SPSO Individual Decisions

C complained to us that the housing association unreasonably failed to investigate and repair defects in relation to the doors, windows and the heating system in their home. We found that that the length of time C waited for replacement radiators, repairs to the windows and a replacement door was unacceptable. The housing association did not carry out the repairs within a reasonable period of them becoming aware that they were needed. We therefore upheld this aspect of C’s complaint. C also complained that the housing association failed to communicate reasonably with them regarding the repairs. We found several examples of C requesting a call back, of long intervals between receiving a response and of C having to chase a response, over the 14 month period we considered. Many of these occurred after the housing association’s initial response to their complaint and promise of improvements. We therefore also upheld this aspect of C’s complaint. We also identified some failures in the handling of C’s complaint.

C complained that they had received substandard care across a series of surgeries to their nose. They said that the board inaccurately stated that C was suffering from a recognised complication and that the board failed to provide C with sufficient information about the possible complications of surgery. The surgery had left C with a deformed nose, significant impairment to their breathing, constant pain and affected their ability to work. C was seen for a second opinion by another Health Board in Scotland and had received surgery in England from a surgeon with expertise in this area. C believed that their medical records had been deliberately falsified or altered to conceal mistakes in their care. The board had responded to a series of complaints from C, but their position was that C was suffering from recognised complications, which treatment had been unable to resolve. They did not accept C had been misled about their treatment, or that C’s records had been altered or falsified. We took advice from a consultant surgeon, with expertise in the type of surgery C underwent. We found that C's complications were ones associated with the type of surgery that they had undergone. Therefore,we did not uphold this aspect of the complaint. Parts of C's records were not well maintained, although there was no evidence of falsification or alteration. Consequently, it could not be demonstrated that C had given informed consent to some of the procedures, and board staff failed to have full and frank discussions with C about their surgeries and the condition of their nose. We upheld this aspect of the complaint around providing sufficient information on the complications of surgery. We found that C was suffering from a recognised complication of surgery, but that the consent process had fallen below a reasonable standard. There were errors in C's medical records, particularly around the first surgery C underwent, but overall, we found that C's care and treatment was reasonably doc

C complained about delays in Social Security Scotland switching their child (A)’s payment of Child Disability Payment (CDP) to their bank account after A moved in with them. Social Security Scotland continued paying Child Disability Payment to C’s ex-partner and did not process the change for over three months from the date that C notified them of the change. C complained that as a result, A did not receive payment of Child Disability Payment for over two months. We found that when C reported that A was living with them, Social Security Scotland told C that they were working to get a process in place for these changes and that they would progress C’s request and would contact C. However, they did not do so for over two months until C followed this up. We found that Social Security Scotland unreasonably delayed in changing responsibility for CDP. We upheld the complaint.

C complained about the service that they received from Social Security Scotland (SSS) in relation to a backdated disability payment. C accidentally gave the incorrect bank account number and the payment was paid into the incorrect bank account. While C contacted SSS to inform them that they had not received the payment, SSS did not action C’s concerns and despite C’s attempts to contact SSS, they did not receive a response. We found that SSS provided incorrect information to C about the backdated payment process and reassured C that the money would, ultimately be returned to them. We also found that they failed to check the full account number when C alerted SSS of the missing payment, that they failed to follow guidance, that they failed to return C’s calls and provided an unreasonable level of service and that they unreasonably delayed starting the payment trace (although an earlier trace would not have guaranteed that the payment be returned). We upheld this complaint.

C complained to the council about a number of aspects of the council’s handling of a planning application for development on a site opposite C’s home, including that the Report of Handling was not reasonable as it did not reference any assessment of how waste would be managed and stored on the site. The council told C that the specific materials that they had mentioned, manure and old bedding, their storage and management, had not been addressed in the Report as they were not part of the application. We took independent advice from a planning adviser. We found that the contents of the planning application meant that the council were entitled to take the view that their policy on waste management requirements for new development were not determinative in this instance and that not explicitly mentioning this in the Report did not make it unreasonable. We did not uphold the complaint. C also complained about various aspects of the council’s response to their complaints. In some cases, we found that the council provided responses which were not reasonable,including responses that were not clear and did not include reasonable explanations, responses that raised uncertainty about planning matters, a response that had been incorrect, not responding to clear concerns C had raised and not confirming whether they considered specific planning conditions had been met. We upheld the complaint that the council did not respond reasonably to C’s complaints.

C complained to us that the board failed to provide them with reasonable care and treatment during an appointment for a cataract procedure. We took independent advice on the complaint from a consultant ophthalmologist. We found that the scratch on the lens was not caused by the doctor but rather by the folding process of the lens in the lens introducer. However, it was unreasonable that a large scratch on the lens had not been identified after it had been inserted during the procedure. Had the issue been noticed at the time of the procedure, C would have been put into an informed position regarding the issue, of the symptoms that they would likely experience and the plan to remedy the issue. It could have been resolved much sooner, thereby lessening the pain and discomfort C endured over an extended period of time and the subsequent effect this had on their life. C also complained that the board failed to provide reasonable follow up care and treatment following the appointment. We found that early follow up and intervention by the board would have allowed for a relatively straightforward lens exchange. Better information and communication throughout this process would have allowed for smoother patient care. Therefore, we upheld both of C’s complaints.

