Decision Reports

July 2019

Case ref:  201705215

Mr C complained about the actions of a court appointed psychologist who interviewed him after he had been convicted of an offence.  In their response to the complaint the board set out the reasons why the court decided to appoint the psychologist. They also explained that specific information was required from Mr C so that the psychologist could prepare a report for the court, prior to Mr C being sentenced.

Case ref:  201805252

Mr C complained about the treatment which he had received at Ninewells Hospital. Mr C said that he had problems with a left-side perianal abscess (a local accumulation of pus that forms next to the anus, causing tenderness and swelling) and that he was taken to theatre for surgery. When Mr C recovered from the surgery he noted that there was a dressing on the right side of the anus and that the abscess on the left side was still present. Staff assured Mr C that the surgery had gone ahead as planned. Mr C attended his GP a few days later and the GP confirmed the abscess on the left side was still present. Mr C felt that the board staff had operated on the wrong side of his anus.

June 2019

Case ref: 201802165

Mr C complained that his stoma reversal surgery (a surgery to reconnect the bowel) was delayed because of his mental health.

May 2019

Case ref: 201705936

Mrs C complained on behalf of her husband (Mr A) regarding the delay in reaching a diagnosis of prostate cancer during consultations at Perth Royal Infirmary. In response to Mrs C's complaint, the board explained that a number of factors had contributed to the time taken to diagnose Mr A. The board said that Mr A's symptom pattern was unusual, and investigations were initially performed to rule out bladder and kidney cancer. Mrs C was unhappy with this response and brought her complaint to us.

April 2019

Case ref: 201707309

Ms C complained to us about the care and treatment her son (Mr A) had received at Ninewells Hospital. Mr A was admitted to the Intensive Care Unit (ICU) with pneumonia (an infection of the lungs) and died within a month of his admission. In particular, Ms C complained that there was a delay in referring Mr A for surgery to treat his pneumonia.

Case ref: 201708281

Mrs C complained about the treatment which she received at Ninewells Hospital. Mrs C had been receiving iloprost infusions (intravenous medication) for a number of years for her medical conditions which included Raynaud's disease (numbness in fingers or toes). However, the board had changed the criteria for iloprost infusions and advised Mrs C that the infusions would stop. Mrs C felt that this was unfair as the treatment had provided her with relief from her symptoms.

March 2019

Case ref: 201706659

Mrs C complained that certain risks associated with knee replacement surgery she underwent at Ninewells Hospital had not been explained to her when she consented to the operation. She also complained that the wrong size of implant was used and that cement had leaked and caused nerve injury. Mrs C underwent additional surgery a couple of days later to remove the cement.

Case ref: 201707406

Mr C complained about the treatment he received from the board for pain in his thigh. Mr C said that he attended Perth Royal Infirmary and Ninewells Hospital over nearly a three year period for treatment for his condition and was seen by three different consultant vascular surgeons (a specialist in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels). Mr C said he was not satisfied with the treatment suggested by the consultants and was subsequently seen and assessed by a surgeon at a private hospital, who carried out treatment which cured the pain in Mr C's thigh.

February 2019

Case ref: 201800216

Mrs C complained about the treatment she received at an appointment with a gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines) at Ninewells Hospital and the response to her subsequent complaint. Mrs C said the doctor failed to properly investigate her condition given her symptoms/medical history and that there were failings in communication.

January 2019

No Decision Reports for NHS Tayside produced this month

December 2018

No Decision Reports for NHS Tayside produced this month

November 2018

Case ref: 201705257

Mrs C complained about the care and treatment she received from Ninewells Hospital regarding a delay in physiotherapy and the board's handling of her complaint concerning the matter.

Case ref: 201705314

Mr C complained that the board delayed in providing his late wife (Mrs A) with a diagnosis of pancreatic cancer. He said that, had Mrs A been diagnosed sooner, her care and treatment may have been different and she could have had a better quality of life. In their response to Mr C's complaint, the board acknowledged a delay in diagnosis and apologised, but they said that Mrs A's illness had been difficult to detect and that her symptoms had been vague. They said that their delay had not affected Mrs C's outcome.

Case ref: 201802126

Mr C complained about the treatment he received in A&E at Ninewells Hospital. Mr C had had attended with symptoms of severe headache and double vision. He was given painkillers and told to return for a scan the following week. A few days later Mr C awoke with blood coming from his nose and mouth and contacted the Acute Medical Unit. He was asked to return the following day for a head scan which found that Mr C had suffered an internal carotid artery dissection (a tear in one of the arteries in the neck). Mr C felt that the head scan should have been taken when he first attended hospital.

October 2018

Case ref: 201607444

Mrs C complained about the care and treatment that her late husband (Mr A) received at Ninewells Hospital after he attended with painless jaundice (a condition with yellowing of the skin or whites of the eyes). Mr A was later diagnosed with pancreatic cancer. Mrs C considered that the board had not taken appropriate action in terms of treating his symptoms as a red flag for cancer, carrying out appropriate investigations, diagnosing the primary source of cancer, acting on problems with a stent that had been inserted to drain a bile duct blockage, decision-making around surgical treatment and prescription of a medication to help digestion.

Case ref: 201701411

Ms C, who works for an advice and support agency, complained on behalf of Miss A about the medical and nursing care and treatment Miss A received at Stracathro Hospital following hip replacement surgery. Ms C raised a number of concerns, including that Miss A suffered a stroke after surgery which was not picked up on by staff, despite her repeatedly reporting visual disturbance and blurred vision.

Case ref: 201704684

Mrs C complained about the in-patient care she received at Ninewells Hospital. In particular, that there was a delay in diagnosing diverticulitis (where small pouches from the wall of the gut become inflamed or infected). She also complained that a consultant surgeon had not examined her when she attended an out-patient clinic appointment at Perth Royal Infirmary and that the care that she received from the out-of-hours service was unreasonable.

Case ref: 201706122

Mr C complained about a Do Not Attempt Cardiopulmonary Resuscitation decision (DNACPR - a decision taken that means a healthcare professional is not required to resuscitate the patient if their heart or breathing stops) taken when his mother (Mrs A) was a patient in Ninewells Hospital where she was being treated for heart failure. Mr C held Power of Attorney (POA, the authority to act for another person in specified or all legal or financial matters) in relation to his mother. He had been told of the decision in a public place, without being consulted. The doctor who spoke to him said he had spoken to Mrs A, who agreed with the decision. Mr C said his mother was very confused and unable to consent to this. Mr C complained that he had not had his views taken into account in relation to the DNACPR decision despite having POA and that the board unreasonably spoke to Mrs A and gained her consent despite her lacking capacity to give consent at the time.

Case ref: 201800927

Mr C complained about a consultation which he had with a consultant surgeon following a referral from his GP. Mr C had a complex medical history, including abdominal pain, and he felt that the consultant was not interested in helping him. Mr C said that he was told by the consultant that his health problems could be in his mind and also that stress could be the cause of his problems, along with him being overweight. Mr C was not satisfied that the plan was for him to be reviewed in six months in the hope that he had managed to reduce his weight. He complained that he did not receive appropriate treatment.

September 2018

Case ref: 201708551

Mrs C was referred by her GP to the orthopaedic department (the area of medicine which deals with the musculoskeletal system) at Ninewells Hospital for consideration of knee replacement surgery. However, there were problems with the communications from the board which resulted in her missing a scheduled out-patient clinic appointment. Mrs C questioned this with the board and she was told that arrangements had been made to reschedule the clinic appointment. However, she was then told that the rescheduled appointment had been cancelled and that the consultant had carried out a virtual assessment of the symptoms reported by the GP, and had subsequently discharged her. Mrs C complained that it was unreasonable that she had been discharged from the orthopaedic clinic without a face-to-face consultation.

