SPSO Individual Decisions

C complained about the standard of surgery and post-operative care that they received when they had an elective operation for a long standing hernia (when part of an organ protrudes through your muscle wall). During the procedure the bowel was punctured resulting in an injury and transfer to another hospital. C said that the small hernia was manageable without an operation, and complained that they had not been told about all the risks and about inadequate care post-surgery. We took independent advice from a consultant general and colorectal surgeon. We found that it was reasonable to offer C an elective repair of the hernia and for this operation be to done by the consultant surgeon. However, more regard should have been given to whether C was at an increased risk due to their BMI. We found that the board failed to provide informed consent at an appropriate time which meant that the risks of surgery were not effectively communicated to C. We also found that the consent process for C did not meet published guidelines. Therefore we upheld this complaint. We found that post surgery, recognition and escalation to start Patient Controlled Analgesia was appropriate, and that C responded well to this pain relief. The timing of the CT scan was reasonable. Following escalation to clinical care specialists and treatment, C was transferred for further care which was also reasonable. We therefore did not uphold this complaint. We provided feedback that consideration should be given to the preoperative risk assessment being carried out at consultant level and that referral to specialist weight management is available for patients who require incisional hernia repairs electively.

C, an advocacy worker, complained on behalf of the family of A, about a failure to appropriately investigate A’s symptoms, and a consequent delay in diagnosing and treating their cancer. We took independent medical advice from a radiology consultant (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans), an Ear, Nose and Throat (ENT) consultant and a general medical consultant. We found that the initial scans A received were reported reasonably and did not show any malignancy. When A’s GP later referred them to ENT, we noted that consideration should have been given to upgrading this to urgent. It remained routine and A was not seen until nine weeks after the referral, at which point their cancer was diagnosed. In the meantime, A had been admitted to hospital under the care of the general medical team. We found that the medical team did not place sufficient emphasis on A’s physical symptoms, which were ‘red flags’ for the possibility of cancer. There was a failure to scan A’s neck, which is where their symptoms were. We also found that A should have been referred to ENT more urgently, preferably as an inpatient. The general medical team wrote to ENT asking for the earlier ENT referral to be expedited, but the letter did not sufficiently emphasise the physical concerns and placed undue emphasis on the likelihood of the problems being of a psychological nature. Had an ENT review been arranged while A was an inpatient, it is likely that their cancer would have been diagnosed at this point. We concluded that the board failed to reasonably investigate A’s symptoms and upheld the complaint. We noted that an earlier diagnosis around the time A was an inpatient would have been unlikely to have affected the outcome for A. However, we recognised it would have given A and their family more time to come to terms with the diagnosis.

C complained about the care and treatment that they received from the community mental health team, after C was referred due to suicidal ideation. C said that they did not have a reasonable level of contact with the team and had difficulty changing the frequency of a prescription. C also said that the board unreasonably made reference to a historical referral to a befriending service in their complaint response. We took independent advice from a specialist in adult mental health nursing. We found that the board’s position that prescribing is a matter for C’s GP to be reasonable. However, we found that C did not receive reasonable or adequate contact from the community mental health team and the board failed to follow through on a plan for C to have a face-to-face appointment with a consultant psychiatrist. We also found that the board failed to follow through with a plan to discuss a referral to a befriending service with the clinical team. The board’s complaint response made reference to a referral submitted several years previously, which we found unreasonable with respect to complaints handling. We upheld C’s complaint.

C complained about the board's decision not to fund the travel and accommodation costs they and their spouse had incurred as a result of travelling to visit their child (A) who was receiving treatment under a compulsory treatment order (CTO) in a different part of the country. C complained that the board's decision had failed to take into account the provisions of section 278 of the Mental Health (Care and Treatment) (Scotland) Act 2003 (the 2003 Act), which they considered placed a duty on the board to continue funding travel costs until A became 18, in addition to other legislation they considered to be applicable. C also complained about the board's failure to respond to correspondence in relation to this issue. The board's position was that C was an adult once they turned 16 and that their patient travel policy did not allow for the funding of visits to adult patients. The board stated that it would have nevertheless considered funding C's visits to A had it been deemed critical by the consultant in charge of A's care but that no request for C's attendance had been made by clinicians. We found that the board's patient travel policy did not allow for visits to patients over the age of 16 years to be funded by the board. However, we found that the board had failed to demonstrate that they had meaningfully considered the provisions of section 278 of the 2003 Act and had not adequately explained why they considered it did not apply to C and A's circumstances. We also found that the board had unreasonably failed to respond to C and their spouse's correspondence. Therefore, we upheld C's complaints.

