Upheld, recommendations

Summary

C attended hospital for gastroenterology procedures (medicine of the digestive system and its disorders). Upon waking from the procedures, C reported experiencing a painful tingling sensation in their mouth, left hand and foot. C informed the nurses of their symptoms and a consultant carried out an assessment. Following the assessment, C was deemed fit for discharge as no clinical concerns were identified. However, C's symptoms persisted upon returning home. They attended an emergency GP appointment the following morning and the GP concluded that C had had a stroke. C was readmitted to hospital for further investigations. A CT scan confirmed that C had suffered a stroke.

C complained that the board's staff unreasonably failed to identify that they had had a stroke following their procedure. We found that, whilst staff identified that C's symptoms indicated they may have had a stroke and an assessment was carried out with this in mind, the assessment was insufficiently detailed and, in light of C's presenting symptoms, further investigation by a neurologist (specialist of the nerves and the nervous system, especially of the diseases affecting them) should have been arranged. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to fully consider the possibility of a stroke prior to discharging them and for failing to seek input from the specialist stroke team. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Clinical staff involved should reflect on C's case and give consideration as to where improvements could be made in their practice to ensure that symptoms of stroke are adequately investigated as soon as possible and input from stroke specialists is obtained in clinically appropriate cases.
• The board said that they would be running education sessions for all staff to raise awareness regarding early signs and symptoms for stroke and the appropriate action to take.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment that their adult child (A) received from the board over a two year period. A had previously suffered an acquired brain injury and since then had developed obsessive compulsive disorder, post-traumatic stress disorder and anxiety, as well as experiencing delusional thinking and periods of psychosis (a mental disorder in which thought and emotions are so impaired that contact is lost with external reality). C raised a number of concerns, including that the board claimed A was reviewed regularly when they were not, that no psychological support was provided for A, that there was a lack of support from the local mental health team, that there was no clear local treatment plan and that in the care programme approach, needs identified were not met, matters were not escalated and no solution was found.

We took independent advice from a consultant psychiatrist (a medical practitioner specialising in the diagnosis and treatment of mental illness). We found that A's records showed that they received regular reviews during the period in question and that the letters on these showed a high level of clinical input. However, the evidence showed that there was a delay of over five months from the date of A's discharge from psychiatric hospital and the issuing of the discharge letter, which we found was unreasonable and, for a patient with less clinical/multi-professional input and family interaction, would likely have resulted in significant clinical risk.

We found that the overall level of support A received was reasonable. However, we found that there was a lack of focus by the board on the organic elements of A's presentation and how these may have contributed to their psychosis and we were critical of the board's failure to utilise locally available specialist advice which resulted in a lack of psychology and neuropsychiatric input in A's case. We found that these failings were significant and, on balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to focus on the organic elements of A's presentation and failing to utilise locally available specialist advice on psychology and neuropsychiatry in A's case. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• In cases such as this, the board should consider organic elements of patients' presentations and utilise locally available specialist advice on psychology and neuropsychiatry.
• The board's patient discharge letters should be issued in a timely fashion.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care provided by the board to their parent (A) whilst admitted at Glasgow Royal Infirmary. A had been admitted with low blood iron levels and a two-week history of back pain, queried to be a spinal fracture of osteoporotic (weakened bones) or pathological (caused by a disease) origin. Following A's admission, they suffered a “controlled fall”. Twelve days later, A complained of being unable to move their legs. An MRI scan of the spine was carried out, which confirmed that A had suffered a fractured vertebra causing spinal cord compression affecting A's ability to move their lower limbs and control bowel and bladder functions. A was subsequently treated conservatively due to their age and comorbidities.

C complained about the circumstances surrounding the fall A suffered and that staff had not recorded details of the incident under the Datix reporting system as required. C considered that A had sustained the spinal injury during this incident and that the lack of Datix report meant that there had been a delay in identifying the injury.

The board accepted that a Datix report had not been completed as required at the time of A's fall but that this had not prevented A from being assessed. The board also stated that a Datix report had been completed retrospectively and that the incident had been reviewed by the hospital falls team. The board stated that it was not believed that A's fall had caused the spinal fracture, which may have been present in advance of A's admission.

We took independent advice from consultants in emergency and general medicine. We found that despite A presenting to the A&E with a queried spinal fracture, no neurological examination was carried out nor was any consideration given to performing an X-ray of A's spine. This was unreasonable practice. In addition, the board's failure to complete a Datix record of the fall A suffered was also unreasonable although it was impossible to say with any certainty that this incident had caused A's spinal fracture.

