SPSO Individual Decisions

C complained that the board did not take reasonable action regarding their referrals. C was privately assessed by specialists in England, who recommended hospital admission for tests. C informed Highland NHS Board and it took over 18 months to approve and arrange referrals. We found that there was an unreasonable delay in progressing C’s respiratory referral and that the board’s communication was inadequate. The board failed to provide reasonable updates, which might have revealed sooner that the hospital C had been referred to had not received their original submission of the referral. Given this, we upheld the complaint. We found that the board unreasonably delayed C’s neurology referral. The board’s said that the delay was due to uncertainty over a consultant’s approval for MRI imaging and whether C wished to remain a private patient. We found that C had advised that they would request private care be paused pending the board’s multi-disciplinary team discussions. While the decision to refer C to another NHS Board was reasonable, taking six months to action this was not. We upheld the complaint. Finally, we found that communication with C was inadequate. Given this, we upheld this complaint and note the steps that the board have taken to address this.

C complained on behalf of a family member (A) about the care and treatment that A received during two presentations to hospital following a fall at their home. Prior to their fall, A was fit and well and independent for activities of daily living. During our investigation the board had accepted that there were failings and had taken action to address these. This included using this case as a case study to ensure any training and development requirements were implemented, delivering training sessions on significant adverse events review and carrying out a review of the duty of candour arrangements which would include training. We took independent advice from a consultant in emergency medicine and a trauma and orthopaedic consultant. We found serious failings in A’s care and treatment and that a number of red flags (specific symptoms or signs that indicate a potentially urgent or serious underlying condition requiring immediate medical attention) had been missed in this case. In particular, we found that there was a failure to take into account relevant national guidance and to perform imaging which meant that the fractures of the vertebrae in A’s thoracic spine were undiagnosed. There was also a failure to take account of the National Institute for Health and Care Excellence guidance which the board had accepted. We found that it had been unreasonable that A had been left to sit during their second visit to hospital for a prolonged period before being assessed given their symptoms. There were also missed opportunities to complete a more thorough neurological examination with a failure to appreciate the presence of a spinal injury and to realise the significance of the signs of limb weakness and incontinence. We also found that the board failed to immobilise A while awaiting the results of a CT scan and during their transfer between hospitals. In view of the failings identified, we upheld C's complaint. During our investigation, we identified issues with the board’s h

C complained about the care and treatment provided to their late parent (A). A was admitted to hospital due to a nose bleed that would not stop. During admission, A used a hospital trolley to cross the ward to the toilet. A jug of water spilt from the trolley and A fell, sustaining a fractured shoulder and a fractured knee. C was concerned about A’s medical and nursing care and about the communication from the board. We took independent advice from a nursing adviser and a consultant geriatrician. We found that the falls screening questions were not completed on A’s admission, safe care pauses were not demonstrable from the daily care plan or nursing documentation, A’s walking aid was not within reach and a decision was made to mobilise A when the floor was wet, rather than call for help and ensure the environment was safe. We found that the board’s investigation into A’s fall did not make attempts to identify the second staff member who witnessed the fall and take a statement from them. There was also a failure to activate the Duty of Candour process in this case. We found that A’s B12 injection should have been administered in a more timely way and that medical staff did not promptly inform C and their family of the results of the X-rays and the implications of the fractures for A. Finally, we found that the board did not respond to all of the concerns that C raised. We upheld C’s complaints.

C complained about the care and treatment that the board provided to their parent (A). The complaint relates to several different primary and secondary care services, including A’s medical practice, which was managed directly by the board. A had a long history of peripheral arterial disease (a condition where a build-up of fatty deposits in the arteries restricts blood supply to leg muscles). A experienced gradually worsening pain in both their legs and had contacts with the Out of Hours (OOH) service, their GP and the board’s vascular team. Ultimately, A was admitted to hospital due to worsening critical limb ischaemia (severely blocked flow to one or multiple hands, legs or feet). It was decided to amputate A’s leg but, following the surgery, A’s condition deteriorated. They were diagnosed with myocardial infraction (a heart attack) and died in hospital. C complained about several aspects of A’s care and treatment which covers both the period up to, and the time during, A’s admission to hospital. Firstly, they complained that the OOH Advanced Nurse Practitioner (ANP) failed to provide reasonable care and treatment. The board’s position was that the care and treatment provided by the ANP was reasonable but they apologised that C and A had been given the expectation that an OOH GP would attend. We took advice from an independent GP adviser. We found that the care and treatment provided was reasonable, and that the ANP had appropriately reviewed A’s medical history before attending. Therefore, we did not uphold this complaint. C’s second complaint related to A's medical practice. C stated that a GP in the practice had unreasonably failed to diagnose A’s condition correctly and provide appropriate treatment. The board concluded there were missed opportunities to see A face to face. However, they considered the practice’s clinical decision-making to be reasonable. We took advice from an independent GP adviser. We found that different GPs may have taken different course

