SPSO Individual Decisions

C complained about the care and treatment provided to their late spouse (A) during their admission to hospital. A was admitted with symptoms suggestive of a stroke and significantly elevated blood pressure. Initial CT imaging and angiography (a type of x-ray used to check blood vessels) were inconclusive, and possible diagnoses included stroke, hypertensive encephalopathy (brain dysfunction caused by severely elevated blood pressure), or a post-ictal state (following a seizure). An MRI scan was planned but aborted for safety reasons. A’s condition later deteriorated, and a repeat CT scan showed stroke in the back of the brain. A died a day after admission. We took independent advice from a consultant stroke physician. We found that there were aspects of A’s care which were reasonable, including prompt assessment, appropriate imaging, decisions made regarding treatment of blood clots, and MRI scanning and safety. We found that it was also reasonable to consider and treat hypertensive encephalopathy. However, we found that record-keeping fell below the expected standard. In particular, there was a failure to keep contemporaneous records on the day that A was admitted as there was no repeat National Institutes of Health Stroke Scale score noted after the initial CT scan. There was also inconsistent recording of staff grades, which reduced clarity regarding levels of clinical oversight. This added to uncertainty about the diagnosis, but it did not affect A’s outcome. We upheld this part of C's complaint. C complained about the board's communication with A and their family during the admission. We found that that the board reasonably explained the working diagnosis, management plan and diagnostic uncertainty. Where miscommunication occurred, the board acknowledged this and apologised. Overall, we found that communication was reasonable and did not uphold this part of C's complaint.

C complained on behalf of their child (A) who is in their late teens. C complained that Child and Adolescent Mental Health Services (CAMHS) failed to carry out appropriate Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) assessments and failed to provide A with appropriate support for a number of years. The board said that A had undergone a number of assessments and reviews within CAMHS prior to turning 18 and no conclusive diagnosis had been reached. During our investigation they acknowledged that the family may have been unintentionally given the impression that an ASD diagnosis was likely or expected. We took independent advice from a clinical psychologist with experience in CAMHS. We found that while there were multiple professionals involved, given the complexity of this case there should have been further demonstration of shared, integrated clinical reasoning by the multidisciplinary team (MDT) in formulating a diagnostic conclusion. We further found that there was a lack of documentation regarding clinical reasoning for the type of psychological therapy offered; and that there was a lack of clarity about the expected/communicated timescales for ASD assessment. Therefore, we upheld C’s complaint. We noted the board’s explanation that service changes have been implemented and are ongoing since the events considered in this investigation, and that this work is being informed by the Scottish Government and the National Autism Implementation Team. It may be that some of the issues identified in this investigation have been addressed by improvements already made. If that is the case, evidence of those improvements can be provided in support of the recommendations being fulfilled.

C complained about the care and treatment that they received during an admission to hospital. C attended A&E and the Acute Medical Unit for symptoms that were later diagnosed as an acute ischaemic stroke. We took independent advice from a consultant physician. We found that some aspects of C’s care were reasonable, particularly the communication between the board and C and their partner.However, we found that C’s assessment in A&E was unreasonably delayed in relation to their triage category. In addition, no structured stroke assessment was carried out. We also found that there was a delay in senior medical review and a lack of specialist stroke input. Furthermore, a prescription for aspirin was not made timeously after a CT scan excluded bleeding. Therefore, we upheld C's complaint.

C complained that the practice failed to provide them with reasonable care and treatment. C attended the practice with symptoms of an ear infection. C said that they were not prescribed appropriate medication and were unreasonably diagnosed with an outer ear infection. C felt that a swab that was taken damaged their ear. We took independent advice from a GP. We found that while their communication could have been better, the practice provided reasonable care and treatment in line with the history and information available at the time, and the relevant guidance. The evidence does not suggest that the ear swab caused C’s hearing loss and the practice's rationale for performing the swab was in line with local guidance. We found that the treatment provided was reasonable. We did not uphold C's complaint. Related reading View Decision Report 202409557 as a PDF (24.16 KB) Updated: September 17, 2025

