SPSO Individual Decisions

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 After a change in the consultant responsible for A’s care, A’s diagnosis was changed and their medication withdrawn over an extended period which led to A becoming unwell.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 that the disconnection date of their water supply was not accurately reflected in their billing. C owned a dog grooming studio that had ceased trading. C said that the original supply to this building was from their home. C had always paid correctly for any water usage. When the business closed, the building was being converted for domestic use. The water supply had been physically disconnected and the building was uninhabitable. C and Clear Business Water (CBW) were in dispute over fixed water charges for the premises. CBW’s position was that a property could not be disconnected until Scottish Water registered it as such. C believed that they had been clear at the outset that this was what they required but CBW had not responded reasonably to C's request, meaning that they had been subject to fixed charges over an extended period. We found that CBW did not make it clear to C that they had the option of de-registering their water connection or applying for permanent disconnection. Had this been done at the earliest opportunity, the responsibility would have lain with C to decide what action to take. We also found that CBW failed to challenge Scottish Water’s refusal to back date charges sufficiently, given that C as their customer was unable to raise a dispute directly with Scottish Water. We upheld C's complaint.

C complained that the board’s mental health services did not communicate information regarding C's adult child (A) reasonably. A, who had experienced various mental health issues, was taken to hospital after taking an unknown quantity of tablets. C and another family member were concerned about A's mental health. A did not wish to remain in the hospital and clinicians assessed that A had capacity to make this decision. A few days later, A agreed to go to the hospital for a mental health assessment. The board referred A to the community mental health team (CMHT) and did not admit them to hospital. A few weeks later, A took their own life. C complained about the board's actions in the lead up to A's death. The board’s complaint response indicated that they had no concerns about the actions taken in relation to A's care. A significant adverse event review (SAER) concluded that communication between agencies (including within the board) could have been improved and an action plan based on the SAER recommendations was developed. The board acknowledged that A had died while in their care and apologised for this. C remained dissatisfied and raised their complaints with SPSO. We took independent advice from a consultant psychiatrist. We found that, as the SAER concluded, there were failures in communication involving the mental health team, including failures to update risk assessments, failures to use the electronic case notes system and inconsistency in referral criteria across CMHTs. We concluded that the board did not take a partnership approach when communicating with Ass family and did not adequately take into account their concerns when assessing risk. Therefore, we upheld C's complaint. During our consideration of the complaint, we gave the board the opportunity to comment on the adviser's views on the SAER Action Plan. The board reviewed and rewrote the SAER Action Plan and the proposed actions now relate directly to the recommendations in the report. However, we a

C complained that the association did not respond reasonably to their requests for repairs. After an initial acknowledgement of C’s concerns there were periods over the following months where the association did not respond or follow up on the matters that C had raised. We found that in some cases the association exceeded their stated timescale for repairs and did not advise C of the delays or respond to their enquiries. We upheld this part of C's complaint. C also complained that a response from the association incorrectly stated that a contractor's report regarding leaks at C's property noted that "any leaks were likely caused by installations made by C". We found that there was no firm, supportable evidence of what the contractor reported to the association. The association acknowledged that this information was received during undocumented, informal discussions. We found that it was unreasonable to describe information given in undocumented, informal discussions with a contractor as being information that ‘the contractor’s report notes’. This form of words suggests a contemporary written report, either directly from the contractor or a record of a discussion verified as accurate by the contractor. We upheld this part of C's complaint.

C complained about the care and treatment provided to their adult child (A). A has hereditary haemorrhagic telangiectasia (HHT, a rare genetic disorder characterised by abnormal blood vessel formation, leading to frequent bleeding, with potentially severe complications). A attended A&E as they had previously been bleeding from the left eye. A was triaged within 30 minutes and seen by a senior nurse within 90 minutes. The senior nurse discussed A’s presentation with a senior doctor. A was advised that they could await clinical review by a doctor, with a likely wait of up to two hours. A decided to leave and see an optician the next day. A was subsequently referred to the ophthalmology department (eye specialists) for further review and then to the oculoplastic clinic (specialists in surgical procedures around the eye) to consider cauterisation of a lesion inside the left, lower lid. C complained that triage and initial review were unreasonable, as no-one examined A’s eyes or nose, staff had little understanding of the condition, on-call ophthalmology were not consulted and A felt pressured to leave. Overall, C was concerned that A could have lost their sight without timeous, specialist intervention. The board considered that A had been appropriately managed in A&E. They noted that the discharge letter advised A had no active bleeding and no visual disturbance. A was offered to wait for medical review but decided to make their own optician appointment. We took independent advice from a consultant in emergency medicine. We found that triage and staff understanding of A's condition was reasonable. We found that it was reasonable to give A the opportunity to await clinical review and not to have ophthalmology input prior to clinical review. No harm came to A and no adverse event review was required. We did not uphold C's complaint. Related reading View Decision Report 202410876 as a PDF (24.78 KB) Updated: December 17, 2025

