SPSO Individual Decisions

C complained about the care and treatment provided by the board in relation to a cancerous lesion (squamous cell carcinoma, SCC) on their middle finger. C received cryotherapy for eight months but at the end of the treatment, the lesion was worse. C said that they should have been reviewed by a consultant sooner when it became apparent the treatment was unsuccessful and they would have chosen surgery at the outset if they had been told of alternative treatment options. As a result of the failings, C said that they developed a more serious lesion. We took independent advice from a consultant in dermatology. We found that the standard of medical care provided was not reasonable in that the uncertainty of diagnosis was not communicated to C and treatment options were not fully considered and discussed. Additionally, cryotherapy treatment was continued without consultant review for an extended period and the GP’s re-referral of C was downgraded to ‘routine’. We upheld the complaint.

C complained about the care and treatment that they received in A&E, and the subsequent handling of their complaint by the board. C initially attended the A&E with vomiting, diarrhoea and abdominal pain. Although C and their partner raised the possibility of appendicitis, this was dismissed. C was diagnosed with gastroenteritis and discharged without a full abdominal examination or review by a senior clinician. The following day C’s condition deteriorated, and C was found to have a ruptured appendix and septic shock, requiring emergency surgery, ventilation, and a prolonged hospital stay. We took independent advice from an Advanced Nurse Practitioner. We found that the care and treatment that C received was unreasonable because a thorough abdominal examination was not carried out by a senior decision maker and documented to exclude appendicitis as a differential diagnosis, prior to discharging C. It was also unreasonable that the board did not initiate an Adverse Event Review at an earlier stage. We upheld C’s complaint. Regarding complaint handling, we found that the board failed to provide a response addressing all issues raised and did not give C a revised timescale for their delayed response, contrary to the NHS Model Complaints Handling Procedure. We upheld C’s complaint about the board’s complaint handling.

C complained about the decision of the practice to remove them from their list and about the way that the practice handled their complaint. C had a consultation with a GP at the practice. A few days later C was removed from the practice list. Practices are entitled to remove patients from their lists in certain circumstances. That said, for a removal to be reasonable, the practice need to be able to demonstrate that they have acted in a way that is consistent with The National Health Service (General Medical Services Contracts) (Scotland) Regulations 2018 (the 2018 Regulations) and General Medical Council guidance to ending a professional relationship with a patient. Regarding C’s removal from the practice, we found that the practice did not act in accordance with the 2018 Regulations and the GMC’s guidance. The practice did not provide any contemporaneous written records setting out the reason why no warning was given in this case and the circumstances of the removal. They also did not provide records of the justification for removing C from the practice list for expressing dissatisfaction about the care and treatment provided and the grounds for it not being considered appropriate to provide C with a more specific reason for the removal. Regarding the handling of C’s complaint, we found that the practice failed to fully investigate and respond to the points of complaint being raised in accordance with the practice’s complaint handling procedure and the NHS Model Complaints Handling Procedure. They also failed to provide C with a copy of the practice’s Public Facing Complaints Handling Procedure. We upheld C's complaints.

C complained about the care and treatment provided by nursing staff to their late sibling (A), who was admitted to hospital with a chest infection. A was discharged with injuries and delirium, which C believed was due to a fall they had shortly after admission. A was a wheelchair user and especially vulnerable to falls because of their bone condition (osteoporosis). C said that a full assessment of A’s risk of falling was not carried out and that the fall caused A to deteriorate, and led to their death three months later. We took independent advice from a registered nurse adviser. We found that the standard of nursing care provided was not reasonable in that a falls risk assessment was not carried out fully and accurately, documentation and record keeping did not meet the required standards, communication needs were not met and full learning and improvement was not achieved because a significant adverse event review was not carried out. We upheld the complaint.