August 2018

Case ref: 201701763

Mrs C complained about the care and treatment provided to her late grandfather (Mr A) at Ninewells Hospital. Mr A was admitted to hospital and treated for sepsis (a blood infection). It was initially thought that this was caused by a chest infection but investigation showed that the source was Mr A's gallbladder. Mrs C complained that staff had not listened to family concerns about the source of the infection and that this had affected his treatment. Mrs C was concerned that the placement of a drain or other treatment was unreasonably delayed and that an appropriate scan had not been done. Mrs C considered that a different approach could have prevented Mr A's death.

Case ref: 201702715

Miss C suffered ongoing complex urological problems (problems relating to the urinary tract, bladder or kidneys), and underwent a dilation and cystoscopy procedure (a procedure to look inside the bladder and stretch the urinary opening) at Ninewells Hospital. During the procedure biopsies (samples of tissue) were taken. Miss C complained about the medical and nursing care during this procedure, which she found very painful and distressing. Miss C also complained about her medical care following the procedure, and that it took several months for the board to refer on to a urological specialist in another board area after she requested this.

July 2018

Case ref: 201701048

Miss C complained about the medical treatment her late mother (Ms A) received at Ninewells Hospital before her death. Ms A had been admitted to hospital on three occasions with exacerbation of chronic obstructive pulmonary disease (COPD, a disease of the lungs in which the airways become narrowed). It was then diagnosed that she had heart failure and Ms A died a week after her final admission. Miss C considered that there had been a delay in making a diagnosis of heart failure, as staff wrongly assumed that Ms A had COPD and delayed in carrying out the tests that showed she had heart failure.

Case ref: 201701675

Mrs C complained about the care and treatment provided to her late husband (Mr A) at Ninewells Hospital. Mr A was resident in a care home and had Alzheimer's disease. He was referred to the emergency department by his GP as he was suffering from hip pain and could not bear weight. The GP asked that staff at the hospital rule out bony injury as a cause of Mr A's symptoms. X-rays were carried out and Mr A was discharged back to the care home after staff found no significant changes from previous x-rays. Four days later, an emergency referral was made for Mr A and he was admitted to hospital. Subsequent tests showed that Mr A had an abscess (a painful swelling caused by a build-up of pus) in his hip. It was determined that he was not suitable for surgery and Mr A was referred to the palliative (end of life) care team. Mr A died in hospital a few days later. Mrs C complained that Mr A's care in the emergency department was unreasonable and that there had been confusion over his palliative care referral. She also complained about how the board handled her complaint.

Case ref: 201702567

Mrs C complained that the board unreasonably discharged her from a community mental health team. She believed that she was discharged due to the absence of her usual community psychiatric nurse (CPN), who had been off work for a number of months at the time of discharge. Mrs C said that she had not been regularly seen or supported during this absence, only receiving two appointments, the focus of which were her discharge from services. While complaining to the board, she also became aware that her previous diagnosis of bipolar disorder (a mental health condition marked by alternating periods of elation and depression) had been changed to a possible diagnosis of borderline personality disorder (BPD, a disorder of mood and how a person interacts with others). Mrs C complained that she had never been informed of this change and that the board failed to communicate with her appropriately.

Case ref: 201703280

Mr C complained on behalf of his late wife (Mrs A) who was diagnosed with cholangiocarcinoma (CCA, a very rare cancer of the bile duct) at Ninewells Hospital. Mr C was concerned that there had been a delay in providing the diagnosis and that, had appropriate tests and investigations been carried out sooner, Mrs A's death may have been avoided. Mr C was also concerned that after diagnosis, the board failed to make further more timely investigations about the spread of the disease (particularly to her bones) for which treatment may have been available. Mr C complained to the board who told him that Mrs A's illness had been life limiting but that throughout her illness, her treatment had been reasonable and appropriate. Mr C was unhappy with this response and brought his complaint to us.

Case ref: 201705169

Ms C complained about the care and treatment provided to her by the board in relation to her hearing. Ms C had surgery to fit a hearing implant and after this she felt that her hearing deteriorated. Ms C also developed tinnitus (a ringing or buzzing in the ears). Ms C further complained that the communication with her from clinicians with regards to her hearing was not reasonable.

Case ref: 201706572

Miss C complained that the board unreasonably refused to perform liposuction (a cosmetic procedure used to remove unwanted body fat) for her lipoedema (a chronic fat tissue disorder in which fat cells build up, typically on the thighs, buttocks and lower legs, which causes tissue enlargement, swelling and pain. This tissue cannot be lost through weight loss). The board had criteria in place for providing this procedure and Miss C did not meet the criteria. Miss C complained that the criteria were unreasonable.

June 2018

No Decision Reports for NHS Tayside produced this month

May 2018

Case ref: 201608947

Mr C complained about the care and treatment that his father (Mr A) received at Perth Royal Infirmary following a fall. Mr C was concerned that a fracture was not identified until Mr A had been in hospital for eight days. Whilst in hospital, Mr A also suffered a period of delirium. Mr C complained about communication issues and the way that Mr A had been transferred between wards at the hospital. Finally, Mr C also considered that the board had not handled his complaint reasonably.

Case ref: 201609690

Mr C complained about the care and treatment his late father (Mr A) received at Perth Royal Infirmary (hospital 1). Mr A was suffering from a chest infection and was also experiencing periods of delirium. Mr A was discharged from hospital 1 to a community hospital (hospital 2) in another health board area, but they refused to admit him due to his condition and he was transferred by ambulance to another hospital (hospital 3). Mr A was later admitted to hospital 2, where he died a short time later. Mr C complained that the decision to discharge Mr A from hospital 1 was unreasonable and that there was an unreasonable delay in replacing his hearing aids which were lost during his admission.

Case ref: 201701250

Ms C complained that the board unreasonably failed to identify her hip fracture. Following a referral to Ninewells hospital, Ms C was reviewed by a consultant orthopaedic and trauma surgeon who considered that she had strained a ligament in her knee. She was then referred for physiotherapy for mobilisation and rehabilitation. Ms C was reviewed over the following months and developed progressively worsening pain. A subsequent x-ray identified a hip fracture.

Case ref: 201703145

Mrs C, who works for an advocacy and support agency, complained on behalf of her client (Mrs B) about the communication with Mrs B's husband (Mr A). Mr A suffered some stroke like symptoms and his GP referred him to the hospital for a scan to check if he had had a stroke or transient ischaemic attack (TIA or 'mini-stroke'). A doctor discussed the results of the scan with Mr A in an appointment at the TIA clinic, about two weeks after his initial symptoms. It was recorded that Mr A was at risk of a further stroke, and the doctor recommended that he take medication to reduce this. Mr A suffered a further stroke some months after this, and later died. Mrs B said that Mr A never told her about the results of the scan, and she queried whether he had fully understood this, given he was suffering from confusion. Mrs B felt it was unreasonable for the doctor to share this information with Mr A at an appointment he attended alone, and not with her.

April 2018

Case ref: 201701995

Ms C, an advocacy and support worker, complained on behalf of her client (Mr A) about the care and treatment he received at Ninewells Hospital. Mr A suffered an injury in which his fingertip was severed at the joint and he wanted to have surgery to have it reattached. However, he was referred for terminalisation surgery (where the finger is shortened and the remaining soft tissue is used to cover the amputated finger stump) instead. Following the surgery, Mr A experienced severe pain and his injury did not heal as quickly as he had hoped. Ms C complained that the board failed to provide Mr A with appropriate medical treatment and that nursing staff failed to appropriately assess and manage Mr A's pain before discharging him home.

Case ref: 201700360

Ms C, who is an advocacy and support worker, complained on behalf of her client (Mr A). Mr A had an operation at Ninewells Hospital and continued to suffer pain for over a year after the operation. Ms C complained that: Mr A suffered unreasonable pain after his operation; Mr A had to wait an unreasonable amount of time to be assessed about his pain management; the board took an unreasonable length of time to establish the source of Mr A's pain; the board provided an unreasonable treatment pathway for Mr A's chronic pain; and the board unreasonably failed to tell Mr A that he could have obtained alternative treatment outwith their area.

