SPSO Individual Decisions

C complained about how the association had responded to reports of antisocial behaviour and remained dissatisfied at the conclusion of the association's complaint procedure. C sought an acknowledgement of failings, an apology and steps to be taken to ensure the association's handling of reports of antisocial behaviour was improved. The association agreed to provide an acknowledgement and apology and had undertaken action to improve their handling of reports of antisocial behaviour. Therefore, we closed the complaint as resolved. Related reading View Decision Report 202501408 as a PDF (23.97 KB) Updated: March 18, 2026

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.

C complained about the care and treatment that their spouse (A) received from the board during admissions to Dr Gray’s Hospital (Hospital A) and Aberdeen Royal Infirmary (Hospital B). A was admitted following episodes of vomiting blood and received treatment for gastric varices (enlarged blood vessels in the stomach lining). C complained that the board did not investigate or treat A’s condition timeously, and that treatment was only given when their condition deteriorated. C complained that an oesophageal perforation occurred as a complication of a procedure to stop bleeding. C also complained about aspects of nursing care at Hospital B. We took independent advice from two advisers, a consultant hepatologist, who provided advice on the medical care and treatment, and a senior nurse, who provided advice on the nursing care and treatment. In relation to Hospital A, we found that there were aspects of A’s care which had been reasonably managed. Specifically, a recognised tool was used to assess the severity of the upper gastrointestinal bleeding which had occurred. However, there were aspects of A’s care which we considered unreasonably managed. In particular, having identified A as being at high risk of bleeding, there were delays in acting on this result, arranging diagnostic endoscopy, and making a timely referral and transfer to Hospital B for ongoing treatment. On balance, we upheld C’s complaint about Hospital A. In relation to Hospital B, we found that it was reasonable to seek specialist advice about the treatment of A’s condition from another health board. While a complication had occurred when inserting a tube to control bleeding, we found that the management of this was reasonable. We also found that Hospital B had reasonably acknowledged the nursing care incidents which had occurred and taken appropriate steps to learn and improve from them. However, there were aspects of A’s care and treatment which were unreasonably managed by Hospital B. In particular, h

C complained about the care and treatment provided to their late parent (A) by the board. A, who was diabetic, had been diagnosed with conditions including Myasthenia Gravis (an autoimmune disorder causing muscle weakness). A was admitted to University Hospital Crosshouse (UHC) as an in-patient four times, initially with a diabetic foot ulcer. This deteriorated over the course of time leading to infection, surgery and amputation. A died during their fourth admission. The board partly upheld C's complaint and identified failures in A’s care, particularly around the administration of medication for the treatment of Myasthenia Gravis and around communication with A’s family. They identified learning and improvements. C remained unhappy and asked us to investigate. C complained that A had been provided with inadequate care and treatment as a podiatry out-patient and as an in-patient at UHC. C also complained that the board had failed to adequately investigate their complaint. We took independent advice from a consultant vascular surgeon. We found that the out-patient podiatry care provided to A was reasonable and did not uphold this complaint. However, while we found that, overall, A’s care and treatment was reasonable during their in-patient admissions, there were failings in relation to A’s Myasthenia Gravis medication and in communication with A’s family. We upheld this complaint and recommended that the board provide us with evidence of the implementation of the learning and improvements they had previously identified. We found that the board’s investigation of C’s complaint was reasonable. However, we were critical of the time taken to respond to the complaint and of the board’s failure to keep C regularly updated on the progress of their investigation. We noted that the board had accepted this and identified learning and improvements. We made no further recommendation for action. Related reading View Decision Report 202309740 as a PDF (24.71 KB) Updated: March 18,