C complained on behalf of their spouse (A). The first of C’s complaints was that the board had failed to reasonably and accurately record and report an alleged incident between A and a member of staff. They also complained about the board’s investigation, and future references in records to the incident. We identified a number of failings including that the incident referred to was not reliably recorded on the board’s incident reporting system, that the board did not properly investigate C’s concerns, and that medical record correction notices issued were inaccurate and inconsistent. We upheld the complaint. C also complained about the care and treatment that A had received. We took independent advice from a psychiatrist. We found that the care and treatment was of a reasonable standard. We did not uphold this aspect of C’s complaint. Finally, C complained about the board’s handling of their complaints. While acknowledging that the complaints were numerous and complicated, we were of the view that the board could have taken action at an earlier point to define the complaints. They also could have investigated to a higher standard and responded more promptly. We therefore upheld this aspect of C’s complaint.

C complained about the care and treatment provided to their parent (A). A suffered a heart attack and was treated with increased levels of digoxin (heart medication) in hospital. Over a two-week period A became increasingly paranoid and agitated and needed to be medicated. A was then transferred to a nursing home. A’s digoxin levels were found to be very high and this medication was reduced. C believed that A was suffering from digoxin toxicity. C felt that A’s digoxin levels were not properly monitored or controlled and that A's outcome might have been different with better monitoring. We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). We found that A’s digoxin was not appropriately monitored. However, it is difficult to assess whether A was suffering from digoxin toxicity. The board acknowledged this failing and provided information on the action taken by individual staff members as well as the board as an organisation to reflect on A’s experience and improve the delivery of care and treatment in the future. We upheld C's complaint and made recommendations to ensure these changes were taken forward.

C complained to us about the pressure damage care provided to their late parent (A). We took independent advice from an appropriately qualified adviser and made some enquiries to the partnership. In response, the partnership offered an appropriate apology to C and explained improvement work they were doing in relation to this matter. C was happy with this outcome and we closed the complaint as resolved. Related reading View Decision Report 202407128 as a PDF (23.96 KB) Updated: December 17, 2025

C complained that the association did not reasonably address reports of antisocial behaviour. C is the Chief Executive of a charity who owns a property in a block where other properties are owned by the association. The charity's tenant complained of antisocial behaviour from one of their neighbours and the charity reported this to the association. A few weeks later, C complained that these reports of antisocial behaviour had not been addressed. C did not receive a response until they followed it up some months later. The association explained that they considered their policies and procedures had been followed. C was dissatisfied and raised their complaints with SPSO. We found that the association did not progress the reports of antisocial behaviour in line with their antisocial behaviour procedure. They did not update C regarding the situation and did not advise C when the case was closed. We found that the association did not keep full and accurate records of telephone calls and verbal discussions regarding an investigation which contributed to the association making an inaccurate statement to the charity. The association also failed to update the relevant recording system in relation to a report of antisocial behaviour, failed to categorise the report or to consider whether the report was substantiated as the antisocial behaviour procedure required. We found that the association did not recognise some of their failures when investigating and responding to C’s complaint. Therefore, they missed the opportunity to take steps to ensure that there could be no recurrence of this at a time when this could have been effective for A and the other residents at the property. We upheld C's complaint.

C complained about the care and treatment that they received during an admission to hospital. C attended A&E and the Acute Medical Unit for symptoms that were later diagnosed as an acute ischaemic stroke. We took independent advice from a consultant physician. We found that some aspects of C’s care were reasonable, particularly the communication between the board and C and their partner.However, we found that C’s assessment in A&E was unreasonably delayed in relation to their triage category. In addition, no structured stroke assessment was carried out. We also found that there was a delay in senior medical review and a lack of specialist stroke input. Furthermore, a prescription for aspirin was not made timeously after a CT scan excluded bleeding. Therefore, we upheld C's complaint.