C complained that they were inappropriately triaged at A&E because sepsis had not been considered, their symptoms and history were not accurately recorded and medication was not appropriately considered. C felt extremely unwell after taking medication for alopecia, attended the A&E and were triaged within one hour. An allergic reaction was considered, observations were taken and cocodamol was administered. C was categorised as a priority level 3 for urgent but stable conditions, which should be seen within one hour. C was advised that they may have to wait seven hours as the A&E was busy. C left the A&E as they felt too unwell to wait. They were returned to hospital the following evening, by ambulance, with sepsis and blood clots in their lungs. The board advised that C was correctly prioritised according to the observations and symptoms recorded at the time. They advised that a nurse in charge would check patients during their waiting time and re-categorise as necessary. They also advised that more detailed checks and tests would be done at the point of medical assessment. We found that the triage process was in line with guidance and that the categorisation was correct. However, we noted that the blood pressure reading was high and should have been rechecked. We also noted that the extended waiting time for triage and medical assessment was not in line with guidance. On careful balance, we found that the triage process was reasonable because C was correctly categorised. We acknowledged that if C had waited, further review and medical assessment would have taken place. We did not uphold the complaint. Related reading View Decision Report 202502009 as a PDF (24.6 KB) Updated: May 20, 2026

C complained about the standard of medical care provided by the board during two attendances at A&E with severe abdominal issues. C was discharged home on both occasions, and shortly after the second discharge, the results of a magnetic resonance scan (MRI) indicated that they had significant abnormalities of the bowel. C was then admitted to hospital for treatment of inflammatory bowel disease. We took independent advice from consultants in emergency medicine and general medicine. We found that the standard of medical care provided was not reasonable in that recordkeeping and communication was poor, C was misdiagnosed with constipation at the second visit, there was a failure to act on the results of the MRI scan and discuss C’s care with the relevant specialists at the second visit, and there was a delay in treating C and admitting them to hospital. We upheld the complaint.

C complained about changes made by the HSCP to their adult child (A)'s personal care allowance, the management of and communication relating to direct payments, the HSCP’s communication with C in their role as A’s carer and appointed guardian, and the handling of their complaints. We took independent advice from a social worker adviser. We found that the changes made to A’s personal allowance were reasonable. This is because the HSCP made decisions about A’s allowance that they were entitled to make, taking into account an assessment of A’s needs. With regard to the management and communication of payments, we found that this was reasonably managed by the HSCP. We noted that communication could have been clearer and provided earlier, particularly in relation to the decision to recover funds. However, overall, the HSCP reasonably managed the direct payment account and took appropriate steps to resolve payment issues when they were identified. We also found that the HSCP’s communication with C, as A’s welfare guardian, was reasonable, with records demonstrating that C participated in assessments and discussions about A’s support needs. We did not uphold the complaint. In relation to complaint handling, we noted the complexity of the case and that a number of enquiries had been made through the council’s MSP enquiry process but on balance, we found the complaint handling to be reasonable. We did not uphold C's complaints. Related reading View Decision Report 202501438 as a PDF (24.47 KB) Updated: May 20, 2026

C adopted a young child (A), however, the placement ended when C relinquished care via Section 25 of the Children (Scotland) Act 1995 due to irreconcilable behavioural difficulties and a breakdown in the relationship. A was placed in the care of the council. C complained that the council unreasonably failed to produce balanced and accurate assessments in relation to child protection concerns and the breakdown of the adoption, and did not reasonably amend these reports when these matters were raised. C also complained that the council unreasonably failed to involve C in ongoing care planning considerations regarding A. Lastly, C complained that the council unreasonably failed to facilitate and enable contact between C and A following the invocation of the section 25 agreement. We took independent advice from a social worker adviser. We found that while it is an essential requirement that any reports be balanced and accurate, the council had failed to give a complete picture of the history of A’s early life, to reflect the positive aspects of C’s parenting, and to reflect the views of other agencies who had provided support to the family. Overall, the reports were of mixed quality and contained inaccuracies. We upheld this aspect of the complaint. We also found that there had been failings in information sharing and case transfer between the council and C’s previous local authority. We also found a lack of formalised adoption support. Significantly, a referral had not been made to the Scottish Children’s Reporter Administration following the adoption breakdown, and there were failings to involve C in ongoing care planning. We upheld this aspect of the complaint. Lastly, we found that while continued attempts had been made to encourage contact, at the time of writing A, who had advocacy support, did not want to engage with C. The actions of the council were reasonable in this regard and we did not uphold this aspect of the complaint.