March 2018

No Decision Reports for NHS Tayside produced this month

February 2018

Case ref: 201609661

Summary - Mr C complained that staff at Ninewells Hospital failed to consider a diagnosis of brugada syndrome when he was being investigated for fainting episodes. Brugada syndrome is a condition associated with blackouts, serious arrhythmias (where the heart can beat too slow, too fast or irregularly) and sudden death. The syndrome is characterised by a particular electrocardiogram (ECG - a test to check the heart's rhythm) abnormality, either spontaneously or after a drug test.

Case ref: 201702200

Summary - Mr C complained about a consultation he had at the fracture clinic at Perth Royal Infirmary and the following care and treatment he received. Mr C was referred to the clinic after he fell and injured his hip. Prior to attending the consultation, an x-ray of Mr C's hip had been arranged by his GP, whilst an MRI scan had been carried out privately. Mr C brought the written MRI report to the consultation, but did not bring the imaging CD. After examination, the surgeon decided that conservative treatment (medical treatment avoiding radical therapy or an operation) was appropriate and they arranged to review Mr C in three months' time. Mr C obtained a different opinion on the treatment of his injury from a surgeon at a different NHS board. Mr C then agreed to have surgery on his hip at this same NHS board and said that this improved his condition.


January 2018

Case ref: 201605213

Summary - Mrs C complained about the care and treatment provided to her at Perth Royal Infirmary when she had back problems. Mrs C complained that when she attended the A&E department on two occasions, she was not appropriately assessed before being redirected to another service. Mrs C also complained that, when she was admitted to the hospital, she was not provided with appropriate pain relief medication and that there was a delay in her being given surgery. Mrs C further complained that the information passed from A&E to her GP was not appropriately detailed.

Case ref: 201606241

Summary - Mrs C's mother (Mrs A) broke her ankle in a fall. Although Mrs A had a complex medical history, including cancer and diabetes, the decision was taken at Ninewells Hospital to fix the ankle surgically. After a period of care in the hospital, Mrs A was discharged to a nursing home. During an out-patient review, it was discovered that the ankle wounds had broken down and that the metal work used to fix the fracture had become exposed. Mrs A was admitted to hospital again and underwent further surgery to remove the metal work. Mrs A was discharged back to the nursing home a few weeks later. At a further out-patient follow up, it was found that Mrs A had an infection in the ankle wound and that the bone had not grown back together. She was admitted to hospital again for treatment with antibiotics and wound care. It was considered that amputation could be necessary to control Mrs A's pain and to improve her quality of life. Amputation surgery did not take place and Mrs A was later discharged back to the nursing home.

December 2017

Case Reference: 201608873

Summary - Mr C complained about the care provided to his wife (Mrs A) during out-patient appointments at the cardiology department at Ninewells Hospital. Mrs A was referred to the cardiology department by her GP because of drop attacks (sudden episodes of collapse). Over the following 18 months, Mrs A attended consultations in the department and a number of investigations into her symptoms were carried out. During the period that Mrs A was waiting to be fitted with a cardiac event monitor device (a device to measure the heart's activity), she sustained a stroke and was admitted to hospital for treatment. Tests carried out during this admission indicated that Mrs A was in atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). Mr C complained that the board had failed to provide Mrs A with a appropriate treatment in view of her presenting symptoms and medical history.

Case Reference: 201604903

Summary - Mrs C complained about the care and treatment that was provided to her following her admission to Ninewells Hospital for induction of labour. Mrs C complained that the midwifery care around her induction, labour and birth was unreasonable. She also complained about the way the board handled her complaints.


November 2017

Case Reference: 201508182

Summary - Ms C complained about the care and treatment provided to her late father (Mr A), who had bowel cancer. She complained that there was an unreasonable delay between a referral being made by Mr A's GP and his treatment starting at Ninewells Hospital. Ms C also complained that the care and treatment provided to Mr A in Ninewells Hospital was unreasonable. She raised further concerns that the standard of communication between the board and Mr A and his family was poor. Finally, Ms C complained that the board's handling of her complaint was unreasonable.

October 2017

Case Reference: 201606218

Summary - Mrs C complained about the orthopaedic care and treatment provided to her by the board. She complained that she was given facet joint injections (injections of anaesthetic to relieve pain) into her spine without being examined by the consultant first, and that at her review appointment she again was not physically examined despite having ongoing pain. Mrs C was also concerned that she was not referred for an MRI scan or CT scan by the orthopaedic consultant. She also complained that the orthopaedic consultant failed to communicate reasonably with her after her review appointment, and that they did not refer her to the pain clinic when they said they would.

September 2017

Case Reference: 201606303

Summary - Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs A). She complained that it was unreasonable for Mrs A's GP practice to fail to diagnose her with whooping cough until a blood test confirmed this. She also complained about communication with the GPs and the impact this had on the diagnostic process.

Case Reference: 201607123

Summary - Mrs C complained about her medical practice, specifically that they failed to recognise or suspect she had whooping cough given her symptoms until a blood test confirmed the condition. Mrs C told us that as a result of the failings, her health needs were not met and she posed an unnecessary risk to her family and other members of the public. Mrs C also raised concerns about the way the board handled her complaint in that a complaints manager had been involved in both supporting her and investigating her complaint.

August 2017

Case Reference: 201600908

Summary - Mr C complained to us that the board had failed to properly assess his mother (Mrs A) before she was discharged from Perth Royal Infirmary. He said that, as a result of this, Mrs A had to go into a care home for full-time care, which had cost the family over £20,000 in charges. We took independent advice from a consultant geriatrician. We found that Mrs A had been discharged without being adequately assessed. There was no evidence of a multi-disciplinary team discussion or of adequate occupational therapy input in the discharge planning process. In addition, we found that that the physiotherapy and nursing notes indicated that she should have had further assessment. Mr C had also raised concerns several times to different members of staff about Mrs A's ability to return home. We found that Mrs A should not have been discharged on the day that she was. In view of this, we upheld the complaint. However, it was likely that she would have been reviewed again a week later and it was possible that a reasonable decision could have been made at that time that she could be discharged. This could have been either to her own home or to a nursing home.

Case Reference: 201507956

Summary - Ms C complained about the care and treatment of her brother (Mr A). Mr A was diagnosed with liver disease and admitted to the acute medical unit at Ninewells Hospital a few weeks later. During the admission, he was also given medication for alcohol withdrawal. Mr A was diagnosed with acute kidney injury and treated with dialysis (a form of treatment that replicates many of the kidney's functions). Mr A's condition worsened suddenly, and he was transferred to intensive care, where he died.

July 2017

No Decision Reports for NHS Tayside produced this month

June 2017

No Decision Reports for NHS Tayside produced this month

May 2017

Case Reference: 201607122

Summary - Mr C complained that, following a collapse in the street where he vomited blood, his son (Mr A) was taken to Ninewells Hospital where he was discharged after treatment for a head injury. Later that day Mr A was again found collapsed in the street and he was again taken to Ninewells Hospital where he died that evening. Mr C noted from the post-mortem report that the cause of death was recorded as a massive gastrointestinal haemorrhage (bleed) and said that had this been identified during the first visit to hospital then the outcome may have been different.

Case Reference: 201604927

Summary - Mr C complained that the prison health centre unreasonably decided to discontinue his medication when he failed a medication check. Mr C said the prison health centre failed to take account of the fact that he had reported to them that he was being bullied for his medication.

Case Reference: 201604427

Summary - Mr C underwent an operation at Ninewells Hospital to remove a skin tag on his penis. He was concerned about the outcome of the operation and the appearance of the resulting scar, and he said that he was left with some disfigurement. Mr C complained that the consultant urological surgeon told him before the operation that the appearance of his penis would improve with surgery and that he was not warned that there was any risk of disfigurement. Mr C also had concerns about the standard of the operation itself, and follow-up care.