C complained on behalf of their client (B) that the care and treatment provided to B's relative (A) was unreasonable. In response to the complaint, the board acknowledged that there had been failings in the delivery of care throughout A’s hospital stay and explained that action had been taken in response to these failings. We took independent advice from a nurse. We found areas of good practice. However, we found significant and serious failings in A’s care in relation to delirium, observations and vital monitoring, record-keeping and escalation processes. Therefore, we upheld C’s complaint. We recognise the learning implemented by the board which has led to significant learning and improvements to patient care and has addressed the failings identified in this case. During our investigation, we identified issues with the board’s handling of the complaint. We made a recommendation to the board to support improvement of their complaint handling. We also provided feedback that the board should reflect on the advice we received that the score given on the serious adverse event review (SAER) report was not reflective of the failures identified in this case. We also noted that a SAER should be reviewed in a timely manner in partnership with the patient and/or their family/carers and that in this case, A's family should have received regular updates.

C complained on behalf of their relative (A) in relation to the nursing care and treatment that the board provided to A in hospital following orthopaedic surgery. A received nursing care in hospital before being transferred to another hospital for rehabilitation, where they died. In the second hospital, A was found to have a large wound on their foot and C complained that they had been unreasonably transferred with this. We took independent advice from an experienced nursing adviser. We found that the wound care management that A received was unreasonable. We also found that it was unreasonable for the board to transfer A to another hospital without documenting this on the transfer document and without an adequate wound care management plan in place. We therefore upheld these complaints, although we found that the board had subsequently taken action to support improvement with regards to care rounding and pressure ulcer prevention.

C complained about the practice’s treatment and diagnosis in respect of issues C had with their leg over a period of 18 months and being diagnosed with deep vein thrombosis (DVT). In C’s view, the practice missed various opportunities to diagnose DVT or refer onwards to an appropriate specialist. C also raised concerns about the general treatment that they received from when they presented with a lesion on their left leg. The practice had acknowledged that there was a delay in diagnosing C’s DVT. However, there remained uncertainty regarding when the practice should have diagnosed a DVT or explored the possibility of this diagnosis. We took advice from an independent GP adviser. In respect of the DVT, we found that this was a more difficult case of DVT to diagnose. However, there were signs that the practice unreasonably missed. C attended a consultation after they had been on a flight. We found that, from this point onwards, there was an unreasonable failure to fully take into account risk factors and symptoms pointing to an alternative diagnosis of DVT. There were also missed opportunities to carry out appropriate investigations that would have supported or ruled out such a diagnosis. We considered that there was less certainty over whether the DVT was present prior to C’s flight. We upheld this complaint. In respect of the more general care of C’s leg, we found that this was initially of a good standard. However, this became less reasonable as the months went on and C’s symptoms persisted. We found that, at a certain point, the practice were not treating C’s symptoms proactively. We also considered an apparent absence of a dermatology referral, despite C’s records indicating that this was part of the treatment plan. For these reasons, we upheld this complaint.

C complained about the care and treatment provided to their parent (A) by the practice. A was described as fit and well but had developed severe diarrhoea. Although the diarrhoea subsided, A continued to feel unwell and breathless. A was seen by an advanced nurse practitioner (ANP) and referred for an electrocardiogram (ECG) as an outpatient a few days later. A attended for these tests, but was not seen by a doctor, and returned home. A suffered a stroke that afternoon and died in hospital the following day. C complained that although A spoke with a doctor by telephone, they were not seen in person by a doctor over a series of appointments. C believed that A should have seen a doctor much sooner and that A should have been considered for hospital admission at their appointment with the ANP. They also said that A’s ECG results were abnormal, had been misinterpreted by the practice and should have resulted in A’s admission to hospital as an emergency. C believed that had the practice provided a reasonable standard of care, A’s death could have been prevented. Although C met with the practice and received two responses to their complaint, they continued to believe the practice’s response was inadequate and brought their complaint to this office. We took independent advice from a GP. We found that A’s care prior to their ECG was of a reasonable standard. It was noted that C disagreed with A’s medical records, but it was not possible to determine precisely what was said at A’s appointments. We did not uphold these parts of C’s complaint. We found that A’s ECG was highly abnormal, indicating A’s heart was lacking in oxygenated blood flow. This should have resulted in a face-to-face appointment, followed by an immediate hospital referral. Therefore, we upheld this part of C’s complaint. However, it was not possible to determine whether A would have survived with an earlier admission as the cause of A’s death was a bleed on their brain. This was an unfortunate but recognise