C complained on behalf of their adult child (A), who underwent septorhinoplasty surgery (to improve the function and appearance of the nose) after a rugby accident. C complained about the care and treatment provided to A following the procedure. C had all skin sutures and brace, seven days after surgery, as per the clinic letters. A developed a post-operative infection and was reviewed again 12 days after surgery, when a further suture was removed. More than a year later, A noted black suture material extruding from the scar line on their nose. They were commenced on antibiotics and further review arranged. C complained that the medical records did not support the board’s position that a suture was intentionally left in place and that the board had failed in their duty of candour. We took independent advice from a consultant otorhinolaryngologist (specialist in ear, nose, and throat medicine). We found the standard of care and treatment when A attended 12 days after surgery unreasonable. We also found that A was wrongly told that all remaining suture material had been removed at that time. With regard to the suture material which extruded from the scar line more than a year later, we found that the board’s explanation that this suture was intended to remain in place permanently was not supported by the records. Had it been intended to remain in place permanently, it should have been clearly recorded. We found the board had failed in their duty of candour and that it was unreasonable for the board not to have offered A a second opinion, even if that required referral outwith the board area. We therefore upheld the complaint.

C complained about the care and treatment provided by the board during a planned caesarean section. C said that complications occurred during the procedure which could have been avoided based on information available from antenatal scans. C also complained about the timing of the procedure, record keeping, delays in arranging a debrief meeting, postnatal care for high blood pressure and infection, and the board’s handling of the complaint. We took independent advice from a midwifery adviser. We found that the care C received during the caesarean section was of a reasonable standard. It was reasonable to schedule C last on the theatre list due to an active COVID-19 infection, and there were no clinical indicators requiring enhanced planning. While complications occurred, we found that these were reasonably managed. We found that offering C the option of vaginal birth reflected good practice. We did not uphold this complaint. In relation to C’s post-natal care, we found that the monitoring and management of blood pressure, infection treatment, and follow-up care were appropriate and in line with clinical guidance, and the medical records were accurate. We did not uphold this complaint. We considered C’s complaint about the board’s handling of their complaint. We found that the board acted unreasonably by refusing to investigate on the grounds of time limits, despite the delay being due to a postponed debrief meeting and reassurances given that a complaint could still be made. The board did not provide a clear explanation for refusing to extend the timescale, contrary to complaint handling guidance. We upheld this complaint.

C complained that the board's communication around their spouse (A)'s care and treatment was unreasonable. C complained about a lack of face-to-face appointments, delays and the board not following their diagnostic pathway. C said that they were informed of A's prostate cancer over the phone, with no support provided to help them come to terms with the diagnosis or deciding on treatment which, due to A’s co-morbidities, was more complex. The board apologised that not all of the appointments were face-to-face but explained that this was due to demands on the service. They acknowledged that this was not ideal but it was necessary to reduce delays. The board said that the MRI result clinic was omitted from the diagnostic pathway in order to expedite A's biopsy. The MRI results were shared at the biopsy appointment. An MDT discussion took place a week after the biopsy results were reported and the diagnosis was shared with A by telephone rather than waiting a further four weeks for a face-to-face appointment. We took independent advice from a consultant urologist (a doctor who specialises in the male and female urinary tract, and the male reproductive organs). We found that the board’s communication was unreasonable. There was a lack of explanation about why the MRI results clinic was omitted from the pathway, as well as an inadequate explanation of the MRI result itself. It is clear that A did not understand the likelihood of cancer that prompted the biopsy and their understanding was not checked until the point of diagnosis. Therefore, we upheld C's complaint.

C, a prisoner, complained that the partnership reduced and then stopped their prescription of co-codomol (a medication used to treat pain) for possible sciatica without consultation. The partnership did not did not identify any failings in C’s care. They said that reduction and discontinuation of the co-codomol prescription was a clinical decision. They acknowledged that C would have preferred to be included in this decision, but that this had not been possible in the specific circumstances. We took independent advice from a GP. We found that C’s prescription had been changed following the opinion of two different GPs. When the decision was made a letter was sent to C informing them of this. While we considered that there should ideally have been prior discussion with C, a letter was sent at the point the decision was made explaining the reasons for the change. In the circumstances, we did not consider this to be unreasonable. We found that the explanation for the reduction and cessation of C’s prescription appeared reasonable as there was no indication for C to be on regular co-codamol and this was not a medication that generally required a patient to be weaned off slowly. Therefore, we did not uphold C's complaint. Related reading View Decision Report 202408118 as a PDF (24.4 KB) Updated: February 18, 2026