We found that the board were unable to produce any evidence to show that a Datix record into A's fall had been completed retrospectively or that the incident had been reviewed by the hospital falls team.

In view of the above failings, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for unreasonably failing to carry out a neurological examination of A, for not considering whether an X-ray of A's spine was required following their presentation to the A&E at Glasgow Royal Infirmary and for providing inaccurate information in their complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• In patients who present to A&E with new onset back pain, a neurological assessment should be performed as part of baseline medical examinations. Where the cause of new onset back pain in patients is suspected to be an osteoporotic or pathological fracture, consideration should be given to performing X-ray imaging to investigate the possibility. Any decision not to proceed with X-ray imaging, should be documented in the clinical records.

In relation to complaints handling, we recommended:

• The board should ensure that information provided in response to complaints is factually accurate and that, where the board has confirmed specific actions have been taken in response to a complaint, evidence of this can be provided.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the treatment a family member (A) had received from the board. A was admitted to hospital three times over a short period with severe stomach and back pain. Following A's third admission, they were diagnosed with kidney failure and discharged to receive palliative care. A died a short time later. C complained that the board had missed opportunities during A's earlier admissions to identify their deteriorating kidney function. C said that an earlier diagnosis could have prolonged A's life expectancy as treatment could have commenced sooner.

C also complained that on A's second admission, their discharge had been unreasonably managed by the board. C complained that A was left all day in the discharge lounge in their nightwear and that staff failed to properly communicate A's discharge arrangements to the family. A was later returned to their nursing home in a taxi instead of an ambulance. C said that this was extremely distressing and undignified for A, and had been unacceptable given A's age and poor health.

We took independent clinical advice from a consultant geriatrician (a specialist in the care of the elderly). Whilst there had been a reasonable approach to investigating A's symptoms on their first admission, we found that there were missed opportunities by the board to diagnose A's kidney failure and infection, and the family's concerns had not been given appropriate consideration during the second admission. On the third admission, there was a delay in the clinical consideration of A's abnormal blood results, and in recognising the severity of their condition. We also noted from the board's own investigations that there had been a failure to move A's personal belongings between wards. Therefore on balance, we upheld this aspect of the complaint.

We also found that A was not clinically fit to be discharged from hospital following their second admission, and given their age, fragility and poor health, that their discharge arrangements had been poorly managed. These failings included A's lengthy wait in the discharge lounge, and A's transportation in their nightwear via taxi. We further noted from the board's own investigation that A had been discharged with the wrong discharge letter and medication, and that there had been a failure to communicate A's discharge arrangements to the family. As a result, we upheld this aspect of the complaint.

We also provided feedback to the board in respect of their record-keeping, reminding them of the importance of ensuring patient records are detailed and fully documented.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family that opportunities were missed to diagnose A's kidney failure and infection, and for not properly taking account of their concerns during A's second hospital admission. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A's family for discharging A from hospital when they were not clinically fit, and for the poor management of A's discharge arrangements. The apology should meet the standards setout in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A's family for the delay in the clinical consideration of A's abnormal blood results, and in recognising the severity of A's condition during their third hospital admission. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Ensure abnormal blood results in a patient's clinical records are followed up appropriately.
• Ensure that relevant staff have appropriately reflected on the complex nature of this case.
• If a patient is elderly, frail or in poor health, patient discharge arrangements should be carefully assessed to ensure that they are appropriate, taking account of discharge wait times, a patient's clothing and methods of transportation.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the planning procedure followed by the council for a planning application to build a dwelling house and garage on the site of a post office in C's street. C raised a number of concerns, including that the garage drawings were not published on the council's planning portal for comment, that the correct garage floor area was not shown on the block plan and that the planning officer approved a garage of 51 square metres and then allowed a garage to be built which was clearly larger than this. We took independent advice on the complaint from a planning adviser.

The council acknowledged to C and this office that they failed to upload all relevant information on this planning application to their planning portal, including the detailed garage drawings. However, they failed to apologise to C for this failing and explain what action they had taken to prevent this type of failing from happening again. We noted that the system upgrade the council advised they were now installing to prevent errors in manual uploading was reasonable and we asked the council for evidence of the completed implementation and confirmation of its scope.