C complained that the board failed to provide them with reasonable care and treatment in relation to their breast cancer care. C raised concerns that that the board failed to carry out necessary scans and failed to offer neoadjuvant chemotherapy (treatment given before the primary course of treatment to reduce the size of the tumour). C also complained about the waiting times in relation to surgeries and the mastectomy report; and that the board failed to adhere to the relevant local and national guidelines. We took independent advice from a consultant breast surgeon. We found that the care and treatment provided to C was reasonable. In particular, we found that C did not meet the requirements to receive neoadjuvant chemotherapy prior to surgery and, accordingly, it was not unreasonable that the board did not perform further scans. We found that the waiting times were reasonable. We also found that the board’s medical team had followed relevant local and national guidelines and C had been provided with reasonable care and treatment based on the information available to the clinicians at the time. Therefore, we did not uphold C’s complaint. In relation to complaint handling, we found that C was provided with updates on the progress of their investigation and the reason for the delay. However, C was not given a revised timescale for completion so we provided feedback to the board on this point. Related reading View Decision Report 202303373 as a PDF (24.42 KB) Updated: January 22, 2025

C, an independent advocate, complained on behalf of their client (B). B’s adult child (A) died from an overdose of dihydrocodeine (opioid prescribed for pain or severe shortness of breath). A had been prescribed a number of different medicines by their GP practice including painkillers and benzodiazepines (depressants). B complained that the practice did not appropriately manage the risks of prescribing A such medication. B questioned why prescriptions were issued to A on a monthly basis, rather than weekly or even daily. B also complained that the practice had insufficient regard to A’s history of overdoses and that A should not have been given additional prescriptions on request, as had happened on multiple occasions. Lastly, B was concerned that A had remained with the practice despite having moved a significant distance away. In their response to the complaint, the practice stated that weekly or dispensing does not necessarily prevent the hoarding of medication, and that A had been maintained as patient due to their local GP being staffed primarily by locum doctors lacking a familiarity with A’s situation. They said that while they were aware of A’s overdoses these were often also due to alcohol or illegal drugs. The practice said that they felt A’s requests for additional medication had been genuine and that they needed to balance the risk that A would seek illicit drugs or street medication if suffering from withdrawal. The practice also stated that following this incident they had reviewed their approach to such patients and had recently refused a number of requests to keep on patients living remotely. We took independent advice from a GP. We found that the kinds of medication prescribed to A are implicated in many drug related deaths, often in combination with other substances such as alcohol. Taking into consideration A’s history, their mental health, alcohol misuse and history of multiple drug overdoses, early prescriptions should not have been given to A

C, a support and advocacy worker, complained on behalf of their client (A) that the board unreasonably prescribed A with Flutiform (a type of medication to treat asthma). A presented to hospital with symptoms of severe asthma and was admitted to the high dependency unit for management of their symptoms. Following assessment, A was prescribed with Flutiform. A’s symptoms improved and they discharged themselves from hospital. A complained that Flutiform worsened their symptoms and should not have been prescribed, as they had previously suffered adverse reactions and informed the nurse of this during their assessment at the hospital. In their response to the complaint, the board said that Flutiform was prescribed in line with relevant guidelines and that there was no record of A having indicated that they had previous adverse reactions to Flutiform. We took independent advice from a consultant physician in respiratory medicine. We found that whilst there is some record that Flutiform had not worked well for A, there was no evidence of an allergy in the clinical records. Whilst A recalled that they raised concerns about the use of Flutiform during the assessment, the contemporaneous assessment records, clinical records available at the time, and relevant guidelines supported the conclusion that there was no evidence against prescribing Flutiform to A. Therefore, we did not uphold C's complaint. Related reading View Decision Report 202210978 as a PDF (24.47 KB) Updated: September 18, 2024