C complained about the treatment provided to their late parent (A) when they attended hospital with shortness of breath and abdominal distension (swelling). Following assessment, A was prescribed a blood-thinning medication and was discharged with a plan to return for a scan within 48 hours to look for blood clots in the lungs. A deteriorated within hours of returning home. They were taken to hospital by ambulance and admitted for treatment. Their condition deteriorated significantly. Investigations revealed worsening heart failure and they died within a few days. The board initially considered sepsis to be A's cause of death but a post mortem later established this as congestive heart failure. We took independent advice from a consultant cardiologist (specialists in diseases and abnormalities of the heart). We found that it was reasonable for A to have been prescribed blood thinners and referred for a CT scan when they first attended hospital. However, on the basis that A’s clinical observations were abnormal, in particular their blood gas results, we found that A should have been admitted as they required oxygen. Therefore, we upheld this part of C's complaint. C complained that the board failed to provide appropriate care and treatment in response to A's deterioration. We were critical of the board for gaps in A’s records, meaning we were unable to establish what nursing checks were carried out on the day A deteriorated. However, we found that medical staff acted appropriately in response to A’s deterioration. A’s deterioration was a result of heart failure, leading to multi-organ failure. A’s family felt that there was a lack of clarity regarding A’s condition and what they were being treated for. The board recognised that there had been communication failings, apologised and confirmed that learning had taken place. We found that the plans for investigation and treatment were appropriate. It was reasonable for clinicians to suspect sepsis when A’s condition dete

C complained about the treatment provided to their partner (A) when they were admitted to hospital. A presented to the A&E after they woke up feeling generally unwell. A experienced weakness, lost vision, and pins and needles in their hands and feet. When assessed in the A&E, A gave a history of a three-day headache. There was a delay in A being assessed in the A&E. Given A’s symptoms, the consultant’s working diagnosis was an atypical migraine. They considered the possibility of a stroke but concluded this was less likely based on A's presentation. A was then transferred to the Acute Medical Unit before quickly being transferred to the care of the Stroke Team. A Computerised Tomography (CT) brain scan was carried out and confirmed a stroke. A further CT scan the next day confirmed that A had suffered a second stroke. C complained that there was an unreasonable failure by the A&E to diagnose that A had suffered a stroke. In addition to this, C complained that A was not provided appropriate treatment in the form of thrombolysis (medicine to get rid of blood clots in the brain) or thrombectomy (surgery to remove a blood clot or drain fluid from the brain). We took independent advice from an emergency medicine consultant. We found that an atypical migraine was a reasonable working diagnosis. We found that reasonable consideration was given to the possibility of a stroke and A’s history of diabetes was taken into account. We considered that there was sufficient reason to arrange a CT scan to assist diagnosis while A was admitted to the A&E. This was due to C’s symptoms and the diagnostic uncertainty. However, earlier imaging was unlikely to have made a material difference to the outcome. In addition to this, we noted that A had suffered a posterior circulation stroke, which is known to be challenging to identify. We concluded that there was not an unreasonable failure to diagnose A's stroke because of the atypical features of A’s presentation. In addition to this, A was

C complained about care and treatment provided to them by the board in relation to diagnosis and treatment of prostate cancer. C had concerns about medical treatment both prior to and after surgery, and about nursing care when they were in hospital following surgery. We took independent advice from a urologist and a nurse. We found that overall, medical care and treatment had been reasonable and did not uphold these aspects of C’s complaint. However, in relation to nursing care, we found that C’s needs and risks were not properly assessed, resulting in a lack of person-centred care planning and implementation. We upheld the complaint about nursing care.

C, an advocate, complained on behalf of A. A had been detained by the board under mental health legislation. C complained as to whether the board had taken steps to address the acknowledged deficiencies in discharge planning experienced by A, and whether A's personal belongings were securely stored in a way which allowed patients to access them. The board said that there was evidence of discharge planning, however they accepted that A’s need for district nursing care was omitted. The process had been reviewed, and the board were happy to provide a report to demonstrate progress had been made. The board said that patients’ rooms were lockable and while staff had the keys for rooms, patient access was not restricted, beyond the need for staff to open and close rooms for individuals. Restricted items were stored separately, and patients would be supported by staff in accessing these. We took independent advice from a mental health clinical adviser. We found that the board’s response demonstrated that they were taking reasonable steps to review the discharge process. However, we found that A’s discharge planning did not include the district nursing team. We upheld this aspect of the complaint but made no recommendations. We found that the board’s approach to the storage of possessions was reasonable. We did not uphold this aspect of the complaint. Related reading View Decision Report 202401449 as a PDF (24.45 KB) Updated: July 23, 2025