C complained about the care and treatment of their adult child (A) following A’s admission to hospital. A had a long standing, complex medical history including two kidney transplants and kidney cancer, and A died during their admission. In particular, C complained about A being prescribed Dapsone for a skin infection without discussion with A’s Renal Consultant and also that the Respiratory Team did not review A in the days prior to A’s death. C also complained that the board had failed to communicate in a reasonable way, in that critical information relating to A’s care had not been passed on between clinical teams or shared with the family. The board said that A’s renal disease did not contraindicate Dapsone which was frequently used following renal transplantation. The progressive respiratory reaction which A suffered would be a very rare side effect. The board said that Dapsone was appropriately discussed with A and prescribed, with no known lung or kidney-related risks in standard guidance. The Renal Consultant was informed and raised no concerns. The board acknowledged that the communication between clinical teams as documented in the medical records was open to interpretation and that this aspect of the complaint could have been better addressed in the formal complaint response. We took independent advice from a Renal Consultant and a Respiratory Consultant. We found that the clinical care and treatment was reasonable, and in keeping with normal practice. There was no requirement to seek advice from A’s Renal Consultant about the prescription, but they were aware of it and had no concerns. The side effect that A experienced is extremely rare such that the effect and outcome could not have been foreseen. We found that the Respiratory Team were appropriately involved where required and that the care provided was reasonable. We did not uphold this complaint. However, we found that the board had failed to communicate in a reasonable way and that communication fe

C complained about the care and treatment provided to their parent (A). A had dementia and had suffered several falls. C complained that the board failed to reasonably investigate A’s fall and that they failed to reasonably consider carrying out a Significant Adverse Event Review (SAER). We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly) and a registered nurse. We found that the board should have identified ambiguous and confusing language was used to describe A’s fall in its investigation. It should also have established that the fall was unwitnessed. We upheld this complaint. In relation to a SAER, the board were able to demonstrate that they had followed the guidelines in place at the time for determining if an SAER was required. In the period following the incident, local guidelines governing the holding of an SAER were superseded by national ones. We did not uphold this complaint.

C complained that their parent (A) suffered a fall while in hospital. C was concerned that bedrails and falls risk assessments were not appropriately completed prior to A suffering the fall. The board said in their complaint response that both bedrails and falls risk assessments had been carried out appropriately. We took independent advice from a registered nurse. We found that, from the evidence available to us, the falls and bedrail risk assessments carried out prior to A’s fall were limited and did not inform a comprehensive care plan. The board’s Policy for the Prevention and Management of Adult Inpatients Falling in Hospital Settings did not appear to have been followed. We upheld the complaint.

C complained about the care and treatment provided to their adult sibling (A). A had treatment for breast cancer, was admitted to hospital a short time later and died approximately two weeks after being admitted. C complained about A’s medical and nursing care and treatment in hospital and about the communication with A’s family. The board said that when A was admitted to hospital, a CT scan (a test that takes detailed pictures of the inside of the body) revealed extensive metastatic disease (disease that has spread from its original location) in A’s liver and bones. Treatment options were discussed with A. A was initially independent after admission to hospital, but A’s condition deteriorated. A was reviewed by an oncologist (a doctor who is a specialist in cancer), and A was deemed too ill for further treatment. The board said that they respected A’s wishes regarding communication with A’s family. We took independent advice from a specialist doctor in palliative care and a registered nurse. We found that the medical and nursing care and treatment were reasonable, and the board’s communication with A’s family was reasonable. Therefore, we did not uphold C’s complaint. Related reading View Decision Report 202409961 as a PDF (24.35 KB) Updated: May 20, 2026

C complained on behalf of their child (A) who was a patient of the practice. A's care was disrupted by COVID-19 and they were not seen by the practice for four years. C complained that the practice unreasonably charged them for white fillings after there was a delay in A being seen for routine check ups and the care could have been provided at a time when it would have been free of charge. C also complained that the practice failed to reasonably respond to C's complaint. We took independent advice from dental adviser. We found that the decision to charge for the care and treatment provided was reasonable. It was not possible to evidence whether appointments had been sought prior to their appointment, and the decision to charge for the treatment provided was reasonable. Therefore the complaint was not upheld. We found that while the content of the practice's complaint response was reasonable, there were significant delays in the practice providing a response and there were a number of times when C requested to escalate their complaint and this was not actioned, which we found unreasonable. Therefore, we upheld this complaint.