C engaged with the board’s mental health services and believed that they had received a diagnosis of Borderline Personality Disorder (BPD, a mental disorder characterised by the instability in mood, behaviour, and functioning). They complained to the board that they had been prematurely discharged from mental health services. They also complained about delays, confusion affecting appointments, as well as a failure from the board to reasonably assess their condition. The board’s position was that C had been discharged originally due to a lack of response to correspondence. When C was thereafter seen by mental health services they acknowledged some confusion with respect to the arrangement for an appointment. With respect to the subsequent appointments C attended, the board explained that there was evidence of possible BPD, but that a diagnosis had not been confirmed. A further appointment was arranged but C did not manage to keep the appointment. The board considered that the psychiatric consultations, over the telephone, were appropriate and did not uphold C’s complaints. We took independent advice from a specialist in community psychiatry. We found that it was reasonable to discharge C given the evidence available and that they had received no response to their attempts to contact them. Given attempts were made to contact C, we did not uphold the complaint that C was unreasonably discharged. With respect to the psychiatric assessment and diagnosis of BPD, we found that the assessments carried out were careful and competent, the diagnostic statement was reasonable and that there was no firm diagnosis made, with reasonable advice and plan for follow up. Whilst it was concerning that C had formed the view that the diagnosis was definite, and it was acknowledged that assessments via Teams were preferred over telephone (as occurred in this case), we found that the assessment of C was reasonable. We did not uphold the complaint. Related reading View Decision Re

C complained that the practice failed to properly investigate their hip pain symptoms, resulting in a delayed cancer diagnosis. C raised concerns that questions were not asked, or tests carried out, that might have led to an earlier diagnosis. The practice responded to the complaint and carried out a Significant Event Analysis (SEA). They noted that a muscular injury was suspected at the initial consultation. At the time of the second consultation, an x-ray had been incorrectly reported as normal by the hospital. Therefore, the practice were not alerted to any need for further tests at that time. We took independent medical advice from a GP. We found the practice's management of C reasonable at the initial presentation. However, when C re-presented a month later with worsening bone pain despite a normal x-ray, further investigation (blood tests) should have been carried out. C was then diagnosed after orthopaedic (specialists in the treatment of diseases and injuries of the musculoskeletal system) review the following month. We upheld C's complaint. However, given the extensive nature of the disease identified, we did not consider that further investigation by the practice at the second consultation would have altered the overall outcome. We also found that the SEA should have reflected the further investigation that should have been considered at the second consultation. We gave some feedback to the practice on learning from adverse events, with reference to Healthcare Improvement Scotland's relevant guidance.

C's child (A) was born with a rare congenital condition where the urethra does not develop properly and underwent reconstructive surgery as a baby. A's doctors said that A had a 60% chance of being dry by the age of ten but would need further surgery when they are older. A had been potty trained, and no longer wore nappies, however they experienced incontinence leaks during some activities. A's health visitor referred A to the board's incontinence service to receive continence products. The board's continence service said A did not meet the criteria for continence products as they had not reached the age of four, as per the guidance for the provision of continence containment products to children and young people. C complained that A was eligible under the guidance after two years of age, given A's disability. C also complained that the decision on A's eligibility was made against advice of the health professionals working with A. We took independent advice from a paediatric nurse. We found that the guidance says children under four would not normally be given continence containment products, however this could be considered where continence issues are as a result of a child's disabilities. We also found that the board failed to complete a comprehensive paediatric continence assessment in A's case. We were also critical that the board did not take in to account the clinical opinion of the health professionals working with A. As a result, we found that the board did not reasonably assess A's eligibility for containment products and upheld this element of the complaint. C also complained that the board's handling of their complaint was unreasonable. We found that the final complaint response was issued without taking into account the comments from A's GP. Additionally, we found that the board did not handle C's complaint in line with the NHS Model Complaints Handing Procedure (MCHP). As a result, we upheld this element of the complaint.