We noted that the block plan did not show the garage floor area and it was not specifically required to do so. However, they said that the garage floor area in the block plan appeared to be considerably smaller than the garage shown in the approved garage plans and elevations and it would have been good practice for the council to have ensured that all plans were consistent.

We noted that although the planning report referred to the garage as being 51 square metres, the stamped plans were what was ultimately approved and what an applicant could then implement and they showed the garage as being 77.8 square metres. The council have said that the reference to a 51 square metre garage was based on a miscalculation by the planning officer and remedial action had been taken to address this.

We were concerned that the planning report did not contain any reference to the assessment of the garage or any evidence that the potential impacts of the garage were considered in the determination of the application. We were critical of the council in this regard.

We were also concerned that, despite being advised by the council that they did not re-notify neighbours about the change in the dimensions of the garage because this was to a reduced footprint with a lower impact, we did not see any evidence that the original proposal was for a garage which was larger than the one approved by the council. As such, it was not possible to determine that re-notification of the neighbours was not required. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to upload all relevant information on the planning application to their planning portal, providing incorrect/misleading information on the size of the garage in the planning report, failing to include information on the assessment of the garage and its potential impact in the planning report, and, in their complaint response, unreasonably failing to explain to C why the planning report stated that the garage was 51 square metres, when at no time was a garage of that size approved. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• For planning reports for applications to appropriately address all aspects of a development.
• For site visits on planning applications to be recorded and include information such as the date of the visit, who attended, what was considered and any photographs taken.
• Plans for development should be consistent, in that the dimensions of buildings should be the same on all stamped approved plans.

In relation to complaints handling, we recommended:

• The council's responses to complaints should address all issues raised, as required by the Model Complaints Handling Procedure.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C, a support and advice worker, complained on behalf of their clients (B) in relation to a child in B's care (A).

It was decided at a Child Protection Case Conference (CPCC) that A be formally placed with B and as such, B were deemed as eligible for kinship care payments. As a result of this decision, a kinship care assessment was started but was not completed. It was also decided at the CPCC that a referral should be made to the Scottish Children's Reporter Administration (SCRA). While a full assessment was completed on A and one of their parents, this was not sent to SCRA. C complained that the partnership had unreasonably failed to carry out a kinship care assessment.

We took independent advice from a social worker. We found that the kinship care assessment which had been started following the decision of the CPCC had not been completed within the timescales set out in the Guidance on the Looked After Children (Scotland) Regulations 2009. We also found that the decision taken by the partnership that a kinship care assessment was not required had not been communicated timeously to the other agencies involved in the CPCC or to B. Finally, we found that the level of record-keeping was unreasonable.

C also complained that the partnership had unreasonably failed to make a referral to SCRA. We found that there was sufficient evidence to show that the referral should have been made at the time and that there was no evidence to support the partnership's decision that a referral was no longer required. We also found that the partnership's decision not to send the referral had not been communicated to the agencies involved in the CPCC or to B.

Finally, C complained that the partnership had failed to provide reasonable social work/kinship care support. We found that the partnership had failed to demonstrate reasonable contact with B and had failed to provide sufficient evidence to support their decision to close the case. They also failed to adequately evidence that a sufficient level of assessment had been carried out to conclude that A was no longer a looked after child (child in the care of a local authority) and that all financial payments should stop. As such, we found that the partnership had failed to provide reasonable social work/kinship care support.

We upheld all aspects of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the failings identified in this case at complaints. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Complete a full kinship care assessment, in line with relevant guidance, in respect of B's care of A. As far as possible, consideration should be given to the circumstances of the household when the assessment should have been completed (not just the current circumstances). This should also take into account the fact that A was formally placed with B, and at the time B had been assessed as kinship carers.

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

• Decision-making should be clear and transparent and recorded to ensure accountability and evidence for the actions taken.
• Record-keeping should comply with relevant regulations and guidance.
• Written case records should be appropriately maintained and retained in accordance with relevant legislation and guidance.
• Kinship care assesments should be completed within an appropriate timescale, in line with relevant guidance and legislation.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C, parents of infant child (A) complained about the care and treatment that A had received from the board. C had raised concerns that A's Hickman line (a central line catheter inserted into one of the large blood vessels to allow permanent access for treatment) may be infected and had sought advice at hospital. A swab of the insertion site had taken place, however A had been discharged without further treatment. C complained that the board had failed to provide a reasonable standard of treatment to A during their admission.