C complained about the care and treatment provided to their infant child (A) who was born with a terminal genetic condition. A's family had open access to the children's ward, allowing them to seek medical advice or assistance when needed. C brought A to the ward as they were unwell. After assessment, A was discharged with advice to return if their condition changed. A's condition deteriorated and they were taken to A&E the next day. When staff were unable to obtain intravenous access (when a needle is inserted into a vein), an intraosseous needle was used (a needle that goes directly into the bone). A complication occurred during the procedure and A was transferred to another health board for specialist care where there were further major complications. C felt that treatment would have started sooner if A had remained in hospital, avoiding the need for the intraosseous infusion and the subsequent complication. We took independent advice from a consultant paediatrician (specialist in children's medical care). We found that A received a reasonable standard of care and treatment and that the harm that occurred was a recognised complication of the procedure. We welcomed the board’s review of the case and noted that it had contributed to important learning in relation to the care of children with complex medical needs. We did not uphold C's complaint. Related reading View Decision Report 202405861 as a PDF (24.52 KB) Updated: February 18, 2026

C complained about the condition of their adult child (A)'s property. C said that the house was impossible to heat, and constantly cold and damp. Following our decision to move the case to investigation, the association offered A a new flat. C was happy with this outcome and we closed the complaint as resolved. Related reading View Decision Report 202503318 as a PDF (23.88 KB) Updated: February 18, 2026

C complained about the care and treatment provided following their referral for a transurethral resection of the prostate (TURP, an operation to reduce the size of the prostate gland). The surgery was cancelled on the day when C's prostate was measured and considered too large for TURP surgery. C was then referred for Holmium Laser Enucleation of the Prostate (HoLEP, a procedure that uses a laser to remove enlarged prostate tissue) at another board. C complained of unreasonable waiting times for surgery; contraindicated medication; lack of prostate measurement during pre-op checks; that the operation was unreasonably cancelled; poor communication and administration of the referral and errors in the board’s complaint response. The board acknowledged delays due to service pressures and apologised for errors in the complaint response. They outlined steps taken to improve waiting times; validate waiting lists; measure prostates during wait; and improve communication and administration. They confirmed that HoLEP is preferred for prostates over 80 cc and explained that C’s prostate was measured at 100 cc. We took independent advice from a consultant urologist (a doctor who specialises in the male and female urinary tract, and the male reproductive organs). We found that the waiting time for surgery was unreasonable and that C should have been given the option of the TURP surgery, with the risk and benefits explained, given the long wait. We found that C was appropriately prescribed medication which was not contraindicated. We also noted that pre-op checks were anaesthetic checks and not usually used for prostate measurement. Overall, we found that C's care and treatment was unreasonable due to the excessive waiting time and lack of option for TURP. Therefore, we upheld C's complaint. However, as the board had taken several steps to address issues, it was not considered that this situation would happen again. No further recommendations were made. Related reading View Decis

C complained on behalf of their child (A) who is in their late teens. C complained that Child and Adolescent Mental Health Services (CAMHS) failed to carry out appropriate Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) assessments and failed to provide A with appropriate support for a number of years. The board said that A had undergone a number of assessments and reviews within CAMHS prior to turning 18 and no conclusive diagnosis had been reached. During our investigation they acknowledged that the family may have been unintentionally given the impression that an ASD diagnosis was likely or expected. We took independent advice from a clinical psychologist with experience in CAMHS. We found that while there were multiple professionals involved, given the complexity of this case there should have been further demonstration of shared, integrated clinical reasoning by the multidisciplinary team (MDT) in formulating a diagnostic conclusion. We further found that there was a lack of documentation regarding clinical reasoning for the type of psychological therapy offered; and that there was a lack of clarity about the expected/communicated timescales for ASD assessment. Therefore, we upheld C’s complaint. We noted the board’s explanation that service changes have been implemented and are ongoing since the events considered in this investigation, and that this work is being informed by the Scottish Government and the National Autism Implementation Team. It may be that some of the issues identified in this investigation have been addressed by improvements already made. If that is the case, evidence of those improvements can be provided in support of the recommendations being fulfilled.