C complained on behalf of their client (B) in relation to the care and treatment provided to B's partner (A) whilst A was a patient at Western Isles Hospital. C complained that the board failed to provide A with reasonable care and treatment whilst A was a patient in the hospital. In particular, C is concerned that venous thromboembolism (referring to blood clots in the veins) testing (VTE) was not carried out and that there was a delay in coagulation screening (screening laboratory tests which allows an initial broad categorization of haemostatic problems). C considered that if reasonable care and treatment had been provided, A may not have died. C also believed that the board did not reasonably respond to their complaint about this matter. The board noted that whilst a VTE assessment was not performed, and there was a delay in coagulation screening, this would not have altered A's clinical management or have changed the outcome, as A was extremely ill. The board stated that they considered they had reasonably responded to C's complaint. We took independent advice from an appropriately qualified adviser who determined that although the overall care and treatment offered to A was reasonable, there was learning for the board. We found that the board had failed to conduct a VTE assessment and had failed to administer a prophylactic dose of heparin on the evening of A's admission which was unreasonable. However, even if a VTE assessment had been carried out, and a prophylactic dose of heparin given, it would not have altered the clinical outcome in this case. We also found that the board's reason for a delay in coagulation screening was reasonable. We, therefore, did not uphold this complaint. Furthermore, we found that the board had reasonably responded to C's complaint. We identified learning for the board which was provided by way of feedback. Related reading View Decision Report 201902832 as a PDF (24.57 KB) Updated: May 19, 2021

C complained about the treatment their child (A) received within A&E at Western Isles Hospital. A was initially seen by a doctor who diagnosed a migraine. A They returned to A&E when their condition deteriorated, and was seen by another doctor, who diagnosed a migraine and possible virus. Following a third visit to A&E, A was diagnosed with a rare condition which is a complication of sinusitis. C complained that one doctor was dismissive and did not take A’s symptoms seriously. We took independent advice from an A&E consultant. We noted that A was diagnosed with a rare condition that A&E staff would not be expected to diagnose. However, we considered that signs were missed that A had a potentially serious underlying condition. While they were satisfied that both initial doctors who saw A initially carried out appropriate examinations, we noted that the blood tests results were not consistent with the diagnosis of migraine or viral infection. We considered that A should not have been discharged before all the blood results were available. We also considered that A should have been reviewed by a senior doctor before discharge on the second attendance, given that it was an unplanned return. We concluded that there was a failure to take appropriate action, which resulted in a delay in investigating and accurately diagnosing A’s serious underlying condition. Accordingly, we upheld this complaint.

C complained about the mental health care and treatment provided by the board. They also complained about the board's communication in relation to their care and treatment. C had been referred to psychiatry by their GP because of difficulties with anxiety and depression. C was seen by a psychiatrist who referred them for cognitive behavioural therapy (CBT) and discharged them from their clinic. C was re-referred to psychiatry urgently by their GP a few months later, following a deterioration in their mental health. C saw a psychiatrist three times and was referred for community psychiatric nurse (CPN) support because of the CBT waiting list and C's deteriorating mood state. C saw a locum psychiatrist four times over a two-month period when C was experiencing a continued deterioration in their mental health. C then saw their original psychiatrist on another two occasions. C's mental health deteriorated further and they were admitted to a psychiatric unit. We took independent advice from a mental health adviser, who noted from C's records that their clinical presentation was complex and multifaceted. We found that there had been a significant interruption in C's psychiatric out-patient care, with a period of 17 weeks elapsing between appointments. There was a further unplanned and unexplained gap of seven weeks between out-patient appointments. We considered these interruptions to be unreasonable, although we could not conclude with certainty that the interruption to continuity of out-patient care led to the deterioration in C's mental state and subsequent hospitalisation. Although we found that the care planning was reasonable, the significant unscheduled gaps between out-patient appointments were not reasonable, causing continuity of C's care to be disrupted. We therefore upheld this aspect of the complaint. Overall, we considered that C had been appropriately enabled to participate in decision-making related to their care, but some failings in communicat