C complained about the care and treatment provided by the board in the lead up to the delivery of their twin babies. One of the twins (A) was stillborn. C complained that the board failed to provide reasonable care and treatment during C’s pregnancy. We took independent advice from a consultant obstetrician and gynaecologist (specialist in pregnancy, childbirth and the female reproductive system). We found that while many aspects of the care and treatment were reasonable, the omission of some key measurements and tests was unreasonable and did not accord with guidelines. This impacted on clinicians being able to reach a fully evidenced position on what care was appropriate. Therefore, we upheld this part of C's complaint. C complained that the board failed to reasonably communicate the risks and options available to them. We found that the records indicated that the board reasonably communicated with C in relation to the risks and options available to them. Therefore, we did not uphold this part of C's complaint. C complained that the board failed to reasonably investigate C’s concerns. We found that many aspects of the reviews which were carried out were reasonable. However, we found that the reviews failed to identify that the significance of the lack of the measurements being taken was unreasonable, leading to a delay in identifying learning that could be taken forward. Therefore, we upheld this part of C's complaint.

C, a support and advocacy worker, complained on behalf of their client (B) about the care and treatment provided to B's spouse (A). A experienced urological symptoms including blood in their urine and a number of infections. After a number of investigations, A was diagnosed with bladder cancer which had spread to their prostate. A died a short time later. C raised a number of complaints and we agreed to investigate four main concerns: that the board failed to provide a reasonable standard of urological treatment following insertion of a catheter, the delay in diagnosing A’s cancer; poor communication with B and A, and A’s poorly managed discharge from hospital. We took independent advice from a consultant urologist. C raised concerns that A’s catheter had to be refitted a number of times, which was difficult to do and caused A pain and discomfort. The board explained that a catheter is commonly fitted after surgery and a permanent catheter was fitted due to A’s past urology history and difficulty in emptying their bladder. We found that whilst it was reasonable to insert a catheter, the reasoning behind the decision was poorly documented and that as A required a number of emergency admissions for catheter related issues, the board should have considered an emergency cystoscopy (a procedure that uses a tube to examine the bladder and the urethra) and TURP (transurethral resection of the prostate) and they failed to do this. Whilst it is agreed that A’s case was complex and a number of investigations were required, we found that there was a delay in arranging a diagnostic cystoscopy following an emergency admission, a breach of the waiting time target for cancer referrals and a failure to recognise the significance of paraaortic lymphadenopathy (lymph nodes of an abnormal size) which contributed to the delay in diagnosis of A’s cancer. We accepted that had this delay been avoided, A’s outcome likely would have been the same, although their quality of life would have b

C complained about the care and treatment that their adult grandchild (A) received from the board. A received regular anti-psychotic medication from the board's mental health service. Separately, A suffered from episodes of paralysis, for which they attended A&E on numerous occasions. A died suddenly at home. C complained that the board failed to recognise A was seriously unwell, with their episodes of paralysis wrongly being attributed to their mental health condition. On the day of A's death, A had fainted at the health centre after receiving their injection. C said that A attended A&E for assessment but was discharged without treatment. The board’s response to C’s complaint advised that A had been fully assessed during each of their A&E attendances, with appropriate referral being made to neurology (specialists in the diagnosis and treatment of disorders of the nervous system) and advice sought from the mental health service. The board said that there was no evidence of A attending A&E on the day of their death so were unable to account for the hospital ID band that they had been wearing at the time. The board completed a Significant Adverse Event Review (SAER) in response to C's complaint. We took independent advice from an A&E consultant and a consultant psychiatrist. We found that A received reasonable care from the board during their A&E attendances and confirmed that there was no record of A having attended A&E on the day of their death. We found that the management and review of A’s mental health was both reasonable and appropriate. Therefore, we did not uphold C's complaint. We found that the board's complaint response was delayed following the conclusion of the SAER. Therefore, we made a recommendation on complaint handling in keeping with our powers to monitor and promote best practice.

