SPSO Individual Decisions

C complained that Lothian NHS Board (Board 1) unreasonably failed to maintain records of specialist advice they provided to another board (Board 2). C attended A&E at Board 2 with symptoms of significant pain, problems passing urine and lack of sensation. On the specialist advice of neurosurgery at Board 1, C was admitted to the Orthopaedics department of Board 2’s hospital and an MRI was carried out the following day. The MRI scan results were discussed with the Board 1's neurosurgery team, following which C was discharged. C later required emergency surgery and considers the outcome would have been better if they had undergone surgery when they originally attended hospital. When C complained to Board 2, they confirmed that they had relied on the Board 1’s specialist advice but Board 1 had failed to keep a record of the referral. C complained that Board 1 unreasonably failed to maintain records of the specialist advice provided to Board 2. C also complained about the neurosurgery advice provided by Board 1 to Board 2. We took independent advice from a consultant orthopaedic surgeon in relation to the complaint about maintaining accurate records. We found that Board 1 unreasonably failed to maintain records of the specialist advice provided to Board 2. We upheld the complaint. We took independent advice from a consultant neurosurgeon in relation to the complaint about neurosurgery advice. We found that C had been appropriately assessed with a thorough examination. As such, we did not uphold this complaint.

C complained that the board failed to provide them with appropriate orthopaedic (specialists in the treatment of diseases and injuries of the musculoskeletal system) care and treatment following a fall. The board operated on C’s left wrist the day after the fall. Two days later, they performed revision surgery on C’s wrist and operated on their left elbow. C said that they had been advised by an orthopaedic surgeon at the board that their initial wrist surgery had not been done correctly. C said they had developed nerve compression pain issues and would require further surgery. We took independent advice from an orthopaedic consultant. We found that C’s initial wrist surgery was reasonable. However, the tilt of the radius was slightly beyond the normal range, which carried a minor increased risk of longer term functional impairment in the wrist. We considered that, if C had not required additional surgery for the elbow, the initial wrist fixation might have been left unchanged, as any potential long-term dysfunction could still have been treated later if necessary. However, given that C was already scheduled for elbow surgery, the decision to proceed with revision surgery on the wrist was considered reasonable. We also noted that key indicators related to pain were appropriately assessed in C’s case, and there was no indication that the surgery had been performed in a manner likely to cause excessive pain. Therefore, we did not uphold C’s complaint. Related reading View Decision Report 202301420 as a PDF (24.53 KB) Updated: November 20, 2024

C complained about the care and treatment that their late parent (A) received while in hospital. A suffered a fall and broke their hip. C complained that A was never provided with a falls monitor despite being assessed as a falls risk. C also said that there was a delay in reporting the fall and having A assessed. The board apologised to C for the fact that, due to a lack of falls alarms, A had not received one. They explained that additional alarms had been obtained to ensure a sufficient supply on the ward. They also accepted that a ‘top to toe’ examination should have been carried out following A’s fall and that there was a delay in identifying that A had a broken hip. They explained that a full review of A’s fall was underway, and if any learning points were identified, they would be acted upon. In addition, a teaching session had been carried out to ensure best practice was followed at all times. The board provided us with details of the learning points that had been identified as a result of the complaint. We took independent advice from a registered nurse. We found that there was no evidence that A received timely risk assessments or person-centred care. Although a fall with harm was apparent from A’s misaligned leg, this went unnoticed. Basic assessments, including pain assessment, were not conducted, resulting in a delay in recognising A’s pain. Additionally, wound charts were not completed, and there was a failure to follow policy regarding pressure ulcer prevention, malnutrition, and wound assessment and management. While the board had taken action in response to the complaint, we considered that there were still areas for learning and improvement. Therefore, we upheld C’s complaint. We also found that the board’s complaint response had not been open, transparent, and accurate. The board had failed to identify a number of failings in A’s care and treatment. Additionally, the board had not provided this office with all relevant information in response to o