Mr C, an advocate, complained on behalf of his client (Mr A) about the care and treatment Mr A received from the board when he attended hospital after his GP sent for an ambulance for him. The GP sent for an ambulance after a phone consultation with Mr A's wife, as they suspected that Mr A was having a stroke. When Mr A was admitted to A&E, he was treated for fast atrial fibrillation (an irregular heart beat) and possible alcohol related issues. Mr A was discharged from the hospital on the day after he was admitted. However, he was admitted to hospital again the following day. A CT scan was carried out and this confirmed that Mr A had suffered a stroke. Mr C said that medical staff within A&E did not act appropriately when Mr A was originally admitted to hospital and that medical staff unreasonably failed to investigate the possibility that Mr A had suffered a stroke, despite symptoms being identified in his admittance notes. We took independent advice from an appropriately qualified adviser. We found that there was nothing contained in Mr A records when he was originally admitted that indicated he had suffered a stroke. Based on the evidence and Mr A's presentation, we concluded that it was reasonable for medical professionals to exclude a stroke at that time. However, we noted that Mr A symptoms were suggestive of a transient ischaemic attack (TIA; a stroke lasting for a shorter period, less than 24 hours). The records suggested appropriate consideration was not given to the possibility and symptoms of a TIA. If a TIA had been diagnosed, then the management of Mr A's atrial fibrillation may have been different. This may not have prevented Mr A's readmission or stroke, but could have changed the overall clinical management. We concluded that medical professionals did not unreasonably fail to identify a stroke when Mr A was originally admitted. However, we concluded that the board did not give appropriate consideration to whether Mr A had suffered a TIA.

Mrs C's complained about the care and treatment provided by the board to her husband (Mr A) over several of years, in a number of respects. Mrs C said that this had an adverse effect on the care provided to Mr A and, as a result, his mental health had suffered. We took independent advice from an adviser who specialises in psychiatry. We found that the standard of care and provision of treatment was reasonable in all respects and we did not uphold this aspect of the complaint. Mrs C was also concerned about the way the board had handled her complaint. We found that the board's complaint response reflected the findings of their investigation and was reasonable. Therefore, we did not uphold this aspect of Mrs C's complaint. Related reading View Decision Report 201806328 as a PDF (24.04 KB) Updated: March 18, 2020

Mr C, a patient advocate, complained on behalf of his client (Mrs B) about Western Isles Hospital. Mrs B was unhappy with the care provided to her mother (Mrs A) who was admitted to the hospital and received treatment for sepsis (a blood infection). Mrs A's condition significantly deteriorated in the weeks following admission. She was then transferred to a hospital in Glasgow, where she died from her illness. In response to the complaint, the board identified learning and improvement in relation to communication and nursing monitoring records. Mr C complained about the care and treatment provided to Mrs A during the admission and that there was a delay in transferring her when her condition deteriorated. We took independent advice from a consultant orthopaedic surgeon (specialist in the treatment ofdiseases and injuries of the musculoskeletal system) and from a registered nurse. We found that medical staff managed Mrs A's condition in a reasonable manner. In particular, there were regular reviews, reasonable investigations were arranged and treatment was responsive to her condition. We did not identify any delay in the board transferring Mrs A when her condition deteriorated. We also found that the nursing care provided was reasonable. We noted that there was evidence of appropriate care planning, monitoring and interventions. We did not uphold these aspects of the complaint. Finally, Mr C complained that the board did not communicate reasonably with Mrs B about Mrs A's care. The board upheld this complaint and outlined improvement work. We were satisfied that the board had taken appropriate action. We upheld this complaint but made no recommendations. Related reading View Decision Report 201804377 as a PDF (24.13 KB) Updated: October 23, 2019