C complained about the care and treatment their late spouse (A) received for a bowel perforation. A died in hospital following a cardiac arrest. C complained that the conservative, non-surgical approach taken to A’s treatment led to a deterioration in their condition, leaving them unfit for surgery. C also complained about the standard of A’s medical records, which made it unclear whether clinical advice and treatments had been followed. Furthermore, C complained that the board’s complaint response contradicted information given at the time, particularly regarding the healing of the abdominal leak and plans for discharge. Instead, the board’s response stated that the treatment had failed, A’s condition was non-survivable, and the leak persisted. Given this, C questioned the board’s decision to attempt cardiopulmonary resuscitation and the lack of palliative care for A. We took independent advice from a consultant surgeon. We found that there were aspects of A’s care which were reasonably managed including timely administration of intravenous antibiotics and a CT scan on admission. However, we found that there was a lack of urgency and clarity following the CT scan, and an absence of documented clinical reasoning such as treatment purpose, an escalation plan, and consideration of palliative care. High dependency care was not provided early despite signs of deterioration. Communication with A and C was inadequate, with no documented discussions about the severity of A’s condition or care decisions. We also found failings in fluid resuscitation and monitoring, with delayed reviews of A’s response to treatment. We upheld C's complaint.

C complained that the practice unreasonably failed to take the appropriate action in response to C's elevated prostate-specific antigen (PSA, a protein in the blood) test result. C requested a PSA test due to having a family history of prostate cancer. C complained about the failure to refer them to urology (specialists in the male and female urinary tract, and the male reproductive organs) based on the test result. The practice had said it was appropriate to advise C to repeat the test in one month’s time. This did not happen and C was diagnosed with prostate cancer 13 months later. We took independent advice from a GP. We found that the practice failed to follow Scottish Referral Guidelines for Suspected Cancer. According to the guidelines, due to C’s age, their family history and the test result, the GP should have referred C to urology for further investigation. We upheld C’s complaint.

C complained on behalf of their sibling (A) about the cancer care and treatment that A received and the handling of C’s subsequent complaint about this. We took independent advice from a consultant urological surgeon (specialist in the male and female urinary tract, and the male reproductive organs) and a consultant oncologist (specialist in cancer). We found that there was a delay in arranging an MRI scan and a ureteroscopy (a procedure that uses a thin telescope with a camera on the end to look inside the ureters and kidneys) for A. We also found that it was unreasonable that A had to involve their GP to prompt urology treatment and that there was no evidence that A’s scan results were revealed or discussed with them. We found that the board’s investigation of the failings were inadequate. The board should have carried out a local significant adverse event review and there appeared to have been no process changes to prevent similar failings in future. The board also failed to keep C updated on the reason for the delay in issuing their complaint response. We upheld C's complaints. However, we considered that it is unlikely that earlier treatment would have changed A's prognosis.

C complained about the care and treatment of their late spouse (A). A had a history of multiple myeloma (a type of blood cancer). C raised concerns about the board’s response to A’s symptoms, including a delay in carrying out a CT scan (a type of medical imaging) and a potential misdiagnosis of pancreatic cancer. The board said that A received prompt and appropriate management. We took independent advice from a consultant haematologist (specialist in blood disorders). We found that the board’s use of CT scanning to explore A’s symptoms was reasonable, and the investigation of a mass near A’s pancreas was reasonable and consistent with National Institute for Health and Care Excellence (NICE) guidelines. Therefore, we did not uphold this aspect of the complaint. We also investigated the board’s communication regarding A. We found no significant failings in communications in this case, and we did not uphold this aspect of the complaint. Additionally, C complained about the handling of their complaint. We found that the board reasonably investigated A’s complaint. Therefore, we did not uphold this aspect of the complaint. Related reading View Decision Report 202401075 as a PDF (24.32 KB) Updated: December 17, 2025