C complained that the board failed to consider their request for bariatric surgery reasonably. C also complained that the board failed to handle their complaint reasonably. C suffers from complex physical and mental health issues. They were referred for bariatric surgery by the clinicians treating their medical conditions. C attended a number of assessment appointments to determine their suitability for surgery. C was concerned by the assessment process and asked to see the report being submitted to the Multi-Disciplinary Team (MDT) meeting but this request was refused. C was not accepted for surgery. C received a copy of the assessment report through a subject access request. C was told by the board that they would accept a complaint from C if their complaint was made within 12 months. C complained a few months later. The board delayed in acknowledging and responding to the complaint but met with C to agree how the complaint would be handled. The following month, the board wrote to C stating that they would not investigate the complaint, because it had been submitted outwith the time limit for investigation. We took independent advice from a consultant psychologist. We found that C should have been allowed the opportunity to provide feedback on the assessment process before it was discussed at an MDT. C had been promised an appointment to do this, but the appointment was not made. However, we considered that the assessment itself had been reasonable. Therefore, we did not uphold this part of C's complaint. In relation to complaints handling, we found that C was not properly informed about the process that the board intended to follow and was repeatedly given the impression that the case would be investigated. The board did not demonstrate how it had determined C’s complaint was out of time. Therefore, we upheld this part of C's complaint.

C complained that their GP practice failed to provide them with reasonable care and treatment. C attended the practice with loss of appetite, vomiting, concentrated urine, poor fluid intake, a temperature of 38.7 degrees, and a high heart rate. C was prescribed antibiotics and given advice on what to do if their condition worsened. C’s condition deteriorated and they attended the practice again. C was referred for a chest x-ray and diagnosed with empyema (pockets of pus that have collected inside a body cavity). C’s condition was life-threatening and they remain impacted by it. In their response to the complaint, the practice arranged an independent review of C's treatment by a respiratory consultant. They noted that C had a significant tachycardia (heart rate exceeding 100 beats per minute at rest). The practice said that this could have been discussed with the Acute Medical Unit at the time. However, it was likely that they would have advised to treat C at home rather than to admit them. We took independent advice from a GP. We found that C’s presentation and clinical examination findings were suggestive of pneumonia at least, and indicated that they were at high risk of sepsis. We found that C should have been admitted to hospital rather than sent home with antibiotics. Therefore, we upheld C's complaint. During the course of our investigation the practice confirmed further reflection and learning. We were satisfied that in doing so they had appropriately addressed the failings in C’s care.

C raised concerns about the care and treatment provided to their sibling (A). A underwent a series of hospital admissions, suffering from bleeding from their bladder, following radiotherapy. During these admissions, the majority of communication between the board and the family was with A’s partner (B). A was initially expected to recover from the radiotherapy but was admitted and discharged repeatedly, with some readmissions happening a matter of hours after A was discharged. A continued to deteriorate and died in hospital. C believed that A was not provided with an adequate standard of urological or nursing care. They felt that A was not provided with appropriate treatment and that they were not reviewed properly by other medical specialties, given the complexity of their case. C was also concerned that A was not provided with adequate nursing care. C believed that the board had not acknowledged systemic failings which impacted on A’s care, wellbeing and adversely affected the outcome of their treatment. We took independent advice from a consultant urologist and a registered nurse. We found that A’s urology care fell below a reasonable standard, as did their nursing care and we upheld these aspects of the complaint. We found that A was reviewed appropriately by other medical specialties and this aspect of C’s complaint was not upheld. Finally, the opportunity to perform surgery on A was missed and this contributed to A’s deterioration. It was not possible, however, to determine whether A would have survived if their care had been different. The board failed to transfer A to a different consultant or offer a second opinion when this was requested and they failed to communicate reasonably with A’s family about their care. We upheld these aspects of the complaint.