Mr C complained about the time taken for the board to refer him to specialist care for pain in his hip following a hip replacement. We found that for several years the board's actions were reasonable. However, at one point, the board recognised the possibility of infection but chose not to aspirate (drain fluid from) Mr C's hip. We considered this to be unreasonable and that Mr C should have been refererred for specialist care. We upheld this aspect of the complaint. Mr C also complained about the boards handling of his complaint. We found that the board complaint handling was reasonable and, therefore, we did not uphold this aspect of the complaint.

Ms C, who works for an advice and support agency, complained on behalf of her client (Mr A) about the care and treatment provided to him at Uist and Barra Hospital. Mr A was catheterised (a process that involves inserting a tube to the patient's urethra to allow urine to drain freely from the bladder for collection), and Ms C complained that this was done unnecessarily, and without his consent. She also complained that the record-keeping for this admission was not of an appropriate standard. We took independent advice from a consultant physician and a nurse. We found that it had been necessary from a medical standpoint to catheterise Mr A. We also found that whilst Mr A's consent was not documented, there is no requirement for this and there was no evidence to suggest that Mr A did not consent to catheterisation. We considered that record-keeping was of a reasonable standard. We did not uphold these aspects of Ms C's complaint. Ms C also complained that Mr A's initial verbal complaints were not handled appropriately. The board accepted that this was the case and we, therefore, upheld this aspect of Ms C's complaint.

Mrs C complained on behalf of her daughter (Miss A), who suffers from quadriplegic cerebral palsy (a condition which results in severe or complete loss of motor function in all four limbs) and other complex additional support needs. Mrs C complained that the board unreasonably withdrew Miss A's physiotherapy. We took independent advice from a physiotherapist. We found that it could have been deemed appropriate for the board to stop Miss A's physiotherapy. However, we found that this was done without any appropriate assessment documented in the notes and without any documented consultation and discussion with Mrs C and her husband (Mr C). This is contrary to the Scottish Government Getting it Right for Every Child guidance. We upheld this aspect of Mrs C's complaint. Mrs C also complained that, when asked, the board unreasonably failed to show her that their decision to withdraw Miss A's physiotherapy was based on clinical need. We noted that, while the board referred to the progress Miss A had made, they did not explain why improvement in Miss A's physical abilities affected her need for physiotherapy. In view of this, it was unclear why the specific physiotherapy was withdrawn. There was also a delay in the board providing this complaint response to Mrs C. We upheld this aspect of the complaint. Mrs C also complained that the board unreasonably failed to carry out a paediatric physiotherapy review of Miss A's physiotherapy requirements, as had been agreed at a meeting with Mrs C and Mr C. We were unable to confirm if a review took place at the time the board said that it would. We upheld this aspect of the complaint.

A firm of solicitors (Firm C), raised a complaint on behalf of their client (Mrs A) that, during an examination under anaesthetic, a consultant had carried out a rectal examination without her knowledge or consent. She only found out about this when she received a copy of her medical records. When Firm C raised concerns about this with the board, they passed the correspondence to the consultant (who no longer worked for the board), who responded to Mrs A directly. The board subsequently accepted the consultant's response as their response to the complaint and did not investigate the complaint through their complaints handling procedure. We took independent advice from a consultant in obstetrics and gynaecology (the medical specialty that deals with pregnancy, childbirth, and the post-partum period and the health of the female reproductive systems and the breasts). We found that it was not routine practice to perform a rectal examination as part of the examination Mrs A was having conducted. The Royal College of Obstetricians and Gynaecologists guidance on Obtaining Valid Consent states that procedures should not fall out-with that which the patient consented to, unless there is an unanticipated emergency. We found that Mrs A should have been aware that a rectal examination was a possibility prior to the procedure and consented as such. In the absence of consent, it was not reasonable for a rectal examination to be carried out. We upheld the complaint. We also had concerns about the way in which Firm C's concerns had been handled. Firm C had clearly raised a complaint and our view was that the board should have investigated and responded to this in line with their complaints handling procedure. We made recommendations regarding this.