C complained about the treatment that the board provided to their late spouse (A) during a lengthy hospital admission. A's agitation and delirium was treated with anti-psychotic medication and sedatives. A was later discharged to a care home. C was concerned about the amount and appropriateness of the anti-psychotic medication and sedatives administered to A. They also highlighted what they considered to be inaccuracies in the recording of the medication administered and felt A was unreasonably discharged. We took independent advice from a consultant in old age psychiatry. We found that the type and amount of medication administered was in keeping with prescription guidelines and accepted clinical practice. Medication was also reasonably prescribed and adjusted after appropriate consideration of A’s history and symptoms. Therefore, we did not uphold this part of C's complaint. In respect of record keeping, we found that there was no firm evidence to indicate staff unreasonably failed to record medication on the electronic recording system. We recognised that there may appear to be discrepancies between what was on the online system and what was documented in the written notes. However, factors such as non-contemporaneous recording and separate medical/nursing records can account for this. As such, we did not uphold this part of C's complaint. Finally, we found that A's discharge was based on an appropriate consideration of their overall health, including delirium. Therefore, it was reasonable to conclude that A’s ongoing health could be managed in a care home setting. We did not uphold this part of C's complaint. Related reading View Decision Report 202405542 as a PDF (24.6 KB) Updated: February 18, 2026

C, who has a progressive neurological disorder, complained that there was an unreasonable delay in the partnership providing adaptions to their home. We took independent advice from an occupational therapist (a healthcare professional who supports people to improve their ability to carry out everyday tasks). We found that this was a complex case in which C's occupational therapist was required to take account of a range of factors. It required multidisciplinary involvement, and it was important for support to be aligned with C’s readiness and preferences. Overall, we found that the timescales were reasonable. We did not uphold this part of C's complaint. C complained that there was an unreasonable delay in social work providing C with an appropriate support package. We took independent advice from a social worker. We acknowledged that there was a delay between C indicating that they required additional support and requesting an assessment for Self-Directed Support (SDS), and the request being progressed four months later. However, we found no evidence that this delay was due to any fault on the part of social work. With regard to the timescale for providing a reablement care package (help with daily activities), we found that the partnership respected the pace at which C was able to cope with the decisions required about their care and support. Therefore, we did not uphold this part of C's complaint. However, we found that there was a period during which social work could have been more proactive. C appears to have had to push in order to progress an assessment for SDS. We recognised the frustration this must have caused at a time when C was experiencing a significant deterioration in their health. While we did not uphold the complaint, we gave the partnership feedback on a number of matters including the tone of the complaint response, their communication with C, and possible areas for service improvement for service users with rapidly progressive conditions. Relat

C complained about the care and treatment provided to their late spouse (A) during their admission to hospital. A was admitted with symptoms suggestive of a stroke and significantly elevated blood pressure. Initial CT imaging and angiography (a type of x-ray used to check blood vessels) were inconclusive, and possible diagnoses included stroke, hypertensive encephalopathy (brain dysfunction caused by severely elevated blood pressure), or a post-ictal state (following a seizure). An MRI scan was planned but aborted for safety reasons. A’s condition later deteriorated, and a repeat CT scan showed stroke in the back of the brain. A died a day after admission. We took independent advice from a consultant stroke physician. We found that there were aspects of A’s care which were reasonable, including prompt assessment, appropriate imaging, decisions made regarding treatment of blood clots, and MRI scanning and safety. We found that it was also reasonable to consider and treat hypertensive encephalopathy. However, we found that record-keeping fell below the expected standard. In particular, there was a failure to keep contemporaneous records on the day that A was admitted as there was no repeat National Institutes of Health Stroke Scale score noted after the initial CT scan. There was also inconsistent recording of staff grades, which reduced clarity regarding levels of clinical oversight. This added to uncertainty about the diagnosis, but it did not affect A’s outcome. We upheld this part of C's complaint. C complained about the board's communication with A and their family during the admission. We found that that the board reasonably explained the working diagnosis, management plan and diagnostic uncertainty. Where miscommunication occurred, the board acknowledged this and apologised. Overall, we found that communication was reasonable and did not uphold this part of C's complaint.