C complained about their experience of labour and post-birth care. C felt that they had been left too long without assessment and without medical review. C also complained about the actions of a specific doctor, who attempted manual removal of their placenta post birth. C said that this had been painful and that their birth plan had not been followed, making the experience distressing and difficult for C and their partner. The board had already acknowledged failings in C’s care and the investigation assessed whether the actions set out were reasonable and proportionate means of addressing these. We took independent advice from an obstetrics adviser. We found that the board had acted to address the identified failings. Although C’s experience was distressing, there was no evidence that their baby was put at risk at any point. We upheld some of C’s complaints, but made no further recommendations due to the appropriate actions already taken by the board. Related reading View Decision Report 202304652 as a PDF (24.25 KB) Updated: February 19, 2025

C complained about the care and treatment that their spouse (A) received during two admissions to hospital. C complained that the board had failed to provide A with adequate personal care during both admissions and failed to adequately manage their medication during their first admission. C also complained that A had been unreasonably discharged following their first admission and that there had been inadequate preparation for A’s second discharge. The board apologised for failures in A’s care and for aspects of their communication. They also apologised for a failure to adequately prepare A’s medication prior to their second discharge. They identified learning from these failures. However, C remained unhappy and asked us to investigate. We took independent advice from a consultant in geriatric medicine and an advanced nurse practitioner. We found that A was unreasonably discharged at the end of their first admission. Therefore, we upheld this part of C’s complaint. However, the board managed A’s medication reasonably and provided adequate personal care during A’s first admission. Therefore, we did not uphold these part’s of C’s complaint. In relation to A’s second discharge, we found that there had been a failure to provide A with adequate personal care and that they had been discharged at the end of this without adequate preparation. We upheld these parts of C’s complaint.

C had a number of concerns about their child (A)’s behaviour, development, and educational attainment. A was referred to Child and Adolescent Mental Health Services (CAMHS) in the board. An assessment was carried out, the result of which was that A was not diagnosed with a neurodevelopmental condition. C complained that the board had unreasonably discharged A from the CAMHS service after having determined that they did not have attention deficit hyperactivity disorder (ADHD), without sufficient consideration being given to other potential diagnoses, and that the board failed to provide reasonable support following the lack of a diagnosis. We took independent advice from a psychologist specialising in CAMHS. We found that the while the board had ruled out ADHD, their assessment had also considered other neurodevelopmental conditions such as autism spectrum disorder (ASD) and intellectual disability (ID), as well as a broader consideration of A’s circumstances and early life experiences. It was evident that A did not meet the criteria for ongoing treatment via CAMHS and that that the board had carried out a sufficiently thorough and comprehensive assessment prior to discharging A. We also found that appropriate thought and consideration had been given to ensuring that A and C were engaged with the relevant agencies with respect to ongoing support being available, in particular through A’s schooling. For these reasons, we found that the care and treatment provided to C and A had been reasonable and we did not uphold C’s complaints. Related reading View Decision Report 202301856 as a PDF (24.6 KB) Updated: December 18, 2024

C complained about the post-operative care and treatment that they received from the board after they suffered a leg and ankle fracture. C said that unreasonable post-operative care led to a poor recovery and the requirement for an additional operation. We took independent advice from a consultant orthopaedic surgeon (specialists in the treatment of diseases and injuries of the musculoskeletal system). We found that the board failed to report some x-rays and to reasonably explain why further x-rays were taken and who had reviewed them. We also found that there had been an unreasonable delay in carrying out a CT scan and in discussing C’s case at a Morbidity and Mortality meeting. Therefore, we upheld this part of C’s complaint. C also complained about the board’s handling of their complaint. We found that the board handled C’s complaint reasonably and did not uphold this part of C’s complaint.