C complained about the nursing care and treatment provided to their late parent (A). A had a fall during an admission to hospital. Their condition deteriorated and a large intracranial (brain) bleed was identified. A died shortly after. C complained that the nursing staff provided unreasonable care and treatment as they did not put the correct safety measures in place, given A's frailty and instability on their feet. The board said that A was reviewed by physiotherapy who assessed A as being safe and able to mobilise independently with a walking stick. The board said that nursing staff carried out care rounding and that A was checked 30 minutes prior to their fall. Following the fall, it was noted that A was able to get up with assistance and an assessment was completed by nursing staff. When checked later, it was found A had become unconscious. The board carried out a scan of A’s head and found a large intracranial bleed. We took independent advice from a registered nurse. We found that there was a lack of documentation and documented evidence of action taken by staff in response to cognition and mobility. Care rounding documentation was not completed to a reasonable standard or carried out to the prescribed frequency. When A’s needs changed, the care rounding was not increased. We found that the nursing staff failed to complete the mobility risk assessment, consider the use of bedrails and identify A required more help when their condition changed. We noted that the care provided by nursing staff when the fall happened and after the fall was reasonable. We also found that the Significant Adverse Event Review that was carried out after the fall was not carried out in line with national guidance. The Duty of Candour process should have been followed in this case and it was unclear from the documentation whether this had been activated or not. We upheld C's complaint.

C complained about the care and treatment that they received from the board. C underwent a left total hip replacement but returned to the consultant orthopaedic surgeon for follow-up three months later as they were continuing to experience pain and mobility problems. C complained that they were told there was nothing the surgeon could do for them. C sought a second opinion and learned that they had impingement (pinching or rubbing together inside a joint) which would require further surgery. C said that they had been significantly impacted by the initial surgery, both mentally and physically. In their original complaint response, the board acknowledged the poor outcome of the surgery. Following our formal enquiry the board acknowledged that a different choice of acetabular (socket) implant would have been appropriate. The surgeon acknowledged that this case was one where they would have benefited from advice from a more experienced surgeon. They accepted that they had failed to discuss with C that a poor outcome from surgery was a risk, and failed to document decision making and consent discussions in C’s clinical records. They apologised for failings in communication with C during their post-operative consultation. They also apologised for record-keeping failings. The board said they should have discussed this case at a departmental Morbidity and Mortality meeting once it became clear that there were ongoing problems requiring further surgery. They considered that not doing so represented a failure of process, prompting them to review their relevant structures and processes. The board confirmed comprehensive measures to address what had gone wrong in C's case. We took independent advice from a consultant orthopaedic surgeon (specialists in the musculoskeletal system). We concluded that the board had now appropriately acknowledged the multiple failings in this case, apologising and confirming extensive learning and improvement. Taking all of this into account, we up

C complained about the care and treatment that their spouse (A) received from the board whilst they were a patient of the cardiology ward. C complained that A collapsed on arriving home having been discharged after undergoing a coronary angiogram (a type of x-ray used to take pictures of the heart’s blood vessels, the coronary arteries) and stenting procedure. A was found to have experienced a vascular complication (a large haematoma, where blood leaks from a large blood vessel) in front of the femoral artery (the main blood vessel supplying oxygen rich blood to the lower body) and had surgery to remove the haematoma. Following the second surgery, A developed an infection in the wound site. The board said that due care was taken to weigh up the risks and benefits of various treatments in A’s case. Whilst there were signs of a haematoma at the puncture site after the procedure, this was not increasing in size when A was discharged, and A’s blood pressure was normal. C complained to SPSO highlighting concerns about the decision to carry out an angiogram, the decision to discharge A, infection control and failures to follow protocol and use an ultrasound to assess the puncture site. We took independent advice from an appropriately qualified consultant cardiologist. We found that carrying out an angiogram was appropriate in the circumstances. We considered the care and treatment following the procedure and on A’s readmission to be reasonable. However, there were a number of factors which should have triggered staff to consider delaying discharge and seeking an ultrasound scan. We found that the need for an ultrasound scan was clinically indicated and that the decision to discharge was unreasonable. As such, on balance, we upheld the complaint.