C further complained that the following day at a home visit, nurses had proceeded to flush A's line (procedure required to ensure the line remains clear of blood and to prevent clotting) in spite of their concerns it might be infected and without the results of the swab testing. C asserted that as the line had been infected, A had received a septic shower (sudden systemic release of pathogens into the blood stream causing septic shock) resulting in A's sudden collapse.

In their response, the board said that as there had been no diagnosis of a line infection, A's line had been flushed in accordance with the board's Care and Maintenance policy (CVAD policy). However, reflecting on the complaint, the board acknowledged that had there been formal communication between services regarding A's swab testing the evening before, this may have influenced their decision-making to proceed with the flush. They said that as a result of the complaint, they would review and update their CVAD policy to incorporate a standard operating procedure (SOP) and checklist so as to improve information sharing between teams and in circumstances of swab testing, or concerns expressed by families, to ensure medical advice would be sought before proceeding.

We took independent advice from a paediatric nursing adviser and consultant paediatric adviser (dealing with the medical care of infants, children and young people). We found that although the board had correctly considered sepsis in their assessment of A during their hospital admission, they had failed to take appropriate account of the Sepsis 6 guidance, had failed to seek senior clinician advice, and further treatment should have been considered. We also found that in light of the known risk of sepsis associated with central line devices, and given the level of concern expressed by C, it would have been reasonable for the board to have delayed the flush of the line until after the swab results had become available. We also found that the board had failed to correctly follow their CVAD policy, specifically, nurses had not sought senior medical advice before proceeding, and the pro forma maintenance bundle had not been completed or recorded for the flushes of A's line.

C further complained that in investigating their complaint the board had failed to seek their account of events, and had only raised a DATIX (incident report) after they had made their complaint. We found that the board had failed to correctly manage the incident in accordance with their adverse event management policy and procedures which resulted in the family being denied the opportunity to present their evidence. We also found that there had been an unreasonable delay in reporting the DATIX, and the incident had not been escalated for consideration as a potential Serious Adverse Event Review.

We fully upheld all aspects of the complaint. However, in making our recommendations we took account of the board's proposed improvements to their existing CVAD policy which we considered adequate to address the failings identified.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to take appropriate account of the Paediatric Sepsis 6 guidance in their assessment of A, failing to consider further treatment in line with the Paediatric Sepsis 6 treatment pathway, failing to seek senior clinician advice and failing to ensure formal communications with the ICCN team regarding A's attendance at the paediatric unit. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for failing to correctly follow their AEM policy and procedures by unreasonably delaying the DATIX and not escalating the incident for consideration as a potential SAER, for failing to carry out a reasonable investigation by not reporting events as a SAER or commissioning a SAER report and for failing to allow the family the opportunity to participate in the adverse review process. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for proceeding to flush A's central venous line without the results of the swab testing, for failing to act on their concerns that the line may be infected, for failing to give fuller consideration to the known risk of sepsis associated with CVAD, for not adhering to the Hickman Patency Troubleshooting guide by failing to seek senior medical advice before proceeding with the flush and for not completing or recording the CVAD maintenance bundle for A's central venous line flushes. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The board should ensure relevant staff are reminded of the Scottish Patient Safety Programme Paediatric Sepsis 6 Guidance when considering treatment, specifically that there is a lower threshold for consideration of sepsis in patients with indwelling devices/lines, complex medical conditions and significant parental concern. The board should ensure that where there is a lower threshold for consideration of sepsis, senior clinician advice is sought.
• The board should ensure relevant staff are reminded of the board's adverse event management policy and procedures, and published best practice (HIS and IHI guidance) with regards to reporting, managing and analysing significant adverse events. The board must also ensure effective communication with families throughout the SAER process, and during any parallel complaint investigation.
• The board should ensure that when carrying out care and maintenance of central venous access devices in the community, that the CVAD maintenance bundle, including associated checklist, is completed and recorded in the clinical records.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C, the parent of A, complained about a delay in diagnosing A's thyroid cancer. A had an emergency admission to Dumfries and Galloway Royal Infirmary with acute tonsillitis and a lump was found on their neck. This lump was subsequently excised four months later, and cancer was diagnosed the following month. C complained that no prior indication had been given that cancer was suspected, and that the delay in diagnosing this led to unnecessary operations. They also complained about a subsequent delay in informing them about identified nodules on A's lung that were being monitored.