Case Reference: 201602612

Summary - Miss C said her mother (Mrs A) had a complex medical history and was admitted to the Royal Victoria Hospital with reduced mobility and delirium (a temporary state of mental confusion arising from, amongst other things, infection). Mrs A was discharged to a nursing home eight days later. Miss C complained that Mrs A was not medically fit to be discharged from the hospital. Mrs A died several weeks after her discharge.

Case Reference: 201601311

Summary - Mrs C complained to the board about the care and treatment provided to her mother (Mrs A) by her GP practice. In particular, Mrs C felt that the practice failed to arrange appropriate investigations in view of the symptoms Mrs A presented with.

Case Reference: 201508596

Summary - Mr C complained about delays and communication in relation to his wife (Mrs A)'s hip-replacement surgery at Ninewells Hospital.

April 2017

Case Reference: 201604614

Summary - Mr C complained to us that when he took his son (child A) to the emergency out-of-hours service, he was not satisfied with the treatment given for child A's swollen eye and temple by the attending GP. The GP diagnosed child A was suffering from a chest infection.

Case Reference: 201508237

Summary - Mrs C complained about the care and treatment she received at Ninewells Hospital after having her jaw joint replaced with an artificial joint. Prior to then, Mrs C had been under the care of an oral medicine consultant who had tried a range of non-surgical methods to manage the pain she was having in her jaw joint. Mrs C was then referred to a specialist surgeon, who recommended surgical replacement of the joint. Mrs C proceeded with the surgery but suffered complications that resulted in the artificial joint being removed for several months and replaced with a different type.

March 2017

Case ref: 201602615

Summary - Mrs C complained about the care and treatment provided to her father (Mr A) during his admission to Ninewells Hospital. In particular, Mrs C had concerns that the effects of the medication Mr A was prescribed for delirium were not monitored, and that after a fall whilst in hospital he was given a further dose of this medication. She also complained that he had not been reasonably checked and monitored throughout the night. By the time nursing staff came to check his observations the next morning, Mr A had died.

Case ref: 201508479

Summary - Mr C was diagnosed with kidney cancer and underwent an operation at Ninewells Hospital to remove one of his kidneys. Mr C felt that, had staff acted appropriately in response to his emails, his cancer may have been diagnosed sooner and he may not have had to undergo the procedure

Case ref: 201507779

Summary - Miss C's father (Mr A) attended his medical practice with urinary problems. Tests and investigations indicated prostate cancer had spread to his bones and Mr A was admitted to Ninewells Hospital. His condition deteriorated significantly due to sepsis (a life-threatening bacterial infection of the blood) and he died two days later. Miss C complained about clinical failings in relation to investigations and treatment decisions by nursing and medical staff, including that Mr A's deteriorating condition was not recognised within a reasonable timeframe.

February 2017

Case Ref: 201602512

Summary - Mrs C, who had a history of osteoporosis, fell whilst in Ninewells Hospital. She complained that despite being in a great deal of pain, her back was not x-rayed.

Case Ref: 201507949

Summary - Mrs C suffered hearing loss following minor oral surgery at Perth Royal Infirmary. She complained that the board failed to provide appropriate treatment and failed to adequately explain the risks of the procedure she received.

January 2017

Case Ref: 201507446

Summary - Mr C complained on behalf of his wife (Mrs A) about aspects of the care and treatment she received at Ninewells Hospital and Perth Royal Infirmary following an injury to her shoulder. He complained that surgery was not carried out when the injury was first diagnosed and that when surgery was carried out, Mrs A was given inaccurate information about the reduction in her pain. Mr C also complained that Mrs A was not warned that general anaesthetic could cause memory loss.

December 2016

Case Ref: 201508622

Summary - Mr C complained that his prison healthcare centre stopped prescribing medication he had been taking for physical and mental problems. Mr C also complained that the board ignored his complaint, which resulted in his health worsening.

November 2016

Case Ref: 201508376

Summary - Ms C, an advocacy and support worker, complained on behalf of Mr A about the care and treatment he received from the orthopaedic and physiotherapy departments at Ninewells Hospital after he fractured his fibula (shin bone). Mr A was unhappy that he was not given surgery at this time and that he was only discharged with crutches and pain relief with no follow-up appointment. Mr A continued to experience pain and self-referred to physiotherapy, which did not help his pain. He was dissatisfied that the physiotherapist did not query why his leg was not improving and he felt there was a missed opportunity to identify the lack of healing.

Case Ref: 201508297

Summary - Mr C attended the chest clinic at Ninewells Hospital with shortness of breath. He said that he was told by the doctor at the clinic that he would be referred for an echocardiogram (a scan used to look at the heart and nearby blood vessels) and an exercise test and that it would be four to six weeks until the tests were carried out. Mr C said that when he phoned the board four weeks later, he was told there was a 28-week waiting time for the echocardiogram/exercise test from date of referral.

Case Ref: 201508062

Summary - Mrs C complained that her husband (Mr A) had received inadequate nursing care and treatment when he was a patient at Perth Royal Infirmary. Mr A had a number of health problems including diabetes and had previously had a toe amputated. He then had a major stroke and was transferred to the hospital for rehabilitation.

Case Ref: 201507727

Summary - Mr C complained that the board delayed in giving him his cardiac medication after he was admitted to prison. Mr C had a heart attack two days later and required surgical treatment. He was unhappy that the board withheld the medication he had in his possession at the time of admission to prison.

October 2016

Case ref: 201508647

Summary - Mrs C complained on behalf of her husband (Mr A) about the way a consultant at Ninewells Hospital managed his care and treatment following the discovery of a nodule (a growth of abnormal tissue) in his lung. Mr A was reviewed over three years and then received a letter discharging him from the clinic because the nodule appeared stable. At Mrs C's persistence, the consultant reviewed Mr A again and further investigation identified that the nodule was a slow growth tumour.

September 2016

Case ref: 201507920

Summary - Mr C complained that following surgery for a hernia repair at Stracathro Hospital, he suffered severe and continuing pain. Mr C complained to the board about the surgery and the reasons for his continuing pain, which he said had an adverse effect on his daily life. Mr C was dissatisfied with the response he received from the board.

August 2016

Case ref: 201508506

Summary - Mrs C complained to us about the care and treatment her late mother (Mrs A) had received in Ninewells Hospital before her death. In particular, she complained about the management of her mother's oxygen therapy immediately before her death. Mrs A had a number of health problems, including idiopathic pulmonary fibrosis (a lung condition that causes scarring of the lungs and where the cause is unclear). She was receiving oxygen therapy and a trial had indicated that she required a consistent high level of oxygen via a rebreathing mask (a mask that provides a high concentration and flow of oxygen and is used to provide patients with very specific oxygen needs).

Case ref: 201508112

Summary - Ms C works for an advice and support agency. She brought the complaint on behalf of her client (Mr B). Mr B had concerns about the treatment his daughter (Miss A) received at Ninewells Hospital after she was referred by her GP with suspected appendicitis. Miss A was reviewed and appendicitis was considered to be unlikely. She was prescribed antibiotics for a urinary tract infection and was discharged home. Miss A did not improve and had to be taken back to the hospital two days later. Although initial assessment found appendicitis to be a possible cause of her symptoms, she was discharged after two days with a diagnosis of gastroenteritis (inflammation in the intestines caused by infection). Her condition did not improve and she had to be readmitted four days later. Miss A underwent surgery to investigate further. During this procedure her appendix was removed as it was found to be gangrenous. An abscess was also discovered. Miss A did not recover well and had to undergo more surgery as she had developed a deep pelvic abscess. In addition to his concerns about the treatment provided to his daughter, Mr B was dissatisfied with the time the board had taken to deal with his complaint.