Mr C suffers from post-traumatic stress disorder and has a longstanding difficulty leaving his house as a consequence. Mr C complained that the practice unreasonably decided that he was not housebound. Mr C's psychiatrist wrote to the practice noting their view that his longstanding mental health difficulties effectively rendered him housebound. The practice had previously refused a request from Mr C for a home visit on the basis that he had managed to attend the surgery in the preceding months. Mr C contacted the practice to ask them to clarify their position in light of his psychiatrist's letter, and they maintained that he is not housebound. We took independent advice from a GP, who considered that the practice's home visit policy was overly rigid in that it appeared to require a purely physical inability to travel and did not give due regard to Mr C's mental disability. Therefore, we upheld this complaint. Mr C also complained that the practice failed to disclose relevant information to his psychiatrist when discussing his situation over the phone. This pre-dated the psychiatrist's letter and the psychiatrist appeared to agree with the practice at that time that Mr C was not housebound. Mr C considered that the conclusions drawn by his psychiatrist would have been altered if the long standing nature of his condition and its symptoms had been discussed. However, we noted that the psychiatrist was already aware of Mr C's long term symptoms and medical history from previous assessments by them. The purpose of the call was to find out if there were any current issues that they needed to be aware of. We found that it was reasonable for the practice not to refer to more details of Mr C's past medical history during the phone call. Therefore, we did not uphold this complaint. In addition, Mr C complained that the practice did not advise him of his right to approach us on completion of their complaints process. The practice complaints policy and NHS complain

Mrs C complained about aspects of the physiotherapy care provided to her child (child A), who has complex care needs. Mrs C complained that the physiotherapy provided to child A did not reflect their needs. We took independent advice from a physiotherapist. We found that, for the most part, child A received appropriate physiotherapy for their condition. Although we found some gaps in the record-keeping, we concluded that, on the whole, the care and treatment provided to child A was reasonable. We did not uphold this aspect of the complaint. Mrs C also raised concern that the board failed to provide appropriate physiotherapy input to child A following administration of a treatment at a hospital in another health board's area. We found that the board had appropriately liaised with the other health board, and that child A received an increase in physiotherapy following the treatment. We found this to be reasonable and we did not uphold this aspect of the complaint. Lastly, Mrs C complained that the board had not communicated with her reasonably about a change in physiotherapy service provided to child A and that child A would no longer be working with a physiotherapy assistant. We found that the board had arranged an event to update families about changes in the physiotherapy service. However, we found that, in the period prior to this, there was no evidence to suggest that Mrs C was informed that child A would no longer be working with the physiotherapy assistant. The advice we received also noted that there was no evidence that a reduction in the frequency of physiotherapy input was discussed with Mrs C. We upheld this aspect of the complaint.

Ms C complained that the dentist failed to provide her with a reasonable standard of dental care and treatment. Ms C attended the dentist over a number of months, concerned about a number of issues. Ms C had experienced pain in one of her teeth which she subsequently discovered had a crack in it. She said that the dentist failed to investigate this appropriately. As a result, Ms C said an adjoining tooth was extracted, and she was unreasonably prescribed three courses of antibiotics before the cracked tooth was extracted. Ms C also had to receive root canal treatment on another tooth which had an infection Ms C said that as a result of the failings, she was in pain for months and needed to get veneers or implants to close the gap at the front of her mouth because she could not eat or smile. We took independent advice from two dentists. We found that there were significant failings around record-keeping, the prescription of antibiotics, and the management of two teeth. We also found that the dentist was not in a position to appropriately monitor any potential decay progression, which was unreasonable. However, we did not find that the extractions were unnecessary. On balance, we found that the care and treatment Ms C received was unreasonable and therefore. we upheld the complaint.