C complained about the care and treatment provided to their parent (A). A was admitted to hospital with a suspected stroke, confusion and poor mobility. A CT scan was performed but the results were not reviewed until a few days later. The result was discussed with other specialists and a further scan was requested. A’s warfarin treatment (blood thinning) was reversed because A’s condition had deteriorated. C was concerned that A’s condition was not properly recognised as a stroke and that imaging of A’s head was not reviewed. Consequently A’s blood thinning medication was not stopped promptly. The board carried out a Significant Adverse Event Review (SAER) which identified delays in reviewing A’s scan, and a lack of clarity between medical staff over who was responsible for organising tests for A, as well as poor communication. C felt the SAER lacked rigour and failed to address all the issues in A’s care. We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). We found that the SAER lacked detail and did not contain sufficiently clear recommendations to ensure the failures in A’s care did not reoccur. It also did not adequately address the decision making around A’s scan or the level of awareness amongst clinicians of the scan being performed. During our investigation the board provided further evidence of the feedback provided to staff, and the actions taken in response to the incident involving A. We found that these were reasonable and proportionate. The board accepted that the SAER had not adequately explored all the issues in the case. Therefore, we upheld C's complaint but did not make any further recommendations. Related reading View Decision Report 202402634 as a PDF (24.68 KB) Updated: December 17, 2025

C complained that the board failed to reasonably investigate and/or diagnose the cause of their symptoms of significant weight loss, intense abdominal pain, vomiting, altered bowel habit and nausea. C also complained that they were discharged from the board’s gastroenterology service (specialists in the diagnosis and treatment of disorders of the stomach and intestines) despite these ongoing symptoms. C said that they were left with no option but to obtain private care and treatment in England where they were diagnosed as suffering from mesenteric ischaemia (restricted blood flow to the intestines). C underwent surgery to correct this privately. While this resulted in significant improvements in C’s health, C complained that this course of action should not have been necessary and that there were cost implications. In their complaints response, the board acknowledged and apologised for issues with delays in providing investigations, and failings with respect to communication. However, they considered the clinical decisions made in relation to the investigation and management of C’s case were appropriate. We took independent advice from a consultant gastroenterologist and a consultant radiologist (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that the board should have considered a diagnosis of mesenteric ischaemia as a strong possibility based on C’s presenting symptoms. Furthermore, when a CT scan was undertaken there was a failure to report the narrowing of the blood vessels supplying the gut. We found that the decision to discharge C from the gastroenterology service was unreasonable given their ongoing persistent symptoms and, of particular concern, their ongoing weight loss. Therefore, we upheld C’s complaints.

C complained about the dental care and treatment that they received. C underwent root canal treatment (RCT) on their lower right tooth. C said that this was not performed appropriately and that they should have been referred earlier to an endodontist (a dentist with special training to treat problems affecting the inside of the tooth). C was also concerned that the dentist had caused injury to the inferior alveolar nerve (a nerve that runs through the lower jaw, providing sensation to the lower teeth, gum, lip and chin), left a gap in their tooth and caused a dent to another tooth. We took independent advice from a dentist. We did not find conclusive evidence that the dentist caused injury to the inferior alveolar nerve or a dent to C's tooth. We noted that the dentist did refer C to the endodontist but we did not find conclusive evidence that this should have happened sooner. However, we concluded that the dentist did not follow current guidance on endodontic practice. There was no evidence of the use of special tests or periapical radiographs (an x-ray that shows the entire tooth, from the crown to the root tip and surrounding bone) taken before the RCT was performed. As such, it was not possible to determine the case complexity. The dentist also used incorrect solution to irrigate the tooth canal and used an old method for assessing the quality of the radiograph imaging taken. Therefore, we upheld C's complaint.

C complained that Social Security Scotland (SSS)'s handling of their transfer application was unreasonable. C received Disability Living Allowance (DLA) which was administered by the Department for Work and Pensions (DWP). C’s condition had deteriorated significantly since their assessment for DLA and made enquires about how to report this. C understood that they were to submit an application to SSS (who were assuming responsibility from DWP for administering disability benefits in Scotland) to transfer from DLA to Adult Disability Payment (ADP). It took more than six months for SSS to identify that C had followed the incorrect process, despite C attempting in the intervening period to check up on the progress of their application. When the correct process was explained to C, C requested a copy of the form they had submitted but they were told that this would require a Subject Access Request. This caused a further delay. Ten months after the form was originally submitted, SSS wrote to C with a transfer outcome letter. They stated that C’s ADP needed to be reviewed and enclosed a paper form for completion. This caused significant distress to C, who had submitted the same form ten months earlier. C complained about the SSS's handling of their transfer application. We found that SSS did not give sufficient consideration to C’s circumstances when maintaining their position that C followed the wrong process. We considered that SSS should have identified that C’s application had been submitted incorrectly at the time of receipt. SSS could then have signposted C appropriately to DWP. Therefore, we upheld C's complaint. We welcomed SSS’s decision to make an ex-gratia payment to C during our investigation, in recognition of a missed opportunity to identify the incorrectly submitted claim and calculating C’s award from that time. In response to our decision, SSS agreed to make a further backdated payment to the date the documentation was received by SSS.