C was concerned about a number of issues regarding their care and treatment, and that of their child (A), during their pregnancy, A’s birth and afterwards. C raised complaints with the board and were dissatisfied by their response. The board’s response accepted that there had been issues with aspects of the boards complaint handling and a number of issues with their communication, but did not indicate that the board considered that there had been any issues with C or A’s care or treatment. We took independent advice from qualified advisers with experience of obstetrics, neonatology and midwifery (the medical specialisms for pregnancy, childbirth etc.). We found that, overall, C and A had received reasonable care and treatment from the board and that, where areas for improvement around communication had been identified, reasonable actions had been taken to address these. We did not uphold these part's of C's complaint. We noted that the board had accepted that C had been assigned to an incorrect consultant’s waiting list for a post-birth debrief and upheld this complaint. We also noted that the board had appropriately apologised to C for this. However, we considered that the board should have taken steps to minimise the possibility of a similar situation recurring in the future. In considering the board’s response to C’s complaints, we found that there were specific areas where the board’s response and actions could have been improved. However, taking into account those areas for improvement in complaints handling the board had identified, the apologies provided to C and the specific circumstances of the time C raised their complaints, overall the board responded reasonably to C’s complaint. We did not uphold this part of C's complaint.

C complained to the board about various aspects of the board’s care and treatment of their partner (A) and their communication with C and A during an inpatient admission covering the end of A’s pregnancy and the birth of their child (B) by caesarean section. The board accepted that a number of areas of communication had not been reasonable and apologised for this. The board explained what action would be taken to address these areas for improvement. The board also accepted that in a few specific cases, A had not received reasonable care but indicated that they considered A’s care and treatment had been reasonable overall. In response to a specific complaint from C, the board stated that A had not had sepsis (blood infection) or been treated for it during their admission. A few months later, however, the board wrote to C and stated that their labour had been complicated by sepsis. We took independent advice from an appropriately qualified midwife. We found that, overall, A and B received good care and appropriate standards of treatment that were in line with relevant professional standards. Given this, and that reasonable actions to minimise recurrence were taken in relation to areas where the board had accepted care was not of an acceptable standard, and where communication could have been improved, we did not uphold the complaint that the board had not provided reasonable care and treatment to A. We found that A had had sepsis during their admission and receive prompt and appropriate care. However, we considered that the board’s repeated altering of their position on whether A had sepsis, both minimised A’s experience and, potentially risked inadequate care and treatment responses being provided to patients with suspected sepsis in the future. We upheld the complaint that the board’s response inaccurately stated that A did not have sepsis and was not treated for sepsis during their admission.

C complained about the care and treatment provided to their parent (A) on two separate admissions to hospital. A was detained on both occasions under the Mental Health (Care and treatment) (Scotland) Act 2003. C had concerns about A being sedated and that staff had restrained A in an inappropriate manner. In their response to the complaint, the board explained the care provided to A, the reasons for the administration of medication, how this was overseen and adjusted to address A’s levels of sedation, and the process and performance of restraints when they were required. C was dissatisfied with the board’s response and brought their complaint to us. We took independent advice from a consultant psychiatrist and a mental health nurse. We found that on both admissions, there was appropriate oversight of A’s medication and care was taken to consider sedative effects and find a balanced approach. We found that medications were administered appropriately to manage A’s distress and aggression. Therefore, we did not uphold this part of C’s complaint. In relation to the use of restraints, we found that these had been performed reasonably and that A’s concerns about pain to their ribs was appropriately assessed. Therefore, we did not uphold this part of C’s complaint. However, we did provide the board with some feedback on the requirements for accurate record keeping. Related reading View Decision Report 202204112 as a PDF (24.47 KB) Updated: May 22, 2024

