SPSO Individual Decisions

Ms C complained about the care and treatment her late mother (Mrs A) received at Gilbert Bain Hospital. Mrs A had widespread bladder cancer and she was admitted to the hospital because she was experiencing pain and discomfort. Medical staff decided it would be appropriate to try to insert a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag). Ms C raised concerns that the decision to try to insert a urinary catheter was unreasonable; and that medical staff should have stopped the attempts sooner, as Mrs A was in pain and shouting for them to stop. We took independent advice from a general surgeon. We found it was reasonable that medical staff tried to insert a urinary catheter. However, we found that the repeated and distressing attempts to do so were unreasonable. We considered that the first attempt to insert a urinary catheter should have been carried out by a more senior member of medical staff. We considered that Mrs A should have been given better pain relief/sedation before any further attempts were made. We also considered that medical staff had failed to recognise Mrs A's distress and to respond to her clear withdrawal of consent. We upheld this complaint.

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mr B) about the care and treatment provided to Mr B's wife (Mrs A) at Gilbert Bain Hospital. Mrs A had pancreatic cancer and when she was admitted to hospital she could not eat. She was later assessed for palliative surgery (surgery which provides relief, but not a cure) at a different hospital, and was ultimately unable to have this surgery. Mr B felt that the reason his wife could not undergo the surgery was because she was not given adequate nutritional support (the giving of nutrients, either intravenously (directly into a vein) or by drip feeding through a tube placed in the digestive system) at Gilbert Bain Hospital. We took independent advice from a consultant physician. We found that it was reasonable not to give Mrs A nutritional support until a decision was made to assess her for palliative surgery at the second hospital. Therefore, we did not uphold the complaint. However, we found that there were discussions between the two hospitals that were not recorded, so we made a recommendation to address this.

Mr and Mrs C complained that midwives at Gilbert Bain Hospital failed to recognise that Mrs C had hyponatraemia (low blood sodium levels). Mrs C was given advice to drink more fluids, which made her condition more severe. Mr and Mrs C also complained that the board failed to handle their complaint and the review into Mrs C's care appropriately. In particular, they considered the review wrongly concluded Mrs C had a condition called syndrome of inappropriate antidiuretic hormone production (SIADH - the excessive secretion of antidiuretic hormone resulting in, among other things, water retention and dilution of the blood) when she actually had hyponatraemia. Mr and Mrs C considered the board failed to identify appropriate learning from the review and share it with them. The board accepted that Mrs C was given inappropriate advice to drink fluids by midwives. However, they said it was unreasonable to expect midwives to have recognised she had SIADH, as it is very rare. The board considered they had undertaken a thorough review of Mr and Mrs C's care and complaint. They explained they had taken learning from it forward by training staff on recognising SIADH. During our investigation we took independent medical advice from a midwife and from a consultant in general medicine. The midwife adviser considered that the midwives carried out appropriate observations and tests in light of Mrs C's symptoms. They considered the advice given to Mrs C to drink more fluids was reasonable in light of those symptoms. Therefore, we did not uphold this aspect of the complaint. The midwife adviser considered that the board undertook an appropriate review into Mrs C's care. However, there was a delay in sharing the action plan with Mr and Mrs C. The general medicine adviser considered it was reasonable that the board diagnosed Mrs C with SIADH following the review. They explained that Mrs C had hyponatraemia, which can have many causes, one of which is SIADH. However, given hy

Mr C complained on behalf of his wife (Mrs A). Mr C complained that, when his wife attended the accident and emergency department at Gilbert Bain Hospital following a fall, she was not given appropriate care and treatment. Mr C also complained that the GPs at Mrs A's GP practice did not provide her with appropriate care and treatment for problems that she had with her legs, and that staff attitudes towards Mrs A at the practice were unreasonable. We took independent advice from a consultant in emergency medicine and from a GP adviser. We found that, when Mrs A attended the accident and emergency department following her fall, a full and thorough history and assessment were carried out. We considered that the care and treatment provided to her were reasonable. We also found that the care given to Mrs A for the problems with her legs by the GP practice was reasonable, and that there was no evidence that the attitude of practice staff towards Mrs A was unreasonable. We did not uphold Mr C's complaints. Related reading View Decision Report 201700761 as a PDF (11.01 KB) Updated: March 13, 2018