Case ref: 201508012

Summary - Miss C complained about the clinical treatment provided to her late brother (Mr A). Mr A was admitted to Ninewells Hospital with chest pain. He was diagnosed with a chest infection and discharged the next day. Mr A died of a heart attack a few weeks later. Miss C was concerned that the hospital did not find a problem with Mr A's heart, particularly as he was admitted with chest pain and had a family history of cardiac (heart) problems.

July 2016

Case Ref: 201507568

Mrs C raised a number a number of concerns about the care and treatment given to her late mother (Mrs A) during an admission to Ninewells Hospital. Mrs C had complained to the board about the general clinical and nursing care that her mother had received. She had complained about the standard of communication and the delay in diagnosing and treating her mother, and she said that her mother had suffered unnecessary pain due to the non administration of medication. Mrs C was also unhappy with the board's handling of her complaint.

June 2016

Case Ref: 201508735

Summary - Mrs C learned that she had a gene mutation which increased the risk of breast and ovarian cancer. She decided to have surgery to remove both breasts to reduce the risk of developing breast cancer, and reconstruction surgery. Her surgery was cancelled on the morning she was due to be admitted. The board said that the cancellation was due to their failure to ensure the correct implants were available for the surgery to progress, and apologised. When she complained to us, Mrs C was concerned that she has not been given an alternative date for surgery.

May 2016

Case Ref: 201501847

Summary - Mrs C complained about the care and treatment given to her late husband (Mr A) at Ninewells Hospital where he was a patient from March to September 2014, when he died. She said that there was a delay in making his diagnosis and that information was given to him in an uncaring and uncompassionate way. She also complained that there was often confusion about her husband's medication and that his pain was not properly managed.

Case Ref: 201501178

Summary - Mr C saw a podiatrist because of the deteriorating condition of his foot due to an ulcer. He then had several admissions to Ninewells Hospital as well as being seen as an out-patient. He underwent an artery bypass (a procedure to improve blood flow) from just below the knee to the foot with amputation of several toes and a skin graft. The bypass and the skin graft failed and Mr C may need further surgery in the future.

Case Ref: 201500190

Summary - Mrs C was referred to Perth Royal Infirmary due to a missing intrauterine system (IUS - a contraceptive device). A scan showed the IUS could be in her abdomen, but she was then found to be pregnant, so no x-ray could be done to confirm the exact location. The pregnancy was not viable and a medical miscarriage was performed. Mrs C was discharged after this without an x-ray to locate the missing IUS. Her GP arranged an x-ray, which showed the IUS was in her abdomen, and she was referred to gynaecology for surgery to locate and remove it. Mrs C raised concerns about the failure to x-ray her after the medical miscarriage, and about her surgery (which was more complex than expected). Mrs C said she was told an x-ray would be taken before the surgery to confirm the exact location of the IUS, and she queried why this did not happen. Mrs C also complained about delays in her gynaecology appointment and in the board's response to her complaint.

Case Ref: 201500037

Summary - Mrs C raised a number of issues about the care and treatment her late husband (Mr C) received during admissions to Ninewells Hospital and Royal Victoria Hospital.

April 2016

No Decision Reports for NHS Tayside produced this month

March 2016

Case ref: 201406403

Summary - Mr C complained about the care and treatment of his mother (Mrs A), who was admitted to Perth Royal Infirmary following some falls, and then transferred to Murray Royal Hospital for assessment. Mrs A remained in Murray Royal Hospital for about three months, although she was transferred back to Perth Royal Infirmary on several occasions.

Case ref: 201405118

Summary - Mrs C's husband (Mr C) was admitted to Perth Royal Infirmary and treated for pneumonia. His condition did not improve whilst in hospital and he died seven days after being admitted.

February 2016

Case ref: 201503628

Summary - Mr C complained about a misdiagnosis of cancer. He said staff at Ninewells Hospital told him about three years ago that he had six to nine months to live, but then told him about a year ago that he did not have cancer. Mr C was concerned about the misdiagnosis, and that the board did not follow up to determine the correct diagnosis for his symptoms. Mr C also raised concerns about the board's handling of his complaint, as they had still not responded to him four months after he complained.

Case ref: 201502164

Summary - Mr C complained because he said the board failed to respond appropriately to his complaint about scheduled appointments with the pain clinic. In particular, Mr C said the board had responded to his complaint saying that there was nothing documented about planned appointments with the pain clinic. However, before receiving the board's response, Mr C said a nurse gave him a written note. The note showed that his medical record had been checked and noted that he was due to attend pain clinic appointments.

January 2016

Case ref: 201500706

Summary - Mr C's daughter (Ms A) was admitted to Ninewells Hospital three times with severe abdominal pain and swelling accompanied by nausea. Investigations and tests were negative. Mr C complained that Ms A was discharged from hospital unreasonably, and that doctors failed to reach a diagnosis, which led to a great deal of anxiety for Ms A and her family. As a result, Mr C said that Ms A’s health deteriorated.

Case ref: 201407896

Summary - Ms C, an advice worker, complained on behalf of Miss A, who had had surgery to her jaw at Ninewells Hospital. Following this surgery, Miss A had been diagnosed with a serious injury to her neck, which had required a second operation to correct. Ms C suggested that the first operation had been inappropriate and that Miss A's injury had taken too long to diagnose.

Case ref: 201407468

Summary - Mrs C and her husband were participants in an egg-sharing programme (as donor) in the Assisted Conception Unit at Ninewells Hospital. As part of the programme, after fertility treatment, Mrs C retained some of her eggs and some were donated to a recipient. Mrs C complained that the care and treatment given to her was unreasonable, and that staff were primarily concerned with the recipient. She said that communication with the staff was also unacceptable, and that she was given information despite saying that she did not want it. She believed she had been looked down upon.

Case ref: 201406517

Summary - Mrs C complained to us on behalf of Mrs A, in relation to an incident of potential contamination due to the use of unclean equipment. Mrs A attended Dundee Dental Hospital for treatment, and during the course of her treatment a microscope was put close to her mouth. She could see dirty marks on the microscope which looked like dried blood. After her treatment she raised concerns with staff. One nurse immediately wiped the microscope. Mrs A said that she was told it would be sent for analysis. Later that day staff contacted Mrs A to provide further information and advice.

Case ref: 201405328

Summary - Mr C complained about the way in which his pain relief medication was handled by the prison health centre. Mr C has osteoporosis (a condition causing weakness of the bones) and had been prescribed tramadol (a strong opioid painkiller). He was unhappy that there was little discussion or information about why it was being stopped. He was also unhappy that the board failed to provide relevant information in their response to his complaint.

Case ref: 201403324

Summary - Mr C has had contact with mental health services in the board area since 1997, and his complaint concerned the care and treatment he received from 2004 until 2014. Mr C said it was clear he had suffered from post-traumatic stress disorder throughout his contact with mental health services during this period, but that the board failed to diagnose him with this or provide appropriate treatment, such as trauma-focussed cognitive behavioural therapy (CBT). Mr C complained this meant that he was unable to return to work and effectively 'lost' ten years of his life.

Case ref: 201301800

Summary - Mrs C complained to us on behalf of her late mother (Mrs A) about the care and treatment she received in the Royal Victoria Hospital during the last three months of her life. Mrs A had fallen while in hospital. Over subsequent weeks her mobility deteriorated and she complained about pain in her hip. Mrs A was referred for a psychiatric review and then a pain assessment that highlighted concerns about her condition. She was referred for an x-ray, which identified a fractured hip. Mrs C complained that this should have been identified earlier, and that staff did not do enough to adequately manage Mrs A’s pain. She said that if the hip pain had been appropriately investigated, Mrs A would have had better pain control in the final weeks of her life.

