• Case ref:
  • Date:
    March 2019
  • Body:
    Dumfries and Galloway NHS Board
  • Sector(s):
  • Subject:
    clinical treatment / diagnosis
  • Outcome:
    Some upheld, recommendations


Mr C complained about the care and treatment provided to him in relation to surgery he underwent at Dumfries and Galloway Royal Infirmary. Mr C felt that the board had failed to provide reasonable care and treatment to him leading up to the surgery and action was not taken to prevent the deterioration which led to surgery. Mr C also felt that when he was in hospital he was not provided with reasonable nursing care and treatment, and that the care and treatment provided to him after surgery in relation to occupational therapy (a method of helping people who have been ill or injured to develop skills or get skills back by giving them certain activities to do) was unreasonable.

We took independent advice from a diabetologist (a doctor who specialises in the treatment of diabetes), a nurse, and an occupational therapist. We found that the care and treatment leading up to Mr C's surgery was reasonable as all appropriate investigations were undertaken and he was provided with treatment in line with the relevant national guidance. We did not uphold this aspect of Mr  C's complaint.

In relation to the nursing care provided to Mr C, we found that Mr C had been provided with the wrong dose of medication for four days during an admission, which we considered unreasonable. We also found that the communication from nursing staff to Mr C was unreasonable as they did not appear to have taken into account his mood or mental wellbeing. We upheld this aspect of Mr C's complaint.

Finally, in relation to the occupational therapy input for Mr C after his surgery, we found that there was no evidence that Mr C's ability to use his wheelchair in restricted spaces was explored, there was little evidence that Mr C was given sufficient opportunity to practice functional tasks prior to discharge and there was no evidence that Mr C's mental health and wellbeing was considered by the occupational therapy team. Therefore, we upheld this aspect of Mr C's complaint.


What we asked the organisation to do in this case:

  • Apologise to Mr C for failing to provide reasonable nursing care, and failing to provide reasonable care and treatment to Mr C after his amputation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

  • Staff should perform medicines reconciliation appropriately to avoid incorrect dosages being given.
  • Occupational therapy assessments should be full and thorough, and in particular take into account the mental health needs of patients.