C complained that the board failed to provide reasonable care and treatment to their late parent (A). A became acutely unwell with uncontrollable diarrhoea, severe abdominal pain and vomiting. After visits from both a community nurse and out-of-hours GP, C called for an ambulance. The ambulance crew called ahead to the hospital to have A admitted, as per the board’s alternative admission pathway. As agreed during the call, A was taken to the Acute Medical Unit (AMU) but there was no bed for A on arrival. Initial observations and ECG/bloods were taken but A was found unresponsive a short time later and died of a cardiac arrest. The board apologised that no bed was available for A. They reviewed A’s case and concluded that the appropriate referral pathway was followed. However, they acknowledged that patients with undifferentiated (undiagnosed) abdominal pain should not be admitted to the AMU. We took independent advice from a consultant physician in acute and general medicine. We found that the board failed to obtain key information to determine which pathway should be followed. This resulted in A not entering the correct pathway. We found that the board failed to escalate A’s care and treatment in line with relevant guidance and with their own policy. We found that A’s care was compromised by the board’s alternative admission pathway. It is possible that the outcome may have been different had the correct pathway been accessed. We upheld this part of C’s complaint. C complained that the board unreasonably failed to carry out a Significant Adverse Event Review (SAER) following A’s death. After being notified of our investigation, the board commissioned a SAER. Although we welcomed this, the board did not provide assurance that they have adequate systems in place to identify, investigate and learn from adverse events. The board’s failure to commission a SAER following A’s death did not meet the standards outlined in the relevant guidance, and was unreasonable. Therefo

C complained about the care and treatment provided to their late parent (A). Scans revealed findings that were suggestive of bladder cancer. Over a number of further admissions, A received treatment to resect (remove) a bladder tumour, fit and remove catheters, treat infection and generally manage A’s condition. Eventually, it was decided that A’s condition should be managed palliatively, and A was discharged home. C complained that the medical and nursing care and treatment A received from the board was unreasonable and that the communication with A and their family was unreasonable. The board said that A was not medically or psychologically fit for further management of their condition and they were not a candidate for chemotherapy or radiotherapy. A was referred to palliative care once it was identified that they were also not a candidate for surgery. The board said A chose not to share their diagnosis for a number of weeks and were unwilling for discussions to take place with their family. We took independent clinical advice from a consultant urologist (specialists in he male and female urinary tract, and the male reproductive organs) and a registered nurse. We found that the surgical care was of a reasonable standard and that the board adopted a holistic approach. However there was a failure to detect the bladder tumour when it was initially suspected and a failure to follow up with A about their nephrostomy (a thin tube inserted through the skin directly into the kidney to allow urine to drain into an external drainage bag) and JJ stents (a thin flexible tube placed to help urine flow). We also found that there was a delay in organising an inpatient CT scan, failures in relation to discharge planning and a failure to care for A’s skin and pressure damage. In relation to communication, we found that the board failed to tell A that there was a suspicion of bladder cancer at an appropriate time and it was unreasonable for the board not to communicate with A’s fam

C complained about the care and treatment provided to their late parent (A) by the board. A, who had a history of breast cancer, was admitted to hospital with pain and vomiting. Tests were carried out and A underwent a liver biopsy. Following the biopsy, their condition deteriorated and they died a few days later. C felt that A’s death was premature and was hastened by the actions of the board. The board said that CT scans showed that A had an abnormal liver and an MRI was requested. This wasn’t completed until eight days later due to high demand. The liver biopsy was undertaken the same day. When A began to deteriorate, an urgent CT scan showed that A was bleeding from an injury to the branch of the cystic artery from the biopsy site. The board said that this is a known complication of a liver biopsy. The bleed was successfully treated but A deteriorated further and died. A had shown signs of potential infection and was commenced on antibiotics. The post-mortem stated that the cause of death was ‘complications of liver biopsy and metastatic breast cancer in liver’, and could not conclude to what extent the infection contributed to A’s death. We took independent advice from a consultant general and colorectal surgeon. We found that the MRI did not appear to have been reviewed prior to proceeding to biopsy and the breast team were not notified of the CT scan results. We also noted that A was not referred to the breast cancer multidisciplinary team (MDT). We found that antibiotics should ideally have been administered within one hour of deterioration and sepsis considered as a main cause of A’s deterioration. A was also given a cystic artery embolization (a minimally invasive procedure that blocks or closes the blood vessel) and two units of blood despite having a normal blood count and no evidence of significant bleeding. Therefore, we upheld this part of C’s complaint. C complained about communication with A and A’s family, stating that A was not given sufficient in