C complained that the Scottish Prison Service (SPS) failed to follow the appropriate procedure after they removed C from association (temporarily separated from the normal prison population. A Governor can order a prisoner be segregated from others for up to 72 hours if they believe it is in the interests of good order in the prison or for the prisoner’s or others’ safety. In response to C’s complaints, the SPS said that C's removal from association had been authorised in line with relevant procedure. We found that the decision to remove C from association was carried out in line with the relevant procedure authorised by Prison Rules. However, the SPS did not properly record the actions taken. These omissions could make it appear that C was held out of association without proper authorisation. Accurate record-keeping is important, especially for decisions to remove a prisoner from association, because it ensures that any time spent under specific rules is clearly recorded and monitored. We upheld C's complaint.

C complained that the council did not properly consider their concerns about work being carried out on a neighbour’s summerhouse by someone that they believed was unqualified. C also said that the council inaccurately stated that no building warrant was required for the summerhouse. The council advised C of the actions that they had taken in response to C's reports and explained why they considered that the summerhouse did not require a building warrant. In relation to electrical and gas safety concerns, the council explained that the necessary gas and electrical certification would be requested as part of the completion process when a completion certificate was applied for. They also advised that any concerns about illegal gas works could be made to Gas Safe Register. We took independent advice from a planning and building standards adviser. We found that the information in the council's response was reasonable and adequately covered the council’s position. We also found that the council reasonably considered and investigated C's reports of works being undertaken by an unqualified individual. Therefore, we did not uphold C's complaints. Related reading View Decision Report 202404014 as a PDF (24.33 KB) Updated: February 18, 2026

C complained that the board failed to reasonably communicate with them about the care and treatment of their parent (A). C said that the board failed to inform them that a lump had been found on A’s breast while A was in hospital. A had been due to go into respite care in a care home but this was delayed. When staff found the lump on A’s breast, A told staff that they did not want it to be treated. This was communicated to A’s GP and respite care home but was not communicated to C. C subsequently learned of the breast lump when A was admitted to another hospital in another board area. We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). With regard to the breast lump, we found that an appropriate hand-over was made to the GP for follow-up in the circumstances. In a non-emergency situation, it was reasonable to take time to establish capacity and consent before informing family. Due to time constraints before A’s transfer, this was not fully explored, but the handover was deemed appropriate under the circumstances. Therefore, we did not uphold the complaint. However, we provided feedback to the board about the need for early assessments of decision-making capacity, re-assessment during admission, and improved engagement with family members where appropriate. We also provided complaints handling feedback. Related reading View Decision Report 202304648 as a PDF (24.51 KB) Updated: February 18, 2026

C complained on behalf of their sibling (A) in relation to the care and treatment that the board provided to A after presenting at an out of hours service with symptoms including epigastric pain, vomiting and shaking. A was sent home with treatment for dyspepsia (indigestion) but died shortly afterwards from acute haemorrhagic pancreatitis. C complained that the board did not adequately take into account A’s full presentation and relevant background information in considering a treatment plan. We took independent advice from an experienced emergency medicine adviser. Overall, we found that the care and treatment that A received was unreasonable because A’s physiological observations showed a significant degree of abnormality, and the board did not have appropriate systems in place to identify the deteriorating patient in the acute community setting. We upheld the complaint.