Mrs and Mrs C complained about a delay in diagnosing their child (child A) with autism spectrum disorder (ASD). In particular, they complained that an autism diagnostic observation schedule (ADOS) was not carried out. Child A was subsequently diagnosed with ASD after an ADOS was carried out. The board did not consider there was an unreasonable delay in diagnosing child A with ASD. They also explained that their ASD assessment pathway has developed since the events complained about occurred. During our investigation we took independent advice from a consultant paediatrician. The adviser considered that child A should have been referred for a multi-disciplinary ASD assessment, given their family history, their symptoms and Mr and Mrs C's strong concerns. The adviser explained that an ADOS is not a requirement to diagnose ASD but that it can be a helpful tool. In light of the failure to refer child A for a multi-disciplinary ASD assessment, we upheld the complaint and made recommendations in light of our findings.

Miss C complained that the board unreasonably removed her from a waiting list for orthodontic treatment. She also complained that they had failed to tell her that she had been removed from the waiting list and had not provided her with a reasonable explanation of why she had been removed. We took independent advice from a dental surgeon. The adviser explained that there are two different types of orthodontic referral, one for consultation and the other for actual treatment. The advice we received was that Miss C's initial appointment was to assess whether she met the criteria for orthodontic treatment. The adviser said that Miss C had not met the required criteria and, therefore, she had not been placed a waiting list for orthodontic treatment. The adviser said that this decision was reasonable. The adviser also said that the board's decision not to provide Miss C with orthodontic treatment in subsequent years was reasonable and was in keeping with relevant guidance. We found that, as a result, Miss C had not been put on a waiting list for orthodontic treatment, which we found was reasonable. As she had not been put on a waiting list, she could not have been told that she had been removed from such a list. Therefore, we did not uphold those aspects of Miss C's complaint. However, we found it concerning that, over a period of several years, Miss C appeared to be under the impression that she had been placed on a waiting list for orthodontic treatment. The adviser commented that Miss C may not have understood that there were two different types of waiting lists and that she did not appear to have been informed about the option of private orthodontic treatment until she complained to the board. We considered that it is essential that a patient understands their treatment plan and that this did not appear to have happened in Miss C's case. For this reason, we upheld Miss C's complaint that the board had not provided her with a reasonable explanation of why s

Miss C was told by dental staff that she would require dental braces. She was subsequently told by orthodontic staff that she would not be provided with braces and she was discharged from the service. Miss C complained that the board failed to provide her with appropriate dental care. We took independent advice from an orthodontics adviser who explained that the assessment criteria to consider whether a patient qualifies for orthodontic treatment funded through the NHS is covered by the Index of Orthodontic Treatment Need (IOTN). It would be expected that an orthodontics practitioner would provide a grade of IOTN which would substantiate their decision as to whether or not the criteria had been satisfied. We found that in Miss C's case the orthodontic staff had assessed her on a number of occasions as having a low IOTN, which was a reasonable judgement for them to make and had indicated that they had considered the IOTN criteria. As such, Miss C would not have qualified for orthodontic treatment and so we considered that the dental care provided had been appropriate. We did not uphold the complaint. However, we did note that there was a failure by orthodontic staff to record the actual IOTN grade in the dental records, and so we made a recommendation in relation to this.

Ms C complained to us that that a GP at the health centre had failed to provide her with appropriate treatment during a consultation. She had attended the GP and had reported that a couple of days earlier she had been woken with severe pain on her left side. She wondered whether she had ruptured an ovarian cyst which she was known to have. Ms C said that the GP did not examine her or take her temperature. Ms C said that five days later she began vomiting and was admitted to hospital, where it was found that she had ruptured her bowel. We took independent advice from a GP adviser. We found that the GP had suspected that Ms C may have ruptured an ovarian cyst and that they did arrange for an appropriate blood test and an ultrasound to be carried out. However, the adviser also said that the GP should have examined Ms C's abdomen and checked a urine sample as she had reported abdominal pain. Although the adviser felt that the GP should have performed a clinical examination, the adviser thought it was unlikely that Ms C had ruptured her bowel at the time she saw the GP as this would normally involve the onset of acute sudden symptoms. Ms C had also reported that her symptoms were improving when she saw the GP. The GP had carried out a Significant Event Analysis and they had recognised that they should have examined Ms C's abdomen. The GP said that they would examine patients' abdomen in future. We upheld the complaint.