C complained that the board failed to communicate appropriately with their partner (A) regarding charges for treatment. A is a non-UK resident and was charged for non-urgent treatment at hospital following an accident. C complained that A was not informed of the financial liabilities they would incur prior to their treatment, despite having confirmed that they were a non-UK resident and having repeatedly tried to ascertain this information. According to the relevant guidance, any liability to charging should be explained from the outset and patients should be asked to sign an undertaking that they agree to this, ideally before treatment commences. In their response to the complaint, the board said that the correct process had been followed, and that the variation to the standard processing of A’s case was due to the local address information that was initially recorded. The board confirmed that further training and advice would be provided for clinical teams to ensure that they are fully aware of the guidance and how to advise potentially liable patients appropriately. We found no evidence that the guidance was followed in A’s case. We considered it a failing on the board’s part that A’s overseas address was not recorded at their initial presentation, noting that their overseas status was documented in the records at that time. We also found that there was a missed opportunity to follow up on matters when A’s relative contacted the Private and Overseas Financial Team with an enquiry a few days after A’s initial presentation at the hospital. Therefore, we upheld C's complaint. We acknowledged that the board had taken significant steps to improve their service following C’s complaint. A's insurer had also settled the outstanding sum. Therefore, we made no financial recommendation.

C complained on behalf of their parent (A) who is a tenant of the housing association. C complained that the association did not undertake roughcast render works at A’s property within a reasonable timescale. A was concerned about the condition of the roughcast render at their property after some had fallen. An inspection carried out found that repairs were required. Over six months later, no work had been undertaken and more roughcast render fell from the property. A complained to the association about the length of time it had taken for the roughcast render works to be undertaken. The complaint was upheld and the association said they were in the process of procuring a contractor which they estimated would take four to six weeks. When this time had elapsed, C escalated A's complaint with the association to stage 2 of their complaints procedure. The association reiterated their previous apology and that they were in the process of appointing an alternative contractor. The association said that they hoped works could begin within a month and that dampness and mould would be treated once those works had been completed. They said that they would provide an update when the programme of works was ready to commence. C was unhappy with this response and raised their complaint with this office. We found no evidence of a proper assessment of the scale of the required works until approximately five months after the need for repairs was confirmed. We also found no evidence of the association taking action to appoint a contractor until more than six weeks after their stage 2 response to C. The association did not assess the urgency of the required works, nor did it consider how failing to undertake them had impacted, or could impact, A’s living conditions. There was also no evidence of structured or consistent action being taken to progress the matter. Therefore, we upheld C's complaint.

C complained that the board failed to provide them with reasonable care and treatment. C had a cancer diagnosis and was concerned about the length of time taken to arrange their surgery. We took independent advice from a consultant clinical oncologist (specialist in the diagnosis and treatment of cancer). We found that it was reasonable for C's treatment plan to change and the delays in arranging a date for surgery were unavoidable due to capacity issues. Therefore, we did not uphold this part of C's complaint. C also complained that the board's communication was unreasonable. We found that the board’s complaint response contained inaccurate information. In particular, it indicated that a provisional date for surgery was offered to C when this was not the case. Therefore, we upheld this part of C's complaint. However, we made no recommendations based on appropriate action already taken by the board. Related reading View Decision Report 202407399 as a PDF (24.26 KB) Updated: November 17, 2025

