained an entry written by a member of staff not named in the complaint. This case note provided a different account from the one Mr C provided. We did not take a view on which account was the definitive one but concluded that there was not sufficient evidence to confirm Mr C's account. Therefore, we did not uphold this aspect of the complaint. Mr C's second complaint was about the fact that all his teeth were removed in preparation for the transplant surgery. We took independent advice from a consultant cardiologist (a doctor who specialises in the heart and blood vessels). We found that, based on the medical records, it was appropriate for Mr C's teeth to be removed. This was because Mr C's records showed he had significant dental and gum disease. Following transplant, Mr C would have to take long-term immunosuppressant medication. As a result, such dental issues would present an on-going risk of potentially life-threatening infection. Therefore, the hospital's actions were appropriate, and we did not uphold this aspect of the complaint. Mr C's third complaint was that the board did not investigate and respond to his complaint appropriately or reasonably. We found that there were some areas where the board's investigation and response to Mr C's complaint could have been improved. In particular, we highlighted a lack of records of who was spoken with as part of the complaint investigation. However, we di

Mrs C complained about the treatment provided to her father (Mr A) while he was a patient at the Golden Jubilee National Hospital. Mr A had been admitted for planned surgery and subsequently his health deteriorated. Mrs C said that Mr A reported problems with his leg/foot and that these were ignored by staff. Mrs C felt that Mr A should have been sent to the high dependency ward after the surgery so that he would have been better observed by staff and that his outcome would have improved. Mr A was then housebound, had limited mobility, and a poorer quality of life. We took independent advice from a cardiothoracic consultant (doctor specialising in operations of the heart, lungs and other chest organs). We found that the planned surgery was carried out without complications and that it was appropriate to transfer Mr A back to a ward rather than a high dependency ward as there were no concerns noted. When Mr A did deteriorate, he developed respiratory failure (a condition in which the blood does not have enough oxygen or has too much carbon dioxide) which was identified by staff and he was then taken to the high dependency ward. Mr A also had other long-standing medical conditions, which were more likely to have contributed to Mr A's deterioration rather than as a result of the surgery he underwent. We did not uphold the complaint. Related reading View Decision Report 201807384 as a PDF (24.02 KB) Updated: September 18, 2019

Mrs C complained about the care and treatment provided to her late husband (Mr A). Following surgery to remove a tumour on this lung, Mr A was treated for atrial fibrillation (AF - an irregular and usually rapid heart rhythm) with amiodarone (an antiarrhythmic drug). Mrs C complained that the board unreasonably prescribed amiodarone as a first line treatment for Mr A's AF. Mrs C noted that patients prescribed with amiodarone after thoracic (chest) surgery are vulnerable to side effects, and she considered Mr A would have survived had a less dangerous drug been used to treat him. We took independent clinical advice from an adviser. We found that guidance supported the use of amiodarone at the time of Mr A's treatment as it is the drug most likely to restore normal heart rhythm and thereby avoid the consequences of low blood pressure, heart failure or stroke, and its use remains common. We acknowledged that amiodarone may not always be the most appropriate first line treatment option in all cases of AF, however, we were satisfied that it was reasonable for medical staff to reach the view that the benefits of treatment with amiodarone outweighed the risks in Mr A's case. Therefore, we did not uphold Mrs C's complaint. However, we provided some feedback to the board that, despite referring to it on a number of occasions in their response to Mrs C's complaint, they did not have a written protocol on treating post-operative AF following lung surgery. We suggested the board may wish to review their practice on the routine use of amiodarone as a first line therapy in all cases of post-operative AF, and consider producing a protocol on the management of AF after thoracic surgery. We also provided feedback with respect to the content and lack of accuracy of the board's response to Mrs C's complaint and invited the board to make a further apology to Mrs C having reflected on the findings of our investigation and feedback with respect to their complaints handling. Relat

Ms C complained about the care and treatment her mother (Ms A) received at the Golden Jubilee National Hospital. Ms A had bilateral uniportal video-assisted thoracoscopic surgery (VATS - a type of 'keyhole' surgery where only very small cuts (incisions) are made to the body). Ms C was concerned about the length of time Ms A had to wait for surgery, that surgery was not the appropriate treatment and that further investigations were not carried out before the surgery. We took independent advice from a consultant in thoracic surgery (also known as cardiothoracic surgery. It is the field of medicine involving the surgical treatment of organs inside the chest). We found that all investigations necessary for surgery were performed according to the relevant guidelines and that the type of surgery was reasonable and performed within a reasonable length of time. We did not uphold Ms C's complaint. Related reading View Decision Report 201707842 as a PDF (23.77 KB) Updated: July 24, 2019