C complained about the care and treatment provided by the board to their late parent (A). Additionally, C complained about the nursing care that A received and the boards handling of C's complaint. We took independent advice from a consultant geriatrician and a senior nurse. We found the care and treatment of A to be reasonable. We did not uphold the complaint. In relation to nursing care and treatment, we found unreasonable care in a number of areas including but not limited to, failures in wound care, a delay in administering pain relief, shortcomings in the documentation of cannulation attempts, inaccuracies in key nursing documentation, errors in medication administration and inaccuracies in fluid balance. While communication with C was compassionate and the timeframes were reasonable, the board’s investigation did not fully identify or address several significant failings in A’s care, resulting in an incomplete and unreasonable response to C’s complaint. We upheld this complaint.

C complained about events at their child (A)'s school, in relation to suspected candidate malpractice and subsequent investigations into the school’s handling of the matters. C queried whether the council followed the correct process when C raised their concerns, as C was of the view the council should have followed the Scottish Qualifications Authority (SQA)’s Centre Malpractice Procedure, rather than the complaint procedure. C also raised concern that the investigating officer had shown bias in the process, that the child friendly complaint process had not been followed, and that the Stage 2 complaint response downplayed or omitted serious breaches, contained inaccuracies and misrepresentations, and directly contradicted the SQA’s findings. We found that while it was reasonable for the council to use the complaint handling process as opposed to the SQA’s centre malpractice process, they appeared to be uncertain about the correct procedures. We also found that the council failed to address legitimate concerns about bias in the appointment of the investigating officer or respond to these issues. We found that the council failed to follow child friendly complaint handling procedures, as they did not seek consent and views from the young person at the appropriate stage, and did not clearly consider and take into account the young person’s views when making their decision. Finally, we found that there were incompatibilities in outcome of the council’s investigation. We upheld the complaint. The council had begun to take action to address these failings including developing a Malpractice Policy, building steps into their processes to ensure the views of young people are included in investigations, and committing to refresher complaint handling training, so we asked for evidence of these actions.

C complained about the care and treatment provided to their adult child (A). A experienced a decline in mental health and was referred to their local community mental heath team by their GP. A was in contact with mental health services for a period of approximately three months before dying by suicide. C complained that the board had not reasonably listened to their concerns about A. C also complained about the board’s assessment and management of risk for A, A’s diagnosis and medications. The board completed a Significant Adverse Event Review (SAER) of the care and treatment provided in the six months prior to A’s death. The review concluded that, overall, appropriate care was provided by mental health services. The review identified some improvements and recognised that communication between A’s family and the consultant psychiatrist was poor. The review found that the issues identified did not contribute to A’s death. We took independent advice from a consultant psychiatrist. We found that the care and treatment provided to A was reasonable, including the assessment and management of risk for A, A’s diagnosis, the prescription of medications and the board’s handling of concerns from A’s family. We found some shortcomings in documentation. We found that the Board’s SAER was reasonable, as the standard of the review was good and the recommendations made by the review were appropriate, however, the review process took significantly longer than timescales stated in the guidance for SAERs, for which the board apologised. On balance, we did not uphold C’s complaint. Related reading View Decision Report 202408872 as a PDF (24.52 KB) Updated: May 20, 2026

C complained about the care and treatment that their late partner (A) received from the board’s gynaecology and oncology services at Glasgow Royal Infirmary. A was admitted to hospital, diagnosed with liver cancer, given two months to live and died. C also complained about the board’s handling of their complaint. We took independent advice from a consultant gynaecologist and a consultant oncologist. We found that there appeared to be no evidence that A had any follow-up appointments with the board until 1 year and 11 months after completion of their cancer treatment, contrary to the west of Scotland cancer network guidelines. We noted that the board had acknowledged that A had a long wait for their gynaecology follow-up appointments, their cancelled appointments were not reappointed within a month, and they had to chase for appointments. We noted that the board had apologised for these failings and indicated that they were taking remedial action to address this. Given the board’s failure to follow the guidelines and their repeated cancellation of A’s gynaecology appointments, on balance, we upheld the complaint. C also said that the board’s response to their complaint did not give them any option to ask for clarification or to challenge the response. We found that the board failed to follow the NHS Model Complaints Handling Procedure and advise C that a named member of staff was available to clarify any aspect of the response. We, therefore, upheld the complaint.