Mr C complained on behalf of his wife (Mrs A) about the clinical treatment she received when she attended A&E at the Gilbert Bain Hospital. We took independent advice from a consultant in emergency medicine. The advice we received was that the assessment and treatment of Mrs A was reasonable and that appropriate investigations were carried out, and that Mrs A did not require hospital admission. We therefore did not uphold this complaint. However, the advice we received said that while written notes made by the doctor caring for Mrs A were of a high standard, one thing that could have been improved was the inclusion of vital signs and we made a recommendation to the board regarding this. Mr C also raised his concern that the doctor had failed to reasonably interpret Mrs A's chest x-ray. The board accepted that the doctor had failed to appreciate the significance of the radiographic appearance on the base of Mrs A's left lung on the x-ray. They apologised for this and explained that the issue of x-ray interpretation had been discussed with the doctor. The advice we received was that the action taken by the board was reasonable. While we upheld the complaint, given the action taken by the board we made no further recommendations. Mr C complained that the board inappropriately discharged Mrs A when she attended the hospital, particularly as she had had to re-attend the following day. The advice we received was that Mrs A did not require hospital admission. We did not uphold the complaint.

Miss C complained that the dental care and treatment she received in relation to the removal of a wisdom tooth was unreasonable. We took independent advice from a dental surgeon. The advice we received was that the procedure was carried out appropriately and in line with relevant guidelines, and that the treatment provided to Miss C was reasonable and appropriate. However, we were concerned that there was no evidence in Miss C's dental records to confirm that she was given sufficient information prior to the extraction to allow her to give informed consent. Although we did not uphold Miss C's complaint, we did make a recommendation to the board with regard to the consent process and providing information to patients prior to surgery.

Mr C complained about the care and treatment provided by a physiotherapist during his recovery from surgery performed on his hand. Mr C complained that the physiotherapist provided inadequate exercise advice at an appointment, in particular by encouraging him to perform intensive exercise on the hand, which led his wound to open. Mr C considered this advice led to ongoing pain in his hand and its reduced function. The board said there was no evidence that advice had been given to perform intensive exercise. The board said advice was provided to perform gentle exercise, which was appropriate, and there was no link between the physiotherapy care and treatment provided and the subsequent problems Mr C experienced in his hand. After receiving independent advice from a consultant physiotherapist, we did not uphold Mr C's complaint. We found there was no evidence that the board provided inappropriate advice, rather the records indicated the physiotherapy advice was reasonable given Mr C's circumstances. Related reading View Decision Report 201503155 as a PDF (11.01 KB) Updated: March 13, 2018

Mr and Mrs C complained on behalf of their son (Mr A) about care he received on two visits to A&E at Gilbert Bain Hospital. Mr A attended the hospital and was diagnosed with a viral infection. He returned two days later and was again diagnosed with a continuing viral infection. A further three days later, Mr A became very unwell and was admitted to hospital. He was later transferred to a hospital in another board area and diagnosed with osteomyelitis (a bone infection caused by bacteria). Mr and Mrs C complained that Mr A had not been reasonably assessed and treated. We took independent advice from an adviser in emergency medicine. They said that Mr A was given a thorough and appropriate examination on both occasions. The adviser said the symptoms were consistent with a viral infection and there were no symptoms which indicated further tests should have been carried out. The adviser also noted that osteomyelitis is a very rare condition and one not often seen in children Mr A's age. Considering the advice we received, we did not uphold this complaint. Related reading View Decision Report 201501839 as a PDF (11.11 KB) Updated: March 13, 2018

Mr C complained that the board provided him with unreasonable dental care and treatment. He also said that they delayed in dealing with his dental problems that developed as a result. We took independent advice from a dental surgeon. We found that, although one of Mr C's teeth had to be removed shortly after it had been treated, an initial examination and x-ray before treatment had confirmed that it was deeply decayed. Mr C wanted to retain his tooth and so the decay had been removed and his tooth had been filled. The tooth did not settle and Mr C then asked for it to be removed. Mr C subsequently asked the board to provide him with an implant or a bridge, but these options were not available to him, mainly because his teeth were severely compromised by gum disease. We did not uphold his complaint. Related reading View Decision Report 201501177 as a PDF (10.99 KB) Updated: March 13, 2018