C complained about the care and treatment provided to their late spouse (A). A was admitted to hospital with a suspected small bowel incarcerated in the hernia (a part of the intestine that becomes trapped in the sac of a hernia). Following a CT scan and assessment by a surgeon, it was decided to treat A’s condition conservatively and transfer them to a larger hospital in the area. However, there was a delay in the transfer taking place due to a lack of ambulance resource and A’s condition deteriorated further during their admission. A died shortly after admission. C complained about the delay in transferring A to another hospital or operating on them sooner. In C’s view, A did not receive a reasonable standard of treatment or end of life care following their admission to hospital. In addition to this, C complained about the board’s communication with the family during A’s time in hospital. We took independent advice from an emergency medicine consultant and a general and colorectal surgeon (specialist in conditions of the colon, rectum or anus). We found that the treatment provided by the board was reasonable. In light of A’s presentation, and without the benefit of hindsight, it was reasonable to treat A conservatively and arrange for a transfer to a better resourced centre. We also found that the end-of-life care provided to A was reasonable, given A’s rapid deterioration and the circumstances within the hospital at that time. Therefore, we did not uphold this part of C’s complaint. In relation to the standard of communication with the family, taking into account A’s rapid deterioration and the circumstances within the hospital at the time, we concluded that communication was reasonable. Therefore, we did not uphold this part of C’s complaint. Related reading View Decision Report 202203142 as a PDF (24.59 KB) Updated: May 22, 2024

C complained about the care and treatment provided to their adult child (A) in relation to A’s pregnancy. A attended hospital on two occasions over a weekend with no fetal movement. The baby (B)’s heartbeat was considered normal on both occasions and A left the hospital with a plan to return on the Monday. On A’s return to hospital, an intrauterine death (when a child dies in the womb) was diagnosed. A requested to have their waters broken to relieve the pressure that they were experiencing. A ‘s labour was very quick and they delivered B in the toilet of the labour suite at the hospital. They called for a midwife to attend and assist them. C complained that the hospital did not listen to their concerns for B to be delivered as an emergency. C and A believed that there was too much focus on B’s heartrate and that further investigations, including ultrasound, should have been undertaken. C also complained about the difficult circumstances of B being born in the toilet, and the care provided in the run up to, and following, labour. In response to the complaint, and following the completion of a Significant Adverse Event Review (SAER), the board found no specific failings of care which led to B’s death. Monitoring of A and B was appropriate, and ultrasound scanning was not available over the weekend. The board noted that A had chosen to return home, rather than be admitted over the weekend which was against medical advice. The board explained that early delivery by caesarean section was not indicated given the clinical picture was reassuring. C and A met with representatives from the board following the complaints response where issues relating to the delivery of B were discussed. The board acknowledged that a midwife should have responded to A’s calls that they were delivering B in the toilet, and acknowledged that A should not have been in a labour ward where they could hear other mothers and healthy babies. C was dissatisfied with this response and brought their com

C complained about the actions taken and treatment provided by the board in respect of their pregnancy. C reported reduced fetal movements and was admitted to hospital with vaginal bleeding. The hospital discharged C as the vaginal bleeding settled and all clinical assessments undertaken were within normal parameters. However, C returned to hospital with significant vaginal bleeding and was diagnosed with placental abruption (a condition in which the placenta starts to come away from the inside of the womb wall). C’s baby was stillborn shortly after. In C’s view, the board failed to take into account warning signs or carry out an appropriate assessment when they were admitted to hospital. C feels the outcome would had been different if their baby had been delivered at an earlier opportunity. The board acknowledged some failings in respect of delays caused by the hospital triage process, IT issues and signage. However, they concluded that these delays were unlikely to have made a difference to the outcome. The board were also satisfied that the broader treatment provided to C in respect of their pregnancy was appropriate. We took independent advice from an adviser with an extensive background in obstetrics and gynaecology (a specialist in pregnancy, childbirth and the female reproductive system). We found that the board’s management of C’s pregnancy was reasonable and in line with relevant national guidance. There was no evidence that the board unreasonably failed to take any actions that they should have. Nor did it indicate that they unreasonably missed any warning signs pointing to this outcome. We noted that guidance prioritises the aim of prolonging the pregnancy in the absence of any signs of maternal or fetal compromise. In addition, we considered the staff’s actions to be reasonable when C presented at hospital. We agreed with the board’s conclusion that it was unlikely that the outcome would have been different had C not encountered the delays at the hospita