The board told us that they recognised that an earlier biopsy could have led directly to definitive surgery, without the need for further investigations or procedures and ultimately to a quicker resolution for A. They confirmed that they developed a new neck lump clinic as a result of this complaint. We took independent advice from a head and neck surgeon. We noted that A should have had an urgent needle biopsy at an earlier point in time. This would have led to an earlier diagnosis and less surgery. We noted that an excision should only have been considered if a diagnosis was not possible from the needle biopsy. Therefore, we upheld the complaint that there was an unreasonable delay in diagnosing A's cancer. We considered that the new neck lump clinic was the best way to avoid this happening again. While we were assured that the delay did not have an impact on A's prognosis, we noted that it will have added to the distress for A and the family.

In relation to C's concerns about not being advised sooner that cancer was suspected, we noted that cancer did not appear to have been considered earlier. We were, therefore, unable to conclude that there was a failure to communicate a suspicion of cancer. We noted that the board had already acknowledged that they did not make A aware of the lung nodules when they were identified. Therefore, on balance, we upheld the complaint that communication was unreasonable. The board had already apologised for this and they told us that they had revised their process to require clinicians to copy GP letters to patients.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for the unreasonable delay in diagnosing A's cancer. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Neck lumps should be investigated with a needle biopsy in the first instance, and an excision should only be considered if a diagnosis is not possible from the needle biopsy. This should be undertaken urgently until cancer is excluded. This case should be discussed at the department's morbidity meeting and the findings of this investigation fed back to relevant staff in a supportive manner for reflection and learning.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment that they received from the board. C said that they had been incorrectly diagnosed with Avoidant Personality Disorder (APD). C said that the board had failed to carry out a proper assessment of their presenting symptoms and incorrectly relied on historic information in reaching their diagnosis. They complained that the board's diagnosis had prevented them from accessing appropriate supports and treatment for other comorbidities.

According to NHS Inform, based on statistical information from England, personality disorders can affect one in 20 people and can be very difficult to live with.

In this case, we took independent advice from an adult psychiatry adviser. We considered that the board's diagnosis had been reasonable, however the possibility of a depressive disorder co-existing with this disorder's traits, and a physical disorder contributing to mood change, had not been adequately investigated. We also found that the board did not have an appropriate care pathway for APD, that staff had been unaware of it and that there was a lack of continuity in the board's procedures for requesting both internal and external opinions. Therefore, on balance we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out a reasonable assessment of their symptoms. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The arrangements for requesting second opinions within the organisation, and external opinions, should be clarified.
• The care pathways for Personality Disorder should be clarified, and in particular the treatment options of Cluster C disorders such as Avoidant (Anxious) Personality Disorder.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained of a delay in diagnosing their late partner (A)'s cancer by medical staff in University Hospital Monklands. A was diagnosed with a rare cancer and died three weeks later. They had been unwell for around five months and had multiple hospital attendances and admissions. C complained that appropriate tests weren't carried out in a timely manner, and that A was misdiagnosed and treated for potential illnesses they did not have.

We took independent medical advice from a consultant in respiratory and general medicine. We found that A's case was complex and unusual and that it was reasonable to consider other diagnoses more likely than cancer, and to treat these accordingly while investigations continued. However, we found that reasonable action was not taken to manage the pleural effusions (fluid around the lung) that A initially presented with. Guidelines indicate that a fluid aspiration (removal of a small amount of fluid for testing) should have been arranged to rule out infection in the pleural space (cavity between lungs and chest wall). This was not arranged until almost eight weeks later. When this was done and the result was inconclusive, guidelines recommended that a biopsy be carried out and this wasn't done either. In addition, an ultrasound scan the following day reported ascites (fluid within the abdomen), and again a fluid aspiration was indicated but wasn't carried out.

A biopsy via thoracoscopy (keyhole camera into the pleural space) was not carried out until a further 14 weeks later. A's cancer was diagnosed thereafter. We found that there were earlier indications for a thoracoscopy and missed opportunities to diagnose A's cancer from the time of their initial presentation. While we acknowledged that an earlier diagnosis was unlikely to have altered A's prognosis, we noted it would have enabled palliative care to commence and allowed the family time to prepare and make the most of the time they had left together. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out appropriate investigations in a timely manner, and for the consequent delayed diagnosis and impact of this on A and the family. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Adherence to relevant national guidelines on managing pleural disease and managing ascites. Appropriate investigations carried out as and when indicated, leading to timely diagnosis.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.