C complained about the ear, nose and throat surgery (ENT) that they received from the board. C was referred for surgery for biopsy of a nasal ulcer that would not heal, and for treatment of a nasal drip. C complained that the biopsy had not been taken as expected, which they were not aware of until making a complaint. C also complained that they had been left worse off due to a perforation being caused during the procedure. This has caused them to have an audible whistling sound when they breathe. C said that, while the risk of perforation had been mentioned at the outpatient appointment, they were led to believe it was not something they had to worry about. Furthermore, they were not told that if it happened, it wouldn’t heal naturally, and surgery to fix it often fails. The board explained that the biopsy had not been taken as the ulcer had healed by the time C attended for surgery. The board apologised for the perforation. They noted that the surgeon was not aware of one occurring before in their career but had since changed their practice to ensure it was discussed when obtaining consent. We took independent advice from an ENT adviser. We found that C had not been reasonably consented for surgery at the outpatient clinic or on the day of surgery. We noted that the documentation did not support the reported discussions which took place about the surgery or the associated risks, or the implications should C have decided not to proceed with the procedure. We also found that the written information provided to C was unreasonable. The patient information leaflet did not provide information about the short and/or long-term implications of a perforation or that it may occur after the surgery has taken place. It did not note that it was unlikely to heal on its own, that surgery to correct it may not be an option or, if attempted, successful. We considered that C had received reasonable post-operative care and follow-up from the board. It was reasonable to plan to see th

C complained about the care and treatment that their late parent (A) received from the board. A was admitted to hospital after a fall at home. A’s condition declined whilst in hospital. C complained that during A’s admission there were clinical errors, inappropriate treatment and insufficient diagnosis work. In C’s view, this contributed to and hastened A’s death. C stated that clinicians had fixated on alcohol as the primary cause of A’s condition. A post-mortem later confirmed this not to be the case and that A had Lewy Body dementia (a brain disorder that can lead to problems with thinking, movement, behaviour, and mood) or similar when they died. C also asserted that A’s two brain bleeds sustained in the fall were not adequately monitored or treated. C highlighted concerns that there was no intervention and no repeat computed tomography (CT) scan carried out to check the condition/size of the two brain bleeds. This was despite a decline in A’s neurological condition. In addition to this, C complained that the board’s communication with A’s family fell below a reasonable standard. C stated that, in their view, A’s two brain bleeds were more significant than clinicians had led the family to believe at the time of admission. They also highlighted an unwitnessed fall on the ward that was not reported to the family. We took independent advice from a neurologist adviser. We found that the treatment provided by the board was reasonable. Given A’s circumstances and presentation, we did not consider the focus on alcohol-related cognitive failure to be unreasonable or that it materially affected the treatment provided. We also found that the decision not to carry out an additional CT scan to be reasonable. However, we highlighted concerns about some of the board’s justification for not carrying out an additional CT scan. We also received a limited amount of advice from an independent nursing adviser about some additional concerns raised by C. We found tha

C complained on behalf of their spouse (A) about the board not issuing a discharge plan at the point A was discharged from hospital for palliative care before A passed away. As their carer, C wanted to know how to provide care and support for A. C said that this plan was subsequently requested a number of times but not provided. C also complained that following A’s death, their GP provided a copy of the Inpatient Discharge Summary which said ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR). C said that they had not been aware a decision had been made on this and as A’s Power of Attorney, and in order to safeguard A, DNACPR should not have been discussed with A without C being present. We took independent advice from a registered consultant geriatrician (a doctor specialising in medical care for the elderly). We found that the board could not have provided C with a discharge plan as C did not attend hospital that day. We also found that A was not given clear discharge information despite this being complex and their care needs being high. There was also a failure to subsequently provide C with a copy of the discharge plan when requested, and record keeping failures during A’s discharge. We also found that the board failed to communicate with C that a DNACPR decision had been made with A. We upheld the complaint.

