Borders NHS Board

Overview
The complainant (Ms C), who is an advice worker, raised a number of concerns on behalf of her client (Mrs A) about the treatment which she received for a swollen leg following her attendance at Borders General Hospital (the Hospital) on 11 December 2008 and 12 December 2008. Mrs A believed that she received an inadequate examination by a doctor (the Junior Doctor) on 11 December 2008 and that her care and treatment was not managed appropriately. Mrs A's leg continued to cause her problems and she returned to her general medical practice who referred her back to the Hospital on 18 December 2008 where an ultrasound scan revealed the presence of a deep vein thrombosis.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) the Junior Doctor failed to carry out an appropriate assessment and examination of Mrs A on 11 December 2008 (upheld); and
• (b) the management of Mrs A on 11 December 2008 and 12 December 2008 was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) share this report with the Junior Doctor and ensure he has a documented discussion with his current clinical supervisor on the issue, which is filed in his training logbook;
• (ii) review the adequacy of the clinical supervision of junior doctors in the General Medical Unit; and
• (iii) apologise to the family of Mrs A for the failings which have been identified in this report.

The Board have accepted the recommendations and will act on them accordingly.