C, an independent advocate, complained on behalf of B, about the standard of medical and nursing care provided to B’s late spouse (A) by the board following a liver cancer diagnosis. B complained about A’s diagnosis, noting that A was initially seen to have one lesion and to be suitable for a liver transplant, however, three months later multiple lesions were found and A was no longer seen as a viable candidate. B also complained of subsequent delays in cancer treatment and that the nursing care provided to A was below a reasonable standard, including failures to prevent an unwitnessed fall. B said that communication from clinicians regarding A’s diagnosis, prognosis and treatment was lacking detail and infrequent, and that the board’s stage two complaints response was inaccurate. We took independent advice from a consultant hepatologist (specialist in diseases of theliver, gall bladder, bile ducts and pancreas) and a registered nurse adviser. We found that A’s diagnosis and treatment were reasonable and did not consider that multiple lesions had been unreasonably missed initially. We did not uphold this aspect of the complaint. However, we found that there had been failings with respect to communication, particularly when A’s care was transferred to a specialist transplant unit outwith the board. We also found that the nursing care provided was unreasonable, including failings to record comfort, pain, and personal care, and in relation to delirium, falls prevention and risk assessments. Lastly, we noted inaccuracies in the complaints responses provided to B. As such, we upheld these aspects of the complaint.

C complained about the standard of care provided to their parent (A) by the board in relation to a scan that was performed after A had been diagnosed with breast cancer. After speaking with a consultant, A and their spouse believed that A's diagnosis of metastatic cancer was certain and that A had stage 4 cancer. A and their family sought a second opinion. Another MRI scan was performed which showed no convincing evidence of metastatic disease. We took independent advice from consultants in radiology and oncology. We found that the standard of medical care provided to A was unreasonable. This was due to a failure to arrange a further review of the scan and obtain a second opinion, a failure to issue an amended report of the scan in light of A’s trauma history and an unreasonable standard of communication around the scan and the related complexities of A’s diagnosis. We upheld the complaint. We noted that the board has acknowledged and apologised for the distress, noted their failings and taken action. In light of this, we made no recommendations. Wehave asked the organisation to provide us with evidence that they have addressed the failings. Related reading View Decision Report 202401974 as a PDF (24.35 KB) Updated: May 20, 2026

C complained about the care and treatment provided to them by the board when they were admitted to hospitalwith chest pain and respiratory issues. C also complained that the board’s complaint response failed to respond reasonably to C’s concerns. We took independent advice from a respiratory adviser. We found that it was unreasonable that the board had not performed a pleural aspiration (a procedure to remove fluidfrom the space around the lungs) and had not inserted a chest drain on the day that C’s condition deteriorated in hospital. We upheld this complaint. We also found that the board’s response to the complaint was unreasonable given that they failed to identify failings in C’s care and treatment in their complaint investigation and failed to carry out a significant adverse event review (SAER). We upheld this complaint, however, we recognised that the board had accepted and apologised for failings.

C complained about the care and treatment provided to their late sibling (A) when they were admitted to A&E, and about the boards out of hours (OOH) service. A was found to have Influenza A and signs of a chest infection. A deteriorated throughout the admission to A&E with increased oxygen requirements and coughing up blood. They then had a cardiac arrest and continued to deteriorate, suffering multiple organ failure. Attempts to stabilise A failed, and A died in hospital. C also complained about the family being pressured to decide whether to have a post-mortem and that a Significant Adverse Event Review (SAER) was not carried out. The board acknowledged failings around appropriately regular observations not taking place whilst A was in hospital. However, they concluded that the overall care and treatment was reasonable given the circumstances at the time. In addition to this, the board did not uphold C’s complaints regarding the OOH service, the post-mortem, and the SAER. In respect of the care and treatment provided by the OOH service, we took independent advice from a GP adviser. We found that it was appropriate for a nurse practitioner to review A at the second of two OOH consultations the day before A was admitted to hospital. We found that the assessments and clinical decision-making, based on A’s presentation at the time, were reasonable. We did not uphold this complaint. In respect of the care and treatment provided when A was in hospital, we took independent advice from a consultant in emergency medicine. We found that appropriate regular observations did not take place. However, we considered that the overall care and treatment provided was reasonable, appropriate tests were carried out and appropriate treatment was provided, given A’s presentation at the time. As such, we did not uphold this complaint. In respect of whether the family was pressured into making a decision regarding a post-mortem, we found that communication with the family about a post-mo