C complained that when they developed complications in their pregnancy, the care that they received fell below a reasonable standard. C was six weeks pregnant and considered a high-risk pregnancy due to four previous caesarean section procedures, as well as surgery to reverse a previous sterilisation. C said that they were treated with a lack of empathy and courtesy by staff during scanning. C also complained that they were refused admission despite being known to be a high-risk pregnancy and despite developing vaginal bleeding. When C was admitted they believed that their surgery was unreasonably delayed, resulting in an avoidable rupture to their fallopian tube. We took independent advice from both a registered nurse and a consultant obstetrician (the branch of medicine and surgery concerned with childbirth and midwifery). We found a number of failings on the part of the board. However, the board submitted new information, which included sections of C’s medical records which had not been provided previously. The board acknowledged that this was a failing on their part. We reviewed this information and determined that some of the original questions over the actions of the board were answered by this information. We upheld the complaint that the board failed to provide a reasonable standard of care during C's admission. In relation to C's complaint about being unreasonably refused admission, we found that C was treated reasonably and that the board demonstrated that their procedures were followed by staff. We did not uphold this aspect of the complaint.

C complained that the board failed to provide them with reasonable care and treatment when they were admitted to an acute medical unit, specifically that they were discharged too soon and that there was a delay in diagnosing that they had suffered a stroke. We took independent advice from an adviser that specialises in acute medicine. We found that the board incorrectly documented that a CT scan had been carried out. Given the seriousness of C’s symptoms and their outcome, it was of concern that this incorrect information was documented in C’s medical records. We found that C should have remained in hospital to be assessed in more detail before they were discharged. We found that more consideration should have been given to C’s symptoms and the possibility that they were related to a stroke. In particular, a CT scan should have been carried out earlier, which could have led to an earlier diagnosis and treatment with medication. On C’s readmission, C’s stroke was visible on a CT scan. It therefore was possible that a CT scan, on their first admission, could have shown C’s stroke. In relation to C’s nursing care, we found that we would have expected to have seen more detailed nursing notes about C before their discharge, for instance, in relation to C’s walking ability. The board apologised for the miscommunication which occurred between nursing staff in relation to C’s fitness for discharge and said that learning had been put in place for effective communication. The board said that this was communicated verbally and therefore there was no paper evidence. We considered this to be unsatisfactory and we upheld the complaint.

C complained on behalf of their parent (A) who was suffering from dementia. A had been found in a neglected state by C’s sibling. A had vomited and it appeared that A had been left unattended overnight with no personal care. A’s incontinence pad had not been changed for what appeared to have been a significant period and was soaked in urine. C believed this failure in care led to A’s resulting aspiration pneumonia (inflammation that's caused by bacteria entering the lungs and causing a severe infection) which was the cause of their death. C also had concerns about other aspects of A’s nursing care including the frequency, quality and recording of care, A's skin care and the monitoring and recording of their vital signs. Lastly, C complained that their complaint had initially been designated a “concern” rather than a formal complaint. We took independent advice from a nurse and a consultant geriatrician (a doctor specialising in medical care for the elderly). We found that there had been a failure to provide reasonable nursing care to A which had been acknowledged by the board. However, we found further issues with respect to ongoing risk assessment, skin care in relation to pressure ulcers, malnutrition screening and the implementation of person centred care planning. It was noted that there were difficulties in definitively assessing the standard of care delivered due to failures to adhere to Nursing and Midwifery Council record keeping standards. Therefore, we upheld this aspect of the complaint. Additionally, we found that unreasonable care had been provided with respect to pain relief. We upheld this aspect of the complaint. We also found that the complaint had not been handled in line with the board’s complaints handling procedure. While there were areas for improvement, on balance, communication with the family had not been unreasonable and we did not uphold this aspect of the complaint. In relation to Cs complaint around the handling of their co