C complained about the standard of care and treatment provided to their parent (A) whilst A was in hospital. C's concerns covered A’s medical care, nursing care and physiotherapy care. C said that A’s myeloma (blood cancer) treatment was delayed by a failure to provide the specialists treating A with blood samples for analysis. Additionally, A was not given an infusion correctly, as nursing staff failed to give A intravenous fluids first to ensure A was hydrated. C felt A’s pain relief was inappropriately managed, with A’s medication being unnecessarily reduced, resulting in A suffering significant and avoidable pain. C also believed that A was injured during a physiotherapy session and that this contributed to A’s decline. We took independent advice from a registered nurse, a consultant haematologist (specialist in the the diagnosis and treatment of patients who have disorders of the blood and bone marrow) and a chartered physiotherapist. We found that nursing staff had not followed written instructions for the administration of A’s treatment, and A’s records showed that they had consumed only around 15% of the food and water that they should have in the period leading up to the infusion treatment. Nursing staff could not therefore have ascertained that A was properly hydrated. Nursing staff did not appear to have taken all the requested blood samples from A, and they had not taken steps to address A’s pain management. Therefore, we upheld this part of C's complaint. In relation to A's medical care and treatment, we noted that their condition was progressing rapidly and that they had already had a number of treatments. The decision that A was not suitable for further treatment was not impacted by the missing blood sample and overall, we found that the medical care A received was reasonable. Therefore, we did not uphold this part of C's complaint. In relation to A's physiotherapy care, we found that there was no evidence within the physiotherapy records th

C complained that their cancer diagnosis was unreasonably delayed. They had previously suffered from cancer which had been successfully treated. C believed there was an inappropriate focus on the wrong part of their throat as a consequence, and that this combined with inadequate review of the CT imaging of their oesophagus had resulted in a delayed diagnosis, much more significant surgery and had allowed the cancer to spread to other parts of their body. C believed the extent of the cancer when diagnosed, meant it must have been visible earlier in the diagnostic process. We took advice from a consultant ear, nose and throat surgeon. We found that C was correctly examined and there was no evidence of failings in their care. It was not possible to determine whether earlier diagnosis would have resulted in a different outcome for C. We did not uphold the complaint. Related reading View Decision Report 202204751 as a PDF (24.21 KB) Updated: January 24, 2024

C complained on behalf of their spouse (A) who was admitted to hospital with pain, spams and weakness in their right leg which was later diagnosed as being caused by an infection in the iliopsoas muscles (a group of muscles running from the lower spine to the thigh). A is a dialysis patient and had also previously suffered a stroke, leaving them with weakness on the right side and wheelchair bound. C therefore usually supports A with dialysis and medication. The complaint centres around an incident in the first week of A’s admission when both C and a nurse separately administered A’s evening medication. C stated that they had previously been given the medication by ward staff to support A. C had administered the evening medication and gone out for a few hours. On return, they had found A to be unresponsive. A nurse said that they had also administered evening medication. C complained that this overdose of medication had occurred and that record keeping and incident management had been unreasonable. We took independent advice from a nursing adviser. We considered that this incident should not have happened, and that it indicated a lack of clarity, process, recording and communication within the ward. We found that record keeping before and after the incident had been lacking, as there had been no clear record in a person centred care plan to state that the medication was being held and administered by C, that there had been a 24 hour gap in nursing records over the period of the incident and that no extra observations or conversations with a doctor had been recorded following the incident. We found that categorisation and management of the incident had been unreasonable. We upheld the complaint.

C complained about the care and treatment that they received from the board’s neurology department. C had been reporting symptoms to the board for several years before obtaining spinal surgery abroad. After surgery, C experienced improvement in their symptoms. C complained that the board did not reasonably investigate or offer treatment for their symptoms. We took independent advice from a neurologist and neuroradiologist (a specialist in reading medical images of the spine). We found that the board had reasonably investigated C’s symptoms and offered reasonable treatment for C’s symptoms. We found that there was no missed opportunity to identify any physical problem in C’s spine that may have caused C’s symptoms, based on MR (magnetic resonance, a type of medical imaging) images of C’s spine. Therefore, we did not uphold C’s complaint. Related reading View Decision Report 202111438 as a PDF (24.17 KB) Updated: December 20, 2023