C complained that Social Security Scotland (SSS) unreasonably delayed in changing responsibility for Child Disability Payment (CDP) when C reported that their child (A) was living with them. C and A's other parent (B) were living apart and A had previously been living with B. However, A moved out of Scotland to live with C. C complained that when this change in circumstances was reported, payments of CDP had initially been suspended pending transfer to C, however, the suspension was subsequently removed and all outstanding payments due before the account was closed continued to be made to B. C complained that B did not make this income available resulting in C and A being negatively impacted financially. SSS agreed that there had been delays in processing the transfer, pending new guidance and processes being put in place. SSS also stated that the transfer of payments to C should have been actioned before the process for ending CDP payments was completed. Nevertheless, SSS stated that their statutory duty was to make payments for A, which they fulfilled, and that any dispute over how the CDP payments were distributed between the two parents was a civil matter. Additionally, they considered that there was no evidence that A was not benefiting from the payments during this time. We found that B had confirmed their agreement for the change in responsibility and that payments to B had initially been suspended only for the suspension to be subsequently removed with no reasoning recorded. We found that there were delays due to lack of formal SSS guidance being in place. Additionally, it was evident that conflicting information and communication received from C and B should have raised concerns about whether A was benefiting from the benefits income intended for them, and there were missed opportunities to give clear advice to both C and B. Additionally, SSS had acknowledged that they should have processed the change in responsibility before processing A’s move out of Scot

C complained about the care and treatment given to their late spouse (A) by the practice before A died from metastatic renal cancer. C raised concerns that A was misdiagnosed by the practice and that they did not make appropriate referral for further investigation when they should have done. In response, the medical practice provided a detailed timeline of appointments, symptoms, treatments, and actions taken. They concluded that A had a complicated medical history and that the fact that A found it difficult to attend face-to-face appointments, made it difficult for doctors to gauge how much pain they were in. The medical practice acknowledged that there was some miscommunication between the practice and secondary care colleagues in physiotherapy. We took independent clinical advice from a GP adviser. We found that much of the care and treatment provided to A had been reasonable. However, we also found that some consultations were unreasonable, and that red-flags were not always appropriately identified and/or recorded and were not followed up. We also found that the SAER was not completed in line with the guidelines. As such, we upheld both complaints.

C complained that the board did not take reasonable action regarding their referrals. C was privately assessed by specialists in England, who recommended hospital admission for tests. C informed Highland NHS Board and it took over 18 months to approve and arrange referrals. We found that there was an unreasonable delay in progressing C’s respiratory referral and that the board’s communication was inadequate. The board failed to provide reasonable updates, which might have revealed sooner that the hospital C had been referred to had not received their original submission of the referral. Given this, we upheld the complaint. We found that the board unreasonably delayed C’s neurology referral. The board’s said that the delay was due to uncertainty over a consultant’s approval for MRI imaging and whether C wished to remain a private patient. We found that C had advised that they would request private care be paused pending the board’s multi-disciplinary team discussions. While the decision to refer C to another NHS Board was reasonable, taking six months to action this was not. We upheld the complaint. Finally, we found that communication with C was inadequate. Given this, we upheld this complaint and note the steps that the board have taken to address this.

C complained that the practice failed to act reasonably on the symptoms and information provided by C to the practice. The practice acknowledged difficulties in handling the complaint and failed to manage its interactions with a specialist laboratory. C has since transferred to a different practice, and has a diagnosis of Sjogren’s syndrome (a disorder of the immune system where the glands that produce fluid, such as tears and saliva stop working properly). C stated that they had specifically raised these concerns with the original practice and believed that their symptoms and related concerns were unreasonably dismissed. We took independent medical advice from a GP adviser. We found that C should have been offered a face-to-face appointment. This would have allowed appropriate assessment of C’s symptoms and the possibility of an earlier diagnosis, although this could not be determined with certainty. Therefore, we found that the actions of the practice were unreasonable. As such, we upheld this complaint.