C complained about the standard of medical care and treatment provided to their late partner (A) by the board in relation to their risk and diagnosis of liver cirrhosis (permanent scarring of the liver which leads to dysfunction) and gastrointestinal haemorrhage. A was initially under the care of the board’s rheumatology service for psoriatic arthritis, which was treated with medication. The board’s gastroenterology service then began to care for A, and, after testing, found that A had liver cirrhosis with portal hypertension (elevated blood pressure in the portal vein). After several months, A’s condition began to deteriorate and they attended the medical ambulatory care unit and A&E within a few weeks. A was discharged home both times. A died two days after their contact with A&E. We took independent advice from four advisers who are consultants in rheumatology, gastroenterology, general medical and emergency medicine. We found that the standard of rheumatology, general medical and emergency medicine was reasonable. However, we found that the standard of gastroenterology was not reasonable in that A’s signs of deterioration were not taken seriously enough by the gastroenterology service including that the signs of abnormalities were not reasonably investigated, that A’s portal hypertension should have been identified following an endoscopy and that A should have been referred to a liver transplant unit. We found that the multidisciplinary team meetings unreasonably failed to pick up A’s clear deterioration and arrange appropriate investigations and treatment, and discussions were brief and decisions were deferred. We found that keeping A in the specialist nurse led clinic when they were diagnosed with liver cirrhosis and portal hypertension, and deemed suitable for a transplant, was unreasonable. Finally, we found that there were record keeping failings including clinic letters that failed to contain important information about A’s diagnosis and condition and we f

C complained about the care and treatment given to their late sibling (A) who had a history of schizoaffective disorder. After a change in the consultant responsible for A’s care, A’s diagnosis was changed and their medication withdrawn over an extended period which led to A becoming unwell. They required admittance to hospital on a number of occasions before their death by suicide. The board carried out a significant adverse event review (SAER) into what happened which identified a number of failures and made a number of recommendations as a result. Later the board issued their complaint response to C’s complaint which detailed the consultant’s position that A’s symptoms were not in keeping with a continuing psychotic illness, and that, this view was shared by the wider clinical team. We took independent advice from a consultant psychiatrist and a mental health nurse. We found that the decision to change A’s diagnosis was not supported by their presentation, that the various diagnoses were referred to with no explanation and that the consultant involved in A’s care held an incorrect belief that schizoaffective disorder and schizophrenia were, in essence, the same condition and were interchangeable. We also found that NICE guidelines were not always followed appropriately, that there was an over-reliance on remote methods of assessment, that changes were made to medication without having seen or assessed A and that clinicians unreasonably maintained that A did not present with psychotic symptoms when the evidence demonstrates otherwise. Finally, we found that the nursing care was reactive and treatment was crisis led and failed to provide support and strategies for early interventions, that there was a failure to create a community care plan and that there was a lack of multi-disciplinary working, and therefore, a lack of challenging decisions on patient care. As such, we found the care and treatment both in hospital and from the community nursing team to have been

C complained on behalf of their friend (A), a care home resident. A became unwell and was in a lot of pain. An Out of Hours GP suspected an internal bleed and arranged for an ambulance to be requested. A call was made to Scottish Ambulance Service (SAS) at 20:20, requesting a ‘one-hour response’ to hospital. The SAS call handler advised that the majority of responses were taking over four hours. An ambulance did not arrive until 02:21, by which time A’s condition had deteriorated and they were too ill to be moved. A was given medication and died in the care home. C complained about the delay in SAS providing an ambulance for A. In their response to the complaint, SAS explained that they operate a priority-based system of dispatch to ensure that emergency ambulances are available to respond to the most serious and life-threatening cases in the first instance. They operate a welfare call back process when timed admission calls are unable to be met within the requested timeframe. Regular welfare calls were made to A’s care home, during which SAS apologised for the delay, checked on A’s condition, and gave worsening advice to call 999 if A’s condition deteriorated. SAS considered that the final welfare call, which was reviewed by a SAS clinician, was appropriately upgraded to an emergency response. We took independent advice from a paramedic adviser. We acknowledged that some of the contributory factors which led to the delay in providing an ambulance for A were beyond SAS’s control. There were significant demands on their service and there were also delays in handovers at the receiving hospital. However, our investigation identified a missed opportunity to escalate the request for an ambulance following an earlier welfare call in which symptoms of faster breathing and agitation were reported, indicating a deterioration in A’s condition. Although it was not possible to say whether the outcome for A may have been different had an ambulance been provided sooner, this may