December 2015

Case ref: 201501070

Summary - Mr C complained that while his wife (Mrs C) was a patient in Murray Royal Hospital, she was assaulted by another patient and suffered a minor injury. The staff told him that Mrs C would be protected from the patient. Mrs C was then assaulted again by the patient and had to receive medical treatment for a severe injury to her eye. Mr C complained that the board staff had not taken appropriate action to prevent the second assault. The board maintained that the risk of the patient assaulting Mrs C on the second occasion was assessed as rare.

Case ref: 201306298

Summary - Mrs C complained about the communication with her family during her late father (Mr A)'s admission to Cornhill Macmillan Centre for end of life care. She raised concerns that the family were excluded from most medical consultations and were not updated on changes to Mr A's condition or treatment. In particular, she complained that the family were not prepared for the fact that Mr A would not receive fluids once he was unable to take them orally. She said there was no continuity of care and there was no single member of staff who seemed to know Mr A well. She also complained that the visiting hours were overly strict, and that staff were defensive and did not support the family to make the most of Mr A's final weeks.

November 2015

Case ref: 201500055

Summary - Mr C complained because he felt the care and treatment he received from the prison health centre was unreasonable. In particular, Mr C said that since taking his prescribed methadone he had been feeling ill. Mr C said a doctor concluded that he should not be prescribed methadone and made arrangements for an alternative medication to be prescribed. However, before that happened, Mr C was reviewed by another doctor who decided that the prescription for methadone should continue. Mr C was unhappy with that decision because he felt he was allergic to the medication.

Case ref: 201406738

Summary - Ms C, who is an advice worker, complained on behalf of her client, whose husband (Mr A) had died following two hospital admissions at Perth Royal Infirmary a short period apart. Mr A had suffered two strokes in quick succession. Ms C complained that he had not been diagnosed quickly enough with a stroke on his first admission. On his second admission, Ms C complained that Mr A was not provided with medical review quickly enough and that nursing staff were slow to address his obvious pain and distress. As a result, although the family accepted that his second stroke was terminal, Ms C said that they were subjected to an unnecessarily distressing and undignified experience.

Case ref: 201403037

Summary - Ms C complained to us on behalf of her partner (Mr A), who had a history of gastroenterological problems (problems with the digestive system). Ms C had previously complained to the board about the care and treatment that Mr A was receiving from them. Ms C then made a second complaint which was considered during this investigation. Ms C complained that the board had not provided reasonable care and treatment to Mr A in the period covered by the complaint. Ms C was dissatisfied that they had been unable to reach a diagnosis for Mr A's condition, and was also concerned that her previous complaint had impacted on the subsequent care that Mr A received.

October 2015

Case ref: 201406593

Summary - Mr C complained that when he called the out-of-hours (OOH) service, the first GP he spoke to did not provide proper care or treatment. Mr C said the GP had been unable to access his medical records and had refused to admit him to hospital, offering an appointment at the OOH centre, which Mr C could not attend because of the level of pain he was suffering. When Mr C had called the OOH service the following morning, a second GP arranged for an ambulance to take him to hospital, where his knee was then treated. Mr C said the second GP had told him that the first GP would have been able to access his medical records and that hospital admission was the only appropriate treatment for his knee.

Case ref: 201402688

Summary - Mrs C complained about the care and treatment that her late mother-in-law (Mrs A) had received. Mrs A had been referred to an orthopaedic consultant (a doctor who specialises in conditions involving the musculoskeletal system) and was seen in January 2013. She was re-referred by her GP practice in May 2013 but was not seen again until late July 2013. Mrs A died of widespread secondary cancer in October 2013, having been diagnosed a matter of weeks previously.

September 2015

Case ref: 201500357

Summary - Miss C raised a number of issues about the time taken by the health board to arrange her appointment for day surgery and that, when it eventually took place, it was outwith the timescales for the Treatment Time Guarantee (TTG) of 12 weeks. Miss C also mentioned that she had told staff she was willing to take a cancellation if that meant earlier surgery but that this was not noted in her records. She was also dissatisfied with the time taken to deal with her formal complaint

August 2015

Case ref: 201406436

Summary - Mrs C complained about the board because she said she had concerns about the way in which it managed her waiting time before she received a clinic appointment. She also complained about the appointment itself, the examination and conclusions. Mrs C said she was left frustrated and depressed as a consequence, and sought private treatment to have a knee operation. She said that, if the board had treated her appropriately, this should have been the outcome of her clinic appointment.

Case ref: 201405098

Summary - Ms C complained that, during a phone consultation, an out-of-hours GP asked a care home nurse if Ms C's father (Mr A) had a do not attempt cardiopulmonary resuscitation (DNACPR) note in his records. Ms C said the GP asked about the DNACPR with the implication that, if there was one in place, the GP should not bother coming to visit Mr A. Ms C also complained that the GP inappropriately prescribed amoxicillin (an antibiotic drug used to treat bacterial infection) to Mr A, which she said was not effective for him, and could be detrimental to his health.

Case ref: 201403076

Summary - Mrs C said her son was admitted to Ninewells Hospital with a suspected infectious disease and was kept in hospital for two nights. Mrs C said she was told that her son's treatment would be free, but during the discharge process she was advised she would have to pay for his treatment as they were visitors to the UK. Mrs C complained that it was unreasonable that she was charged for his care and treatment. Her concerns included that her son's treatment was not immediately necessary and the board's actions were contrary to Scottish Government Guidance CEL 09 (2010) (Overseas Visitors' Liability to Pay Charges for NHS Care and Services) as she was not given the opportunity to make an informed decision about whether, or to what extent, to proceed with treatment.

July 2015

Case ref: 201403582

Summary - Mr C told us that when he attended Ninewells Hospital after he was referred by his GP he was told on arrival by a doctor that he should be at a different hospital. He said that another doctor then arrived in the waiting area, apologised for the mix-up and referred him to the phlebotomy department (which deals with taking blood samples). Mr C wrote to the board to complain about the conduct of staff on duty whilst he was at the hospital. Mr C disagreed with the board's response that the staff concerned could only remember limited information, and brought his complaint to us.

Case ref: 201402360

Summary - Mr C sustained an injury to his right hip/leg, which he said was caused when he fell off a chair. Mr C attended the prison health centre regarding his injury on several occasions. Mr C complained that the prison health centre failed to provide him with appropriate care and treatment. He said there was an unreasonable delay in the prison health centre carrying out an x-ray of his hip. He also said the prison doctor inappropriately failed to see him at a scheduled appointment.

Case ref: 201303704

Summary - Mrs C was referred by her GP to the Acute Medical Unit of Ninewells Hospital after reporting a ten-day history of increasing chest and upper abdominal pain. She was admitted in the afternoon and blood tests and a measurement of her heart-rate were taken. She was then reviewed by a consultant later in the evening who told Mrs C that her condition was 'not cardiac' (not related to her heart). The blood test results were not available during this review and were not checked until the following morning. Mrs C was placed on a heart monitor overnight but when she needed to use the lavatory, she was taken off the monitor and not reconnected when she returned to bed. Mrs C was reviewed the following morning by a different consultant who told her that the blood test results confirmed she had had a heart attack.

June 2015

Case ref: 201405374

Summary - Mrs C complained about her treatment at A&E at Ninewells Hospital. She told us that when she attended with a broken foot she was fitted with a moon boot (a removable cast) and told, since it was the weekend, she was to return home and wait for a phone call on Monday. Mrs C said that she was in extreme pain at home and she said she noted trauma blisters on her foot. She said she phoned the hospital for some advice. She said that the staff member that answered the phone did not give any guidance and said that it was Mrs C's choice as to whether she went back to the hospital or not. Mrs C received a call from an orthopaedic consultant the following day who told Mrs C that she should not have been sent home and asked her go to hospital immediately. Mrs C believed that the delay in treatment had contributed to having to spend more time in hospital and having to have two operations

Case ref: 201401646

Summary - Mr C complained that the board unreasonably advised the Scottish Prison Service (SPS) that it was safe for him to be subject to metal detecting equipment, although he has an implantable cardioverter defibrillator (ICD) (a device that regulates irregular heart rhythms). Mr C also complained about the board’s handling of his medication. He said that staff altered his medication inappropriately, and made mistakes in administration. He also said that there was no reason for his medication to be supervised (taken in front of prison staff, rather than given into the patient’s keeping), as it was degrading to be required to open his mouth to show he had taken the medication, and this supervision resulted in him being harassed and bullied for his medication.