C complained about the care and treatment provided to their spouse (A). A had been diagnosed with lung cancer and were due to start treatment. A had become unwell overnight and attended the A&E twice in 24 hours. At the first attendance A had been examined but sent home. A’s condition had worsened, and they had been taken back to the A&E by paramedics. A had been examined and then admitted to hospital but died shortly after. C believed that A’s first assessment was inadequate, and that their concerns about pneumonia were dismissed unreasonably. They felt strongly that had A been given antibiotics and admitted, they might have had a better outcome. C believed that on A’s second attendance, A’s cancer specialists should have been contacted sooner. We took independent advice from an emergency medicine adviser. We found that A’s assessments were reasonable and that it was unlikely that the outcome would have been different had A been prescribed antibiotics or admitted sooner. We did not uphold the complaint. Related reading View Decision Report 202210503 as a PDF (24.28 KB) Updated: October 23, 2024

C complained on behalf of their parent (A) who passed away in hospital. During the admission, A was diagnosed with B cell lymphoma (a type of blood cancer) and received palliative radiotherapy treatment. C complained that A’s pain medication was incorrectly managed as they experienced both delirium and extreme pain, that A’s nutrition and fluid intake was incorrectly managed as A became dehydrated and lost weight, that A was left in a general ward rather than being moved to a cancer ward and that A was not offered chemotherapy. C complained that there had been a lack of communication regarding A’s palliative treatment plan, A’s deterioration and death. The board advised that A’s pain medication had been appropriately reviewed and adjusted. C’s fluid intake was difficult to manage but there was no indication for nasal gastric feeding. They apologised that there were gaps in the records in relation to fundamentals of nursing care, including nutrition, fluids and skin care and that nurses had since undertaken training. They noted that A was deemed too unwell to tolerate chemotherapy or a move and they stated that a number of discussions took place with the family to explain A’s changing condition. We took independent advice from a consultant geriatrician, a registered nurse and a consultant haematologist. We found that A’s pain had been reasonably controlled and the decision not to offer chemotherapy was reasonable. However, medical staff should have considered nutrition support earlier and nursing care had been unreasonable in relation to nutrition, fluids and skin care. Communication from doctors and nurses on the ward was reasonable, but there had not been any communication from a specialist about A’s cancer prognosis and palliative radiotherapy treatment. Therefore, we upheld all aspects of this complaint.

C complained that the board failed to provide C with appropriate treatment for a shoulder fracture. C was admitted to hospital suffering from alcohol related seizures. It became apparent that C had also suffered a shoulder fracture. C was discharged 12 days later with an orthopaedic referral (specialists in the treatment of diseases and injuries of the musculoskeletal system) for the following week. C was then scheduled for surgery to realign the fracture. This was subsequently cancelled. When C was seen again the following week a different consultant determined that C’s fracture had now healed to the extent that surgery was no longer a viable option. C complained that the shoulder is now misaligned, causing discomfort and a reduced range of motion affecting day-to-day life and their ability to work. C believes that opportunities were missed to prevent this outcome. The board’s response stated that C was initially too unwell for surgery, and that the cancelled procedure was because of an emergency admission that had to be prioritised. They also noted that there was reason to suspect that the injury was older than C had stated upon admission. We took independent advice from an orthopaedic consultant. We found that there had been some challenges for the board in providing care and treatment to C. However, it had been evident from three days before C was initially discharged that the fracture was healing out of alignment. We also found that there was insufficient evidence on which to conclude that the injury was older than stated. We noted that various opportunities were missed for earlier surgical intervention and that there was a lack of ownership of C’s case from an orthopaedic perspective, contributing to a series of small delays which ultimately led to the window of opportunity for effective surgery passing. This amounted to unreasonable care and treatment. Therefore, we upheld C's complaint.