C complained about the care and treatment provided to their late parent (A) by the board. A was under the care of another board and investigations undertaken were suggestive of cancer in the bile drainage system, which was initially thought to be operable. A was referred to the board and admitted to hospital for a percutaneous transhepatic biliary drain (a procedure to drain bile to relieve pressure in the bile ducts caused by a blockage) and biliary biopsies. This was carried out and the three biopsies taken were sent back to the ward with A. The duty consultant and the clinical nurse specialist met with A and relayed the findings of the multi-disciplinary team discussion the previous day. The specialist radiologists felt that there was a thickening of the lining of the abdomen that may suggest the disease had spread and that the nature of the tumour was unresectable. A check tubogram (a dye test to check whether the stent had opened up) indicated that the stent inserted had not fully drained the bile ducts and a second stent was inserted, with the external component of the biliary drain removed. A was discharged shortly afterwards. At a multi-disciplinary team discussion less than two weeks later, it was highlighted that there were no biopsies currently in the pathology laboratory. Further investigation found that A’s biopsies had been disposed of. Four months on, A was made aware by the referring board that the biopsies had not reached the laboratory. A died after a short period. We took independent advice from a general and colorectal surgeon. We found that whilst A had been given sufficient information regarding their care and treatment and the need for a biopsy, the board unreasonably lost biopsy samples and failed to inform A that they had been lost. We also found that the communication between departments, wards and with another board was unreasonable. We upheld the complaint.

C complained about the care and treatment that they received from the board prior to and during the birth of their child (A). C complained that the midwives were dismissive of their pain levels during labour, failed to properly assess their condition, was wrongly sent home to allow labour to progress, and that staff denied their requests for an epidural. C also complained about the poor communication from the clinical team when they were in theatre for a caesarean section. The board said that they considered the decision to send C home was made in line with current guidelines but apologised if the reasons for the decision were not communicated at the time. The board explained that C’s request for an epidural was not actioned as labour was progressing rapidly and consideration was being given as to whether an emergency caesarean section was required. We took independent advice from a midwifery specialist. We found that the midwifery care provided to C was reasonable. We noted that the board apologised for some shortcomings in the care provided and that this was a reasonable response. Overall, we were satisfied that the decisions taken by the midwives were based on a reasonable assessment of C’s presenting condition. In respect of the medical care provided during the birth, we acknowledged that there may have been a lack of clarity around the consent process, however, overall, we did not find any significant shortcomings in the clinical care and treatment provided to C. We did not uphold C’s complaints. Related reading View Decision Report 202208600 as a PDF (24.52 KB) Updated: December 20, 2023

C complained about the care and treatment that they received in respect of their cancer. C was diagnosed with colorectal cancer which had spread to their liver and required surgery. The surgery was to be performed in two stages. C complained that the second surgery was not performed within a reasonable timescale and about poor pain relief following the second surgery. The board apologised to C for the poor communication about the arrangements for the second surgery and explained that repeating imaging was required before arranging the surgery and that they did not consider the delay to be significant. The board provided an overview of the pain relief provided and noted that any issues identified were addressed at the time. We took independent advice from a colorectal and surgical consultant. We found that communication with C about when they could reasonably expect to have their second surgery was poor and there was an unexplained delay in their case being reviewed by the multi-disciplinary team. This resulted in a delay of around one month, however we did not consider this would have caused further spread of C’s cancer. We upheld this complaint. We noted that there were some issues with the equipment used to deliver pain relief post surgery, however these were rectified and appropriate additional pain relief was provided promptly. We found the post surgical care and treatment provided to be reasonable and we did not uphold this complaint.