Mrs C complained that the board had delayed in arranging an appointment for her to have a tooth extracted. She had seen a dentist from the board about the tooth and the dentist considered that the tooth needed to be taken out. Mrs C wanted to know if there was any way that the tooth could be saved and the dentist referred her to a consultant in restorative dentistry to discuss this. The consultant examined the tooth and then wrote to the dentist to say that the tooth should be taken out as soon as possible. After receiving the letter, the dentist contacted Mrs C to say that the tooth would be extracted at her next arranged appointment, a few weeks later. Mrs C considered that the tooth should have been extracted without delay. She contacted NHS 24 for advice over the following weekend and an emergency hospital appointment was arranged for her to have the tooth extracted. We took independent advice on the complaint from a dental adviser. We found that it had been reasonable for the dentist to decide to wait until Mrs C's next appointment to extract the tooth. There was no evidence in the records to suggest that Mrs C was in such pain that an emergency appointment was required. We did not uphold this aspect of her complaint. Mrs C also complained that the board had failed to phone her back when she contacted them for advice after the tooth had been taken out. There was no evidence that staff did call Mrs C back about this and we upheld this aspect of her complaint. We also upheld Mrs C's complaint about how the board had handled her complaint. However, we were satisfied that the board had apologised and learned lessons from these failings, and we did not make any recommendations. Related reading View Decision Report 201406408 as a PDF (11.36 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment Mr A was given by his medical practice in the weeks and days prior to his death. We took independent advice from one of our advisers who is a GP. We found that Mr A, who had a history of pulmonary disease, was seen by a GP at home after complaining of nausea and dyspepsia and of being giddy for three days. We found his treatment to be appropriate. A month later, Mr A attended the practice again complaining of having had nausea and stomach pain for four days. He was examined appropriately and prescribed paracetamol with a plan to see him in five days. However, before this, the practice received a call to see Mr A at home as he had been vomiting. It was planned to visit him after the regular surgery but within a short time another call was made to the practice because Mr A was still vomiting and he had pains in his upper abdomen. A GP attended at Mr A's home and decided that he should be admitted to hospital and he returned to the practice to make the necessary arrangements for Mr A's transfer to hospital. An ambulance attended shortly afterwards but Mr A died before he could be transferred to hospital. Our investigation confirmed that none of this could have been predicted and that, despite Mr A's sudden death, he had been treated reasonably and appropriately, so we did not uphold Mrs C's complaint. Related reading View Decision Report 201402012 as a PDF (11.28 KB) Updated: March 13, 2018

Mrs C complained about the care and treatment the board provided to her two-year-old son (Master A). She said that he had a high temperature and had been unwell for three to four days, when she took him to Gilbert Bain Hospital accident and emergency department. Mrs C complained that the board did not keep her son under appropriate observations after initial assessment and that he was inappropriately discharged home. Mrs C and her son returned to the hospital the following day, as his condition had deteriorated. After initial assessment, he was seen by a doctor and was admitted to hospital and later flown by air ambulance to a mainland hospital, where he was diagnosed and treated for a type of flu. Mrs C again complained that staff failed to keep Master A under appropriate observation after initial assessment of his condition. She also said that on both occasions there were delays before a doctor saw her son. We took independent advice on this case from one of our medical advisers, a consultant in emergency medicine. He explained that the doctor's decision to discharge Master A on the first occasion was reasonable. The documentary evidence suggested that Master A was seen 19 minutes after triage (the process of deciding which patients should be treated first, based on how sick or seriously injured they are). The adviser explained that although a target time for Master A to be seen would have been ten minutes, the wait of 19 minutes was reasonable, given that Master A had none of the symptoms of an exceptionally unwell child. On the following day, Master A was triaged, was observed again just over an hour later, and was seen by a doctor about 20 minutes after that. Although his total waiting time was considerably longer than the target time of ten minutes, the adviser indicated that, in the circumstances, this was not unreasonable if there was greater need elsewhere in the department. We also noted that there was a handover between clinical shifts while M

Mr C was dissatisfied with the physiotherapy treatment he received from the board and complained to us about it. We did not, however, reach a decision on the issues involved in Mr C's case as he decided to withdraw his complaint. Related reading View Decision Report 201004933 as a PDF (15.89 KB) Updated: March 13, 2018

Mr C complained about the physiotherapy treatment he received from the Board. We did not reach a decision on the issues involved in Mr C's case as we found that it was out of our jurisdiction under Section 7 of the Scottish Public Services Ombudsman Act 2002. Related reading View Decision Report 201004933 as a PDF (13.22 KB) Updated: March 13, 2018