Mrs C complained on behalf of her husband (Mr A). Mrs C said Mr A had undergone an operation on his heart, which they had believed would be routine and uncomplicated. Mr A suffered serious complications during the surgery, resulting in a long period of recuperation and life altering consequences. Mrs C said they accepted that what had happened was a recognised risk of the surgery, however, she complained that Mr A had not been provided with adequate information during the consent process. Mrs C felt her complaint had been poorly handled, and although the board had apologised to Mr A, Mrs C was unhappy with this response. We took independent medical advice. We found that Mr A was not provided with sufficient information during the complaints process. The advice also stated that the board needed to ensure that consent was taken early enough to allow patients to consider properly the potential complications and risks associate with their surgery. We found that the board's response to the complaint was reasonable in terms of practical solutions to the failings identified, but that they had not fully accepted responsibility for the failings, which devalued the apologies they offered. We upheld both aspects of Mrs C's complaint.

Mr C, an advocate, complained on behalf of his client (Miss A) about the post-operative care Miss A received at Golden Jubilee National Hospital. Miss A underwent a total hip replacement and was discharged under a week later. Miss A complained that she did not feel ready to return home so soon after surgery and wished to be admitted to a community hospital to recuperate. She was advised that she did not meet the criteria for admission to a community hospital, so she arranged to be transferred to a nursing home. Miss A said that, prior to her discharge, no one had explained to her she would have to pay to stay in the nursing home. She also complained that no referrals had been made for physiotherapy (the treatment of disease, injury or deformity using physical methods such as massage, heat treatment, and exercise) or occupational therapy (a method of helping people who have been ill or injured to develop skills or get skills back by giving them certain activities to do), and said that her recovery time was longer as a result. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that Miss A's discharge and arrangements for follow-up care were reasonable. We noted that Miss A's concerns had been discussed with her and extra help for when she returned home was offered but declined. Miss A had been assessed as having achieved her rehab goals while an in-patient and was assessed as being safe for discharge home. We did not find any evidence why Miss A would have expected to receive respite care following her surgery. Therefore, we did not uphold Mr C's complaint. Related reading View Decision Report 201800979 as a PDF (24.19 KB) Updated: May 22, 2019

Mr C complained on behalf of his late wife (Mrs A) about a decision by staff at the Golden Jubilee National Hospital not to perform a heart transplant on her. Mr C highlighted that Mrs A had been working to lose weight so she could potentially receive a heart transplant. Mr C was concerned that Mrs A was not given the opportunity to be included in the major decision made not to allow her a transplant. We took independent advice from a consultant cardiologist. We found that there was evidence to support that much consideration had been given to the heart transplant and that Mr C and Mrs A had been reasonably involved in the decision making. We did not uphold the complaint. Related reading View Decision Report 201701694 as a PDF (10.89 KB) Updated: December 2, 2018

Mrs C complained that, following a foot operation at the Golden Jubilee National Hospital, she continued to suffer pain and discomfort. During the surgery a bone fractured and had to be fixed by a wire. Mrs C reported continuing problems and was reviewed at both the Golden Jubilee National Hospital and the orthopaedic department of her local hospital, where it was established that she had also suffered a further complication of the surgery where there was a non-union of the bone. Mrs C believed that the original surgery had not been performed properly and that she had not been told of the risks of surgery prior to her operation. We took independent advice from a consultant orthopaedic surgeon. We found that both the bone fracture during the surgery and the subsequent non-union of the bone were recognised, but rare complications, of the surgery. We found that there was no indication that the original surgery was not performed to a satisfactory standard. The fracture was caused when inserting a screw in order to fix a bone into place and we found that it was appropriate to change the fixation method to wire when the bone fractured. The two complications of the surgery which affected Mrs C were not specifically mentioned in the operation consent form as they were rare; however, it was found that the actual risks mentioned on the form were adequate as they had identified the most common types of complications. We did not uphold the complaints. Related reading View Decision Report 201707403 as a PDF (11.24 KB) Updated: December 2, 2018

Mr C had a scan at the Golden Jubilee National Hospital. A mass was discovered on his lung, which could have been either a spread of his existing bowel cancer or a new lung cancer. His consultant arranged some tests to help determine which it was, but because they were busy, they asked another consultant to carry out the tests. Both consultants thought that the other would be responsible for Mr C's ongoing care, so neither of them wrote a discharge letter. While Mr C attended a follow up appointment at the second consultant's clinic, he saw another doctor who referred him back to the first consultant, instead of to the multi-disciplinary team (MDT), which is what should have happened. The first consultant did not see the referral. Mr C and his GP both tried to contact the first consultant to find out what was happening, but it is not clear whether Mr C's phone messages were passed on and his GP's letter was not seen by the first consultant. Eventually, about six months after the scan, Mr C's GP spoke with the first consultant, who then referred Mr C to the MDT for consideration and Mr C was offered palliative radiotherapy. Mr C was told that his cancer was terminal, and he was concerned that the delay may have affected this outcome. He complained to the board about this. In response to Mr C's complaint, the board accepted that there was an unreasonable delay and a failure to communicate with Mr C about his treatment. They apologised for this and said that they had taken action to prevent this happening again. The board had put in place a new protocol for passing care between two consultants, and a message book to ensure phone messages are recorded and signed off by consultants. The board said that the delay would not have affected the outcome in Mr C's case, although they acknowledged that palliative radiotherapy should have been offered sooner. Mr C remained unhappy and brought his complaints to us. We took independent advice from a thoracic surgeon (a