C complained about the nursing care provided to their late spouse (A) during their admission to hospital. C raised specific concerns about the personal care and stoma care provided. We took independent advice from a nurse. We found that the personal care provided to A was reasonable. However, we identified significant failings in how A’s ileostomy care needs were provided and significant gaps in documentation. Therefore we upheld this part of C's complaint. C also complained about the communication with both A and C about A's health and prognosis. We found that prior to A’s decline C was communicated with in a reasonable manner. In relation to the communication with A in the days before their passing, we found that A was experiencing increasing confusion and cognitive impairment throughout their stay in hospital and at times lacked capacity. In light of this, it was unreasonable to inform A of their poor health without C present. Therefore, we upheld this part of C's complaint.

C complained about the care and treatment provided to their parent (A) during an admission to hospital. At the time of admission, A was taking medication for atrial fibrillation (a heart condition affecting the rhythm and rate of the heart). The medication included a blood-thinner to reduce the risk of blood clots. While A’s condition was being assessed, a decision was made to withhold this medication. A developed pain and discolouration in their leg and was unable to weight bear. C complained that there was a delay of 12 hours before medical staff acted upon this. A required a transfer to another hospital by ambulance, where they underwent emergency surgery for clots in the leg. A has been left with deep incisions in the lower leg and their mobility has been significantly reduced. The board discussed the case at a Morbidity and Mortality meeting, and following review of the circumstances did not think that there was anything from a system perspective that should be changed. We took independent advice from a consultant physician and geriatrician (specialist in medicine of the elderly). We found failings in record keeping and examination. We found that the board ought to have been alert to the risk of A developing blood clots after the blood-thinning medication was withheld, and should have acted more promptly when A started to deteriorate. We considered that A suffered pain for a longer period because their deterioration was not recognised in a timely manner. Their situation might not have been so serious had their condition been recognised sooner. We also found that the board did not carry out a suitably rigorous analysis of what happened, including review by staff who were not involved in A’s care. The board’s review failed to identify appropriate learning. Therefore, we upheld C’s complaint.

C complained about the care and treatment that their late sibling (A) received from the practice. A attended the practice with back pain and was given painkillers. Clinical staff noted comments on A’s appearance and demeanour during the appointment. They also noted that they considered A to be drug seeking. A died a few days later. C complained that the examination was not thorough enough and that clinicians missed the fact that a lung infection was the cause of A’s symptoms. The practice said that they considered the examination to be reasonable, that they felt that A did not present with typical signs of respiratory concern and so auscultation (listening to the lungs) was not indicated. They did not identify anything that could have been done differently. We took independent clinical advice from an advanced nurse practitioner. We considered that there were enough complicating factors in A’s history and presentation to warrant a more thorough examination of A. Therefore, the examination carried out was unreasonable. We found that the opinion that A was drug-seeking was premature as no differential diagnoses were considered or ruled out. We also noted that an adverse event review was not carried out which we considered to be unreasonable. Therefore, we upheld C’s complaint.

C complained about the care and treatment provided to their parent (A). A had been admitted to hospital before being transferred to a mental health facility. A then developed abdominal symptoms, which required them to be transferred to an acute hospital for treatment. A had been considered for surgery, but this was changed to treatment with medication. A was transferred back to the mental health facility but became unwell again and was taken to A&E. A died from a pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung). C said that A’s medical and nursing care fell below an acceptable standard which resulted in A’s dignity being compromised, their personal care neglected and A not receiving the medication that they required. C believed that A’s death was caused by a failure to examine A properly or ensure that A received anti-clotting medication. C felt that this resulted in A developing deep vein thrombosis (DVT, a blood clot in a vein) which led directly to their death. C was also unhappy with the board’s response to their complaint. C felt that the board had not represented meetings with the family accurately, and failed to follow up on the actions that they had told the family were being taken, despite acknowledging that there was significant learning to be gained from the family’s experience. We took independent advice from a registered nurse and a consultant geriatrician (specialist in medicine of the elderly). We found that A’s nursing and medical care had fallen below a reasonable standard. We also found that the board failed to communicate reasonably with C and their family and that they could not provide evidence that they had taken the actions promised to the family following the board’s complaint investigation. In addition, the board’s Significant Adverse Event Review had been delayed, reducing the utility of it to the board. We upheld all of C’s complaints.