C broke their leg and underwent an operation. Following a scan the next day, C was told that the results were fine and that they could be discharged home. However, a few days later, C was contacted and told that a further review of the scan indicated that they would require further surgery, and this was performed by another surgeon a few days later. C complained to the board about several aspects of their treatment. The board apologised that C was told two different things about their scan results and explained that there was an anomaly in the image that wasn’t seen at first, but was noticed on further review. C remained dissatisfied and raised their complaints with the SPSO. We took independent advice from an adviser specialising in orthopaedic surgery. We found that a note of a discussion between clinicians in C’s medical record does not accord with another clinician’s later view, and that the board’s position that the discussion was wrongly recorded was the most likely explanation of what occurred. This meant that, from C’s perspective, the board had unreasonably reached different conclusions following the two reviews of the scan. Given these circumstances, the complaint was upheld.

C complained on behalf of their partner (A) about the care and treatment that A received from the board during their two admissions to hospital for suspected pulmonary embolus (when a blood clot blocks a blood vessel in the lungs). A had a stroke during their second admission. We took independent advice from a consultant in general medicine. For A’s first admission, we found that the triage nurse who took A’s bloods, clearly documented that a D-Dimer (a test to detect blood clots) had been done and the results were available on the board’s system before A was discharged but it was not noted or considered. We found that A’s D-Dimer result should have been considered and doing so could have led to an earlier diagnosis of A’s pulmonary embolus. We found this aspect of A’s care unreasonable and we upheld this aspect of the complaint. For A’s second admission, we found that the treatment of A’s blood clots with medication appeared to be in accordance with relevant guidance which was reasonable. We did not uphold this aspect of the complaint. We noted that the board advised C in their complaint response that they would take A’s case forward to their adverse events review group for further consideration and that 16 months later, there had been no indication that a significant adverse events review had taken place, which appeared unreasonable. In addition, we found that in their complaint response, the board should have provided C with an explanation of what happened when A was readmitted to hospital, and the nature of A’s stroke, as well as more detailed description of when the adverse events review group’s decision would be made and if this would be communicated to C.

C complained about the care that their adult child (A) received from the prison healthcare team and particularly a failure to formulate a treatment plan for ongoing symptoms of stomach pain, nausea, diarrhoea and weight loss. The board noted that numerous tests had been carried out to investigate the cause of A’s symptoms, which had come back negative. They initially mistakenly stated that tests were negative for Irritable Bowel Syndrome (IBS), then later clarified that there is no definitive test for IBS and it is diagnosed by a process of elimination. They said that A had no formal diagnosis of IBS, but received treatment and dietary advice for this possibility. They noted that tests for Inflammatory Bowel Disease (IBD) were negative. As A did not have a diagnosed long-term or chronic condition, the board said a treatment plan was not required and they concluded that A received appropriate care. We took independent advice from a general practitioner. We found that reasonable and thorough tests were done regarding A’s symptoms but a reasonable care plan was not put in place to address possible IBS. Staff appeared to lack a clear understanding of the difference between IBS and IBD. A had an inflammatory eye condition which is associated with IBD, and there was a failure to note this potential link and consider a referral for a colonoscopy (examination of part of the intestines with a camera on a flexible tube). If a colonoscopy was negative for IBD, this would point towards a diagnosis of IBS and a dietician referral and care plan would be appropriate to support dietary changes. We upheld this complaint.