C, a council tenant, complained that the council had failed to replace their kitchen, which was outdated and in a state of disrepair, and their windows, which were aluminium framed, did not have working vents, and as such were promoting the growth of mould. C gave up the tenancy due to concerns about the condition of the property, the potential health impact, and their frustrations with the delays. C complained that the council remedied both longstanding issues very shortly after, to allow the property to be re-let. C also complained that the council’s complaints response was inaccurate. The council had stated that C’s kitchen was due to be replaced, however, that there had been a backlog due in part to the pause in all but essential works during the pandemic. They said that when C moved out the kitchen was replaced by a team whose role was to prepare tenancies to be re-let, who had a different caseload and worked to different timescales. The council stated that C’s windows had been replaced as part of a broader programme of window and door replacements. They said that this had been communicated to C earlier in the year, and that the work had not been brought forward because the tenancy had been vacated. We found that a referral had been made for a new kitchen to be installed approximately a year prior to C moving out. It was also evident that the council had engaged with C regarding the condition of the windows, and that they had instructed a contractor to survey the windows and to make minor repairs. It was communicated to C on a number of occasions that the windows were due to be replaced and a survey had been carried out in preparation. It was also apparent that C’s property had been prioritised as part of the scheme. As the council had taken steps to investigate these issues and make the necessary referrals and preparations, acknowledging the impact of COVID-19 and the council’s discretion with respect to planning large scale works, overall, we did not consider

C complained on behalf of their client (B) about the care provided to B's late parent (A) during their admissions to hospital. A was admitted and discharged from the hospital. A was readmitted a few days later following a fall at their home. A suffered significant injury including spinal and sacral fractures. A remained in hospital for treatment but died a few weeks later. C's concerns related to the clinical and nursing care provided to A during their admissions, particularly in relation to the assessment of A’s cognitive function and capacity, their falls risk, and overall assessments carried out with respect to their condition and deterioration. In response to the complaint, the board acknowledged that protocols on completion of falls and bed rail risk assessments were not followed and that in the day prior to A’s death, guidance on the timeliness and extent of observations which should have been carried out were not followed, and that the care fell below the expected standard. The board confirmed that appropriate documentation with respect to the assessment of A’s capacity was completed during their admission. C was dissatisfied with the board’s response. We took independent advice from a consultant geriatrician and a registered nurse. With respect to A’s clinical care, we found that documentation used to assess A’s capacity was not completed to a reasonable standard and we upheld this complaint. We found that the clinical treatment of A during the two days immediately prior to their death was reasonable and we did not uphold this aspect of the complaint. We considered the nursing care provided to A during the two admissions. We found that the care regarding falls management was unreasonable as appropriate documentation and assessments were not completed correctly or in a timely manner. We also found that there was a lack of evidence of the monitoring of A’s condition which would have made clinical assessment of A’s condition and deterioration more difficult. We

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.

C owns a holiday let in a conservation area. The adjacent, terraced property was demolished but not rebuilt, leaving an unsightly gap. The site is now for sale, causing uncertainty and delays. They complained that this had been allowed to happen, citing financial loss. C advised that the council had failed to enforce the conditions of the Conservation Area Consent, as demolition had occurred without the required construction contracts being in place. They noted that there were no provisions to ensure effective communication, property protection, or insurance. They stated that the council’s departments lacked coordination, noting that Building Standards had been present during demolition but had not alerted Planning and the demolition had not been stopped. The council agreed that although the Planning Consent conditions had been met, the Conservation Conditions had not been met. They stated that the applicant was responsible for compliance with the conditions of the Conservation Area Consent. They acknowledged that they could have reminded the applicants and would provide training to planning officers. However, there was no statutory requirement to do so. They were now taking appropriate enforcement action as a breach had occurred. They advised they had fulfilled their statutory requirements in terms of communication and advertisement and that it was not within their remit to stipulate communication, protection or insurance between neighbours. They added that Building Standards do not have a remit to regulate compliance with planning conditions. We took independent advice from a planning consultant. We found that it was the applicant’s responsibility to comply with conservation conditions, as this was stated in bold on the Conservation Area Consent decision notice. We considered that it was not up to Building Standards to alert Planning to the demolition. Therefore, we did not uphold the complaint as we did not consider that maladministration had been demonstrated. R

C complained that the board failed to carry out their sibling (A)'s hip replacement surgery within a reasonable time. C said that A had made no progress with their surgery since their pre-assessment appointment. We took independent advice from a consultant orthopaedic surgeon (specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that A's surgery was Category 2 (urgent) which meant it should have been carried out within 90 days. Given A's significant mobility issues and difficulties with day-to-day living, it was unreasonable to leave their case for more than 90 days. We were concerned that A waited 15 months for their surgery and that the surgery only took place after intervention from this office. Although the board apologised for the delay in A's surgery, we found that the reasons given were unreasonable. The board had a contract with another health board to provide the type of surgery A required during the time period under consideration and as A met the criteria for acceptance, it was unreasonable that the board did not explore this avenue of care. We noted that the board could also have explored an out of area and exceptional referral for A to another health board and considered the use of non-NHS providers who specialised in filling gaps where there were staffing issues due to staff absences. We upheld C's complaint.

C complained about the care and treatment provided by the board in relation to excision of a right sided neck lesion. C had been undergoing monitoring for a neck swelling thought to be a benign tumour. After a number of years of monitoring, C reported that they were experiencing pain and asked to have the mass removed. C underwent surgery to have the mass removed. The lesion had grown on the vagus nerve (the main nerve of the parasympathetic nervous system, which controls some body functions including digestion) and encased