Case ref: 201304603

Summary - Ms C complained on behalf of her late partner (Mr A) about his care and treatment at A&E at Ninewells Hospital. She said that Mr A was not assessed properly and she was unhappy that he was referred under the board's redirection policy to a primary care doctor (a doctor providing day-to-day medical care, such as a GP) rather than being seen and treated in A&E. Ms C said that the board had refused to treat Mr A.

May 2015

Case ref: 201404004

Summary - Ms C, who is an advice worker, complained that the care and treatment provided by the prison health centre to her client (Mr A) for pain in his arm was unreasonable. In particular, Mr A had been unhappy because a nurse had questioned why he was being prescribed a certain type of pain killer. Mr A felt the nurse did not have the authority to do that.

Case ref: 201402874

Summary - Mrs C complained on behalf of her client (Mrs A) about the board's care and treatment of Mrs A's finger injury. Mrs A attended the minor injuries and illnesses unit with an injury to her finger, but she was discharged as the nurse considered it a superficial wound. However, after some weeks, Mrs A's GP referred her to the orthopaedic unit, as she still could not bend her finger. After further investigation she was diagnosed with an incomplete tear of the flexor tendon (the tendon that connects the arm muscles to the bones in the finger). Mrs A was referred for physiotherapy, but this did not help, and the orthopaedic surgeon offered Mrs A surgery to try and improve the movement in her finger. Mrs A agreed, but the surgery was delayed four months while waiting on an echocardiogram (a scan of the heart), which Mrs A had been referred to by the general medical clinic (for an unrelated issue). Mrs C complained about the care and treatment and the delay in Mrs A's surgery, as well as about the board's response to her complaint to them.

Case ref: 201402090

Summary - Mr C complained on behalf of Mrs A, the widow of Mr A. Following a referral by his GP, Mr A was seen in Ninewells Hospital for advice and investigation in May 2013. He was given a computerised tomography (CT) scan (which uses x-rays and a computer to create detailed images of the inside of the body) which showed an abnormality on one of his ribs which was suspected to be sinister. In July 2013, a biopsy was attempted but this failed because it was too uncomfortable for Mr A. The following month, a further CT scan was taken as was a biopsy under general anaesthetic. The results confirmed that Mr A had cancer. Mr A had further investigations the following month and a treatment plan for him was discussed by a multi-disciplinary team. Mr A was advised of his diagnosis and plan in October 2013. Regrettably, Mr A's condition continued to deteriorate and he died in May 2014.

Case ref: 201305105

Summary - Mr C complained about care and treatment provided to his daughter (Miss A) at Perth Royal Infirmary when she attended the eye clinic there. Mr C believed that her condition was misdiagnosed, and that the treatment prescribed may have aggravated her condition and led to her sudden death.

April 2015

Case ref: 201403471

Summary - Mr C complained to the board that a decision had been taken inappropriately to reduce the number of gluten-free foods available on prescription for his mother (Mrs A) who suffers from a coeliac condition.

Case ref: 201305243

Summary - Miss A is profoundly deaf and uses British Sign Language (BSL). Ms C, an advocate, complained on her behalf that the board did not arrange a BSL interpreter for her. We found that Miss A was left in Ninewells Hospital without an interpreter for nearly three days, which was unacceptable. The board had initially tried to get an interpreter, but it was then left to Miss A's family to do so. When they could not, the board arranged for an interpreter to attend. There were also problems in ensuring that interpreters were there at the same time as doctors.

Case ref: 201305032

Summary - Mr A suffered from advanced cancer, and was admitted to Ninewells Hospital for treatment to control his pain. While there, he fell and a fractured hip was suspected, although it was established this was not the case. He was transferred back to a palliative care centre (a place providing care to prevent or relieve suffering only), but was semi-conscious on arrival, and died shortly afterwards.

March 2015

Case ref: 201402018

Summary - Mr C had a shunt (a thin tube that drains fluid from the brain to another part of the body) in place in order to relieve his severe headaches. He complained to us that when he was having this replaced at Ninewells Hospital, he contracted an infection. Mr C was readmitted to the hospital several days after the operation, with a severe abdominal infection. It was thought that the infection came from the new shunt and this was subsequently removed. Mr C said that he had been unable to return to work after contracting the infection.

Case ref: 201304734

Summary - Ms C, an advocate, told us that her client (Mr A) was referred to the neurology department at Ninewells Hospital because of continuing back pain. In November 2012, a neurologist (a specialist in diseases of the nerves and the nervous system) decided that further investigations, including an magnetic resonance imaging scan (MRI scan - used to diagnose health conditions that affect organs, tissue and bone), would not be beneficial as it was extremely unlikely that further back surgery would be considered. The following month, Mr A was admitted to hospital for a different problem but his back and leg pain were noted. An anaesthetist suggested that the neurosurgical team review him but they declined, saying he had been seen three weeks previously. Mr A continued to suffer back pain and in March 2013 his GP wrote to the neurosurgical team requesting an MRI scan, who responded saying that this would not be helpful. In June 2013, because of the level of his pain, Mr A paid for a private MRI scan which was forwarded to the neurosurgical team. Several weeks later, an out-of-hours (OOH) doctor saw Mr A, again because of his pain, and phoned the hospital about admitting him. Mr A was not, however, admitted and said that a member of the neurosurgical team refused to see him again. However, after reviewing the MRI scan the neurosurgical team did then arrange decompression surgery (used to treat some conditions affecting the lower back that have not responded to other treatments), which was carried out at the end of July.

Case ref: 201303648

Summary - Mr C complained that staff at Perth Royal Infirmary refused him permission to take his elderly mother (Mrs A) out of hospital on a specific occasion, and about the board's handling of his complaint.

February 2015

Case ref: 201403201

Summary - Mr A had suffered a morphine overdose and become unwell. An ambulance was called and the crew assessed Mr A. He was nauseous and vomiting, had abdominal (stomach) pains and was unable to keep down food or drink. He was taken to Perth Royal Infirmary, where he was triaged and sent to the out-of-hours service. He was assessed there by a primary care nurse, and deemed fit to be discharged.

Case ref: 201304484

Summary - Mrs C had an operation at Perth Royal Infirmary, after which she experienced complications and was transferred to Ninewells Hospital for more surgery. Her husband (Mr C) complained on her behalf about how clinical and nursing staff responded to her pain levels and other concerns. He also complained that, after Mrs C was transferred, there was a delay before she was taken to an operating theatre. Finally, he said that the risk of the complications (perforation of the uterus and damage to the bowel) were not included in the information leaflet sent to her before the surgery.

Case ref: 201300300

Summary - Mrs C complained to us about aspects of her care and treatment by the gynaecology and obstetrics department at Ninewells Hospital. We began an investigation into her concerns, but did not complete it as Mrs C decided to take legal action against the board.

Case ref: 201204456

Summary - Mr C's father (Mr A) suffered from lung cancer, and was being treated with palliative erlotnib therapy (a drug used to treat some types of cancer) by a consultant at Ninewells Hospital. Mr A became ill while on holiday with his family and was admitted to hospital. When the family returned home, Mr A was transferred to Ninewells as he was too ill to go home.