Ms C, an advocacy and support worker, raised a complaint on behalf of her client (Mr A) about the care and treatment he received for a bunion from Golden Jubilee National Hospital. Specifically, she complained that appropriate surgery was not carried out, that the cause of infection following surgery was not properly investigated and that Mr A had not been advised of the problems which could occur with the surgery. We took independent advice from a consultant orthopaedic trauma surgeon and found that there was evidence to support that discussion had taken place with Mr A about the recognised complications associated with the bunion surgery. Some of these included the possible risk of non-healing and a need for further surgery. We considered that the surgery was appropriate and that, whilst there was no clear evidence of infection post-surgery, it was appropriate to consider the possibility of infection when Mr A experienced problems following his surgery. We noted that the board had apologised to Mr A regarding the lack of communication about this. We concluded that there was no evidence of unreasonable treatment and that delayed healing had been the likely reason for Mr A's protracted recovery. We did not uphold the complaint. Related reading View Decision Report 201605577 as a PDF (11.21 KB) Updated: March 13, 2018

Mr C complained about the care and treatment provided to his late wife (Mrs A) at Golden Jubilee National Hospital. Mrs A had been diagnosed with bladder cancer by another health board, but before being able to receive treatment for the cancer had suffered a heart attack. She was referred to the hospital for cardiac surgery. Mrs A was to receive treatment for the bladder cancer after having cardiac surgery. However, by the time she had recovered sufficiently from the cardiac surgery, the cancer had progressed and curative treatment was no longer possible. Mr C said that there had been unreasonable delays in Mrs A undergoing cardiac surgery, that informed consent had not been obtained for Mrs A's cardiac surgery, and that there had been unreasonable failings in communication between the specialists treating Mrs A. We took independent advice from a cardiac surgeon. The adviser commented that the hospital could have considered treating Mrs A as an in-patient at an earlier point, as this may have been a more holistic approach given her co-existing cancer diagnosis. However, we found that although Mrs A's cardiac surgery had been postponed several times, it was still carried out in a reasonable and appropriate timeframe from a cardiac point of view. Mr C had been concerned that staff at the hospital were aware that Mrs A would not be able to undergo treatment for her bladder cancer and therefore her consent to undergo cardiac treatment, which had been based on her understanding that without it she would not be able to have her bladder cancer treated, was not fully informed. Our investigation found that throughout Mrs A's patient journey at the hospital, all staff had been working under the impression that her bladder cancer was operable. We did not uphold this aspect of Mr C's complaint. We found that after Mrs A's cardiac surgery, staff at the hospital failed to send a discharge letter to the other health board to inform them that the surgery had been successfu

Mrs C underwent cataract surgery to her right eye at the Golden Jubilee National Hospital and had no concerns. However, she then complained about the care and treatment she received following subsequent cataract surgery to her left eye because she was experiencing pain and double vision. Mrs C was concerned that she was not informed prior to the operation that a different doctor would be performing the second surgery, that her left eye was not properly anaesthetised, and about the lack of treatment after she raised her concerns, post-surgery. We took independent medical advice and found that it was reasonable for a different doctor to have performed the second surgery. However, we found that it should have been properly explained to Mrs C when she consented to the surgery that it could be a different doctor. In addition, we found that the consent form did not clearly state all of the known risks and complications of her surgery, which would have been accepted good practice. There was documentation indicating that some form of conversation took place with Mrs C about the risks of post-operative inflammation and the possibility that further surgery might be needed. However, we were critical that it was not clearly completed and recommended the board take further action to address these two issues relating to the consent process. However, we did not uphold Mrs C's complaint on the basis that there was no definitive evidence to support that there was a problem with the anaesthetic or the operation itself. There was a small amount of plaque left behind but we considered it was reasonable not to remove it due to there being an increased risk of complications if removed. We considered that it was reasonable for Mrs C to be discharged to the care of her optician after the operation. We noted that the optician referred Mrs C to a different hospital when she experienced pain and inflammation in her left eye, and that the care plan was to carry out further surgery. We