C complained that the Scottish Prison Service (SPS) failed to take reasonable steps to ensure that they had prompt access to medical attention. C stopped taking prescribed medication after experiencing side effects and submitted a request to be seen by a nurse. C was not seen by a nurse during the following two-week period despite their symptoms worsening. C was then informed that they would be seen by a nurse that day but this did not happen. C raised this with prison staff who advised a call had been placed to NHS 24 instead, given healthcare staff were no longer available. C was later informed the call had been ended due to the expected wait time. In response to C's complaint, the SPS said that the correct procedure had been followed by staff in attempting to call NHS 24. However, it was recognised alternative arrangements could have been made to facilitate the call. We found that it was unclear whether C’s request for medical attention was communicated properly by SPS to healthcare staff. Whilst a reasonable attempt was made to contact NHS 24, and the SPS acknowledged the call could have been facilitated despite the wait time, the SPS did not explain what action had been taken to remedy matters. While there appeared to have been a protocol in place for such situations, it was not clear that prison staff were aware of this. C also complained that the SPS failed to handle their complaint reasonably. We found that the SPS’ handling of the complaint was poor because not all of the issues raised by C were responded to and they did not communicate what remedial action was taken. The SPS also failed to provide accurate information in response to our initial enquiries. Therefore, we upheld C's complaint.

C complained about the nursing care provided to their late parent (A) during their admission to hospital. A arrived at the emergency department before being admitted to a ward. While in hospital, A lost weight and had difficulty eating. Due to delirium, A’s mobility was poor and they experienced a number of falls whilst in hospital. This resulted in a broken hip requiring surgery. In response to the complaint, the board agreed that there had been multiple failings in relation to the management of A’s diet and reduction in weight. When mobilising A, it was explained that staff did so in accordance with physiotherapy assessments and a number of measures were put in place to prevent A from falls. However, the board acknowledged that due to staffing levels, A did not receive the level of care that they should have. We took independent advice from a nursing adviser. We found that basic nursing care could not be evidenced in A’s case due to a lack of individualised care planning and delivery. We found that the care provided to A was inadequate and inconsistent and was not provided to the standard required. Therefore, we upheld C's complaint.

C complained that the partnership failed to handle their application for their child (A)'s placement at a residential facility reasonably. A has a genetic condition, mental health issues and significant learning disabilities. A had identified a residential placement for individuals with their condition. C applied for a place supported by A’s social worker and medical professionals. The decision on the placement was taken by the Strategic Resource Allocation Group (SCRAG). The SCRAG met to discuss and declined the placement on the basis that A could explore support closer to home, in keeping with the national ‘Coming Home’ agenda. C believed that there had been a second SCRAG meeting that also rejected the application but that no minute was available for it. C said that the SCRAG had not given due consideration to the medical and other supporting evidence. We took independent advice from a social worker. We found that the SCRAG had followed procedure and considered all the evidence submitted. The Ombudsman does not act as an appeal body for SCRAG decisions and so our investigation looked at whether procedures had been properly followed. We noted that the second meeting was not a SCRAG meeting but a meeting in response to the placement decision, which had asked social workers to explore support options for A further. We found that the SCRAG was conducted in line with its terms of reference and the decision was one it was entitled to make. Therefore, we did not uphold this part of C's complaint. However, it should have been made clearer to the family what the SCRAG process involved and that the decision from the first meeting was final. C also complained that the partnership failed to follow the Child Friendly Complaints Process reasonably. We found that A was capable of understanding and being involved in the complaint process. The partnership failed to comply with its legal duty to involve A in the complaints process and give them the opportunity to express their vie

C complained about the care and treatment that the board provided to their elderly parent (A). A was an active and independent adult who tripped in the community and was admitted to hospital. In hospital, A developed a grade 4 (most severe) sacral (lower back) pressure sore. The board treated A’s pressure sore using Negative Pressure Wound Therapy (NPWT). A deteriorated while in hospital and died approximately twenty weeks after they were admitted. C raised concerns about the medical and nursing care that the board provided to A. In particular, C was concerned about how the board handled A’s deterioration in hospital, that there were missed opportunities to discharge A from hospital and A’s end of life care. The board said that A’s mobility was limited due to pain after admission and that there were no missed opportunities to discharge A. The board apologised for delays in obtaining pressure-relieving equipment for A and that discussions with A regarding the commencement of NPWT were not fully recorded. The board shared an improvement plan regarding the care of pressure sores. We took independent advice from a consultant geriatrician (medicine of the elderly) and a registered nurse. We found that the medical care provided to A was reasonable. We did not uphold this point of C’s complaint. We found that A’s pressure sore was avoidable. We also found that the board failed to provide reasonable nursing care and treatment to A, failed to reasonably assess and treat A’s wounds, failed to reasonably use NPWT in A’s case and failed to complete a significant adverse event review and follow duty of candour procedures in response to A’s avoidable pressure sore. Therefore, we upheld this point of C’s complaint.