January 2015

Case ref: 201304706

Summary - Miss C complained there was an avoidable delay before her hip replacement surgery was carried out. We took independent advice from one of our medical advisers, who explained that total hip replacements are best avoided in younger patients until all other possibilities have been considered. This is because such replacements have a limited time span and in younger patients they wear out and loosen earlier due to physical activities. In such cases the patient might need at least one further surgery, if not two. As Miss C was a younger patient, the delay before surgery was appropriate as it was important to explore all other non-surgical options before operating. We also found that Miss C asked to delay the surgery further, for personal reasons, and so not all of the delay was caused by the surgeon

December 2014

Case ref: 201302796

Summary - Mr C complained on behalf of his daughter (Ms A) about the care and treatment she received at Perth Royal Infirmary and Ninewells Hospital. In particular, he said there was a protracted period of complacency by the staff involved in his daughter's care. At the time Mr C complained to us, Ms A had been experiencing severe and debilitating pain for over 18 months. A number of diagnoses had been suggested, and while treatments were ongoing, no single definitive cause had been found for her pain and other related symptoms. Mr C said that the medical team had ruled out endometriosis (a condition where cells similar to those that line the womb lie outside it) without adequate investigation or involving a colorectal surgeon.

Case ref: 201303349

Summary - Mrs C had suffered from knee pain for a number of years. She was diagnosed with degenerative changes in her knee and a meniscal tear (a tear in the pad which provides shock absorption and other functions in the knee). She also had a meniscal cyst (a cyst often found in the presence of a meniscal tear and which can cause pain and discomfort). Following an initial course of physiotherapy, Mrs C had surgery at Perth Royal Infirmary to treat her meniscal tear and decompress the cyst. Although she experienced some initial improvement, her knee pain returned. She had further physiotherapy and a second operation. However, again her pain returned and in fact became worse. She complained that the board did not adequately treat her knee problems or provide appropriate follow-up care.

Case ref: 201304138

Summary - Mrs C, who is an advice worker, complained on behalf of her client (Mrs A) about the care and treatment given to Mrs A's late husband (Mr A) before he died. Mr A had bowel cancer and his prognosis (the forecast of the likely outcome of his condition) was not good. He was discharged home from hospital into the care of his GP and the district nursing service. After being at home for a short while, Mr A died. Mrs A complained about the various agencies involved in her husband's care and was particularly unhappy because she considered that district nurses had failed to properly care for her husband in the final weeks and days of his life and that levels of support, communication and standards of care had been poor. In responding to her complaint, the board agreed that there were failures in the support and care offered to Mr and Mrs A, and apologised for this, but Mrs A remained concerned that lessons had not been learned nor had procedures been put in place to prevent this happening again. She also complained about the way in which her complaint had been handled.

Case ref: 201401164

Summary - Mrs C complained that the board failed to diagnose her with rheumatoid arthritis while she was under their care. Although she had a number of appointments in just over a year, Although she had a number of appointments in just over a year, Mrs C was only diagnosed with this after she moved out of Scotland.. She said that this was despite the fact that there had been sufficient indicators present to have confirmed this. She said that, as a consequence, she was not properly treated and that she had subsequently lost her independence.

November 2014

Case ref: 201306202

Summary - Mr C requires regular blood sampling due to the medication that he is prescribed. At one appointment there was difficulty obtaining a blood sample and Mr C was in pain. He attended his GP who referred him to a neurologist who diagnosed nerve damage, possibly caused by the attempt to take blood. Mr C complained that the board had not provided him with a reasonable standard of care and that they had not properly responded to his complaint.

Case ref: 201303576

Summary - Mr C raised a number of concerns regarding the care his father (Mr A) received in Ninewells Hospital. Mr A had existing diagnoses of lung cancer and diabetes when he was admitted to the hospital with an infection. Mr C said that his father's initial treatment was excellent, but when he was later transferred to another ward, the standard of care dropped. Mr C raised a number of concerns regarding the standard of clinical and nursing care on that ward, where Mr A died three days after his admission. Mr C complained that family members were not made aware of Mr A's deterioration. He also complained that staff failed to adequately manage Mr A's diabetes and food and fluid intake. Mr C believed his father's death was caused by a failure to identify and treat hypoglycaemic shock (severely diminished blood sugar levels), rather than as a result of his underlying cancer and infection as the board suggested.

Case ref: 201302794

Summary - Mr C complained on behalf of his wife (Mrs C) who suffers from various life-limiting medical conditions, including Raynaud's Disease (a condition where the blood supply to the extremities is severely restricted, causing pain and ulcers). Mrs C receives regular infusions of a drug to help with this condition, and Mr C complained about the way this treatment was administered during one period of time. He also complained about the way the board handled his complaints about this.

October 2014

Case ref: 201401557

Summary - Mrs C's son (Mr A) sustained a head injury while playing sport. He attended A&E at Perth Royal Infirmary where he was examined and discharged. He was later found to have suffered a fracture to his neck which required surgery to correct. Mrs C complained that her son was not properly assessed in A&E and should have been sent for medical imaging. The board stated that they had followed established guidance on the decision-making process regarding medical imaging and that on the information available at the time regarding Mr A’s symptoms there was no reason to perform any medical imaging.

Case ref: 201303271

Summary - Mrs C complained about the treatment she received as an out-patient at Perth Royal Infirmary. She was being treated for a bladder complaint and was prescribed a drug (trospium chloride) as part of her treatment. Shortly after this she had a relapse of a previous mental health problem, and she attributed this to being prescribed the drug.

Case ref: 201303170

Summary - Mr C had an accident at work and was taken to Perth Royal Infirmary A&E, where his back and neck were examined and x-rayed. No bony injuries were identified and Mr C was discharged. He said that he told hospital staff that his arms and shoulders were extremely painful and heavy, but the only test that they carried out was that he was asked to squeeze the doctor's fingers. Mr C continued to have pain in his shoulders and arms and his GP referred him for an MRI scan (magnetic resonance imaging - used to diagnose health conditions affecting organs, tissue and bone). This showed that he had torn the rotator cuffs (the muscles around the shoulder joint) in both shoulders. Mr C continued to have shoulder problems, and complained that the A&E examination was inadequate and did not properly assess the extent of his injuries.

Case ref: 201300828

Summary - After Mr C's daughter (Miss A) was in a road traffic accident, paramedics took her to A&E at Ninewells Hospital strapped to a spinal board (a specialised stretcher, designed to protect patients with spinal damage). Mr C complained that the board then failed to adequately assess and treat Miss A, and said that she was not x-rayed at any point before she was discharged. Following her discharge she remained in significant pain and discomfort and Mr C took her to the family GP who, after a brief examination, referred her as an emergency to a different hospital. An x-ray taken there revealed a fractured vertebrae in Miss A's back and a CT scan (a scan that uses a computer to create an image of the body) revealed two further fractures.

September 2014

Case ref: 201301814

Summary - Ms C had surgery on her foot to treat bunions at Ninewells Hospital. She complained that the operation did not relieve her pain and discomfort, but made it worse, and so the operation was unsuccessful. After treatment, other possible surgical options were discussed with her, but Ms C was anxious about having further surgery without assurances that she would be properly assessed and treated in future. She was particularly concerned that no x-rays were taken before or after her operation.

Case ref: 201400815

Summary - Mrs C complained that she had been refused cosmetic surgery based on an incorrect mental health diagnosis. She also said that the investigation into her complaint was not thorough.

August 2014

Case ref: 201304404

Summary - Mr C complained about his care and treatment while he was being treated by a consultant surgeon in Ninewells Hospital. He said that, although he had lost weight, lost his appetite and become increasingly thin and lethargic, the surgeon discharged him and referred him to the care of a consultant gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas). Mr C said that it was only by chance that the seriousness of his condition was appreciated. He also complained that the board delayed in responding to his complaint about this.

Case ref: 201400126

Summary - Mr C, who is a prisoner, complained that the board were failing to follow his agreed dental treatment plan and failed to provide adequate care and treatment for his sleep disorder.