C complained on behalf of B about the care and treatment provided to B's spouse (A) by the practice. A attended the practice on a number of occasions over a few years with ongoing and worsening abdominal and lower back pain. C complained that the practice assumed A was suffering from a musculoskeletal problem and failed to consider other diagnoses sooner. A was later diagnosed with lymphoma and died at the time of diagnosis. In responding to C's complaint, the practice undertook a Significant Adverse Event Review (SAER) and noted it was not clear when the lymphoma started. The practice also found that A had several normal or reassuring examinations and tests, and that several of A's presentations and tests pointed towards other diagnoses including liver disease and prostate disease. The SAER ultimately concluded that it seemed very unlikely that A had lymphoma for a long period of time given the very aggressive nature of their disease. We took independent advice from a GP. We found that a number of tests and investigations were reported as normal and therefore there was no cause to refer A to specialists on suspicion of cancer. However, when concerns were raised about a possible missed renal cause for A's pain, we found that further investigations should have been undertaken at this time. These did not occur until almost a month later. A was suffering from an aggressive and difficult to diagnose cancer and, while the care and treatment provided by the practice was generally considered to be reasonable, the review should have triggered further tests at the time. On balance, we upheld C's complaint.

C was sent to hospital by the GP with a diagnosis of severe cellulitis (an infection caused by bacteria getting into the deeper layers of your skin). Prior to being sent to hospital, C received paracetamol, intravenous fluids and intravenous antibiotics. On arrival at hospital, C had a long wait until being treated and C complained that the delay in admission and treatment was unacceptable. The board apologised that C had to wait in their car and explained that patients were seen on a clinical priority basis. They advised that C's clinical priority was not deemed to be urgent as C had received paracetamol, fluids and antibiotics before arrival. We took independent advice from an acute and general medicine adviser. We found that at the time, there was no clear system for prioritising patients. However, since then the board have improved their practice. We found that the triage which had been undertaken after admission had not followed guidelines. Additionally, we found that the waiting time to receive antibiotics was longer than the recommended maximum wait between antibiotic doses. As such we upheld the complaint.

C complained that the board failed to provide their late spouse (A) with reasonable care and treatment during three attendances at A&E and an admission to hospital. The board said that A complained of pain in their right forearm causing them sleep disturbance. However, there was no indication that imaging scans were required as an emergency. A was already under the care of orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) which was appropriate for the muscle injury A had. Therefore, the assessments, plan, and discharge of A at the first two attendances in the emergency department were appropriate on the basis of what was known at the time. During the third attendance at the emergency department, the board said that investigations indicated that A had a raised marker for infection and inflammation which could have been an indication of underlying condition or malignancy. At this point it was identified that an MRI scan should be carried out, but there was no indication that this was required as an emergency. A was admitted to hospital for further investigations. We took independent advice from a consultant in emergency medicine. We found that appropriate and timely emergency care was provided to A on each of their attendances at A&E. We also noted that a clinical significant event review was carried out. The issues were fully explored and the board had appropriately reviewed and reflected on learning. We considered that A received reasonable care and treatment at A&E and as an inpatient. Therefore, we did not uphold this part of C's complaint. C also complained about the board's handling of their complaint. C said that the board did not contact them during their complaint investigation. They also highlighted that the board did not address all their concerns. We found that the board failed to address and respond to a significant part of the complaint raised by C until prompted to do so by this office. Therefore, we uphe

C, an advocate, complained on behalf of their client (A) about the care and treatment they received from the board. A had attended the board for a chest x-ray following respiratory symptoms but the x-ray was reported as normal. A had a second chest x-ray a few months later which led to them being diagnosed with lung cancer. On review of the first chest x-ray it was found that this had been abnormal and was reported incorrectly. The board's response to C's complaint recognised a mistake had been made by the reporting radiologist (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). The board advised that the chest x-ray had been outsourced to an external provider for reporting, and they had fed back this incident to the provider and radiologist, which had been investigated accordingly. The board apologised to A and confirmed the event met the criteria for duty of candour (a legal requirement on all health and social care providers in Scotland which seeks to ensure there is openness and transparency with the aggrieved party when something has gone wrong, and which seeks to learn from the incident). The board also advised the incident had been reviewed internally and concluded that the mistake had occurred due to human error, and that it was not considered to be indicative of a wider problem within the organisation. We took independent advice from a lung cancer physician. We confirmed that A's diagnosis of lung cancer had been delayed by around three months due to the first chest x-ray being incorrectly reported. We found that it was reasonable for A to have expected the abnormality in their chest x-ray to be identified. However, once the mistake had been recognised, the steps taken by the board had been reasonable in alerting the external radiology company to the problem, and in terms of the board's own internal investigation into the matter. Therefore, we upheld this aspect of C's comp