Mr C complained that he had been refused a patient escort to his hospital appointment. Mr C lives far away from the hospital and said that he could not travel on his own due to his health conditions. The board said that Mr C did not meet the criteria for a patient escort. We took independent advice from a nurse. They said that there was insufficient evidence to demonstrate that the board had reasonably assessed Mr C's health conditions and their impact on his ability to travel. We considered that it was not clear why Mr C did not meet the criteria and what, potentially, would be sufficient to meet the criteria. Therefore, we upheld Mr C's complaint.

Ms C complained that there had been a delay in transferring her mother (Mrs A) from Uist and Barra Hospital to Western Isles Hospital. Mrs A had a stroke and after the emergency services were called, she was taken by ambulance to Uist and Barra Hospital. The Scottish Ambulance Service had been called prior to her admission, and a plane to transfer Mrs A to Western Isles Hospital then left the mainland. Because of adverse weather, the plane was unable to land at the nearby airport and as a result, the transfer could not take place that evening. In response to Ms C's complaint, the board explained that there is a four and a half hour window to assess a patient who is suspected of having had a stroke and judge the potential benefit of thrombolysis (clot busting) treatment. The board said that the delay in transfer was caused by bad weather, which meant that the cut-off time for potential treatment with thrombolysis medication had passed. We took independent advice from a specialist in emergency medicine. They did not find evidence of a delay in contacting the ambulance service regarding air transfer and said that the decision whether it was safe to fly or not, and the assessment of the likelihood of being able to land, rested with the aircraft captain. The adviser said that once it became apparent that the plane was unable to land, the opportunity to get Mrs A to Western Isles Hospital, complete a CT scan and consider the possibility of thrombolysis in under four and a half hours had passed. Whilst the adviser considered that the care surrounding the transfer was reasonable, they considered that the doctor's records should have been more detailed. We did not uphold this complaint, but we made a recommendation. Ms C also raised concern about the communication during the transfer process. We found that the board had apologised for any upset and distress Ms C's family experienced. Having considered the evidence available, the adviser concluded that the communica

Mr C complained about the care and treatment provided by the medical practice to his late wife (Mrs A), who suffered from diabetes. In particular, he complained about the treatment of Mrs A's ulcers, decisions made by the practice during home visits and the practice's initial decision to refuse a home visit. Mr C also complained about the practice's response to his complaint. During our investigation we took independent GP and nursing advice. The advice we received from the GP adviser was that the care and treatment given to Mrs A was in line with NHS guidance on the management of diabetes, and the decisions taken by the practice during home visits were reasonable. The advice we received from the nursing adviser was that the nursing care provided by the practice was reasonable. We found no evidence that a home visit had been refused by the practice, but that the practice had been hesitant to visit given that a home visit had been carried out within 24 hours prior and the complaint remained the same. The advice we received and accepted from the GP adviser was that in these circumstances it had been reasonable to question the necessity for another home visit. The practice had accepted that there were inaccuracies in their response to Mr C and in their clinical records. We therefore upheld this aspect of Mr C's response.

Mr C complained about the care his late wife (Mrs A), who suffered from diabetes, received from the board. In particular he complained that when a home visit was made by a district nurse, his wife's podiatry appointment was not brought forward by the board. During our investigation we took independent advice from a consultant podiatrist. The adviser considered that when Mrs A's diabetic foot ulcer was noted during the home visit, an urgent referral should have been made to the board's multi-disciplinary diabetic foot care service which would have given her access to vascular assessment and a vascular consultant. The adviser, when commenting on the care given during the home visit, also referred to the podiatry care Mr C's wife received when she was admitted to Western Isles Hospital. In particular, the adviser commented that there was no record of a vascular assessment having being carried out and that this represented a failure in assessment by podiatry.

Mrs C complained about several aspects of the nursing care that had been provided to her mother (Mrs A) at Western Isles Hospital and about the nursing staff's communication with the family. We took independent nursing advice. We found that while some aspects of nursing care were reasonable, the board had already carried out their own review which had identified a number of failings with care and communication and apologised for these. We found that there had been poor practice in relation to the use of a hoist when lifting Mrs A. We therefore upheld Mrs C's complaint.