C complained to the board about the midwifery care and treatment that they received during and following the birth of their baby. In particular, C complained that they had been unsupported during the birth, that their birth plan had not been followed, that the umbilical cord had snapped during delivery and that no meeting had been arranged to discuss the incident despite requesting one. C also complained that there had been a failure to recognise that this had been a traumatic incident for them, and that the board’s response to the complaint had lacked empathy. The board’s response advised that C had been assisted during the birth, however they apologised that C's expectations had not been met at the time. The board also apologised that it had not been understood that C had intended to use the water pool for pain relief only, and that they did not want to give birth in the pool. In relation to the cord snapping, the board explained that this had been recognised as an emergency incident straight away, but on reflection, the emergency buzzer could have been activated sooner. In terms of communication, the board explained that the circumstances of the birth had been discussed with C by the delivery midwife during a post-natal visit to C's home. When a further meeting was requested, the board said a meeting date had initially been offered by text message which C declined. In hindsight, the board recognised it would have been better to arrange this with C by phone. It was further explained that C had been given contact details to arrange discussion with a consultant in keeping with their request, however C had not gone on to take up that offer. We took independent advice from a consultant of obstetrics and gynaecology. We found that a minimum standard of care had not been met on this occasion. We noted that key aspects of the medical notes and birth plan had not been read, as C’s preference not to birth in the pool was clearly documented but had not been known

C complained on behalf of their parent (A) who had been admitted to hospital with pneumonia. C complained that they found medication on the floor and in A's bedside cabinet. C complained that A's personal care needs had not been met, as they had not been washed and they had sore gums and an ulcer in their mouth. C also complained that A had red, sore skin in the groin area. The board apologised for the fallen medication and advised that they were undertaking a project to reduce medication errors. They advised that A had not wanted to shower and that both personal and oral care had been undertaken regularly. They also said that the skin in the groin area had been checked and had only become red on the day that C visited. We took independent advice from a nurse. We found that there appeared to be a design fault with the lockers, such that medication could fall out of the medication pod. We also found that A should have had a personal care plan and had not been offered sufficient personal care or oral care. We found that red skin had been noted 11 days prior to C's visit but had been recorded as healthy in the interim period. This would suggest that the skin was not properly checked. Therefore, we upheld C's complaint.

C complained about the attitude of a doctor during an inpatient admission. C stated that the doctor had treated them in a dismissive, derogatory and unprofessional manner. C further complained that the doctor removed their diagnosis, stopped their medication and made no arrangements for them to receive support following their discharge. C told us that the actions of the doctor had resulted in them not receiving a reasonable standard of care. We found that the inpatient doctor's communication and documentation did not meet the required professional standards and impacted on the board's overall communication of C's care and treatment needs. The clinical records evidenced a dismissive and disrespectful attitude towards C. The doctor's documentation lacked a clear clinical rationale for the decisions that they made about C's diagnosis and medication. Therefore, we upheld this part of C's complaint. In relation to the standard of care C received, we found that board staff had ensured that C's care and treatment needs were met. The decision to discharge C from inpatient care was reasonable and the community-based care that was provided was appropriate to C's identified needs at the time. When it was clinically indicated, the board arranged a further inpatient admission and reviewed C's diagnosis and treatment plan. There was evidence that the doctor did not stop C's medication. Therefore, we did not uphold this part of C's complaint.

C complained about the care and treatment provided to their late partner (A). A had a history of Chronic Obstructive Pulmonary Disease (COPD, a group of lung conditions that cause breathing difficulties). A was suffering from constipation which was treated by the district nursing team at home. When this did not resolve, A was admitted to hospital for review and treatment of their constipation. C said they asked that A be treated and discharged home as quickly as possible. A fell whilst in hospital and fractured their shoulder. A developed a chest infection and subsequently died in hospital. C believed A's condition could have been treated in the community. C felt A's vulnerability had not been recognised by nursing or clinical staff in hospital. C said that A had been designated as an adult with incapacity (AWI) and do not attempt cardiopulmonary resuscitation (DNACPR) without discussion with them as A's power of attorney (POA). C felt A's fall was avoidable had staff listened to the family's requests for 1-to-1 nursing. We took advice from a registered nurse and a consultant respiratory physician. We found that A was not provided with a reasonable standard of nursing care in the community, as more could have been done to treat their constipation at home. Therefore, we upheld this part of C's complaint. In relation to A's care while in hospital, we found both the standard of nursing and medical care to be reasonable. Therefore, we did not uphold these part's of C's complaint. In relation to communication with C as A's next of kin and POA, we found there was a lack of communication regarding A's care and in particular decisions around designating A as AWI and DNACPR. Therefore, we upheld this part of C's complaint. Finally, we found that A's death certificate should have included the fall as a secondary factor in their death. Initially it was believed that C would need to request this amendment, but the responsibility in fact lay with the board, who have been asked t

C complained about the care and treatment they received from the board in relation to knee replacement surgery. C said that a surgeon failed to adequately advise them of the potential risks of a total knee replacement and therefore failed to obtain their informed consent for the operation. C also complained that the surgeon failed to adequately examine their leg either pre or post operatively. C said that they had experienced a mal-alignment of their leg as a result of the operation leading to significant pain and loss of mobility. The board was unable to identify the cause of the mal-alignment of C's leg, but did not identify any failings in their care and treatment. 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, despite some failings, the consent process in C's case was reasonable. We also found no evidence that the board's surgeon failed to adequately examine C's leg either pre or post operatively. Therefore, we did not uphold these parts of C's complaint. C also complained that the board failed to adequately investigate or respond to their complaint. We found that the board's complaint response was unreasonable and upheld this part of C's complaint.

C complained about the care and treatment provided to their late spouse (A). A was diagnosed with pancreatic cancer. C was unhappy with the delays with A's treatment and said that these prevented A from receiving any treatment before their death. The board said that their intention was to treat the cancer and that A was required to meet with a consultant to assess their fitness for surgery. The board said that the delay in meeting with a consultant was to allow the health board to carry out two multidisciplinary meetings, for some of A's symptoms (such as jaundice) to improve, and for other investigations and procedures to be carried out (such as, imaging scans and the fitting of stents). The board acknowledged that there was a delay in a PET-CT scan (where a drug is injected before the scan to help clinicians identify how certain body functions are working) being carried out due to failures in the drug production. The board said that when this fails, there is no back-up facility in Scotland to provide a replacement batch. We took independent clinical advice from a consultant colorectal and general surgeon. We found that the timeframe for A's treatment could have been improved even with the allowable delays from the PET-CT scan. We considered that the investigations carried out were reasonable and the early scan and procedure to fit a stent were good points in the treatment pathway. However, the length of the pathway could have been improved and A's lengthy pathway to the offer of chemotherapy was unreasonable. The timing of the clinic appointment and PET-CT could also have been improved. Whilst we recognise some of the delays experienced could not be predicted or avoided, on balance, the timescale for A's pathway was unreasonable. Therefore, we upheld C's complaint.

C complained about their care and treatment following a hysterectomy (a surgical procedure to remove all or a part of the uterus). C complained that they were not provided with adequate pain relief following the surgery, and that they were not fitted with an abdominal drain (a thin plastic tube which is inserted into an abnormal collection of fluid to help remove it from the body). C was discharged a few days later but disputes whether they were fit to be discharged home at this point. C was later readmitted suffering from a blood clot and an infection. C was discharged with oral antibiotics and again disputes whether they were fit to be discharged at this point. A few days later, C began to bleed heavily. An ambulance was called but the wait was likely to be significant and C was taken to hospital by their partner. C was triaged but asked to sit on a chair in a corridor, despite suffering from obvious heavy vaginal bleeding. C was reviewed by a consultant and sent up to the gynaecology ward where they were then taken for emergency surgery. We took independent advice from a consultant obstetrician (specialists in pregnancy and childbirth) and a consultant in emergency medicine. We found that C received a reasonable standard of care following their surgery and was appropriately discharged on both occasions. Therefore, we did not uphold these parts of C's complaint. In relation to C's attendance at A&E, we found that they were not triaged sufficiently quickly and the way C was asked to wait was not appropriate given their condition. C was medically assessed within an appropriate timescale within A&E and appropriately transferred. The board had accepted there were failings in C's care, but they had not set out clearly how they planned to address these issues. Therefore, we upheld this part of C's complaint. C also complained that the board failed to handle their complaint reasonably. We found that the board handled C's complaint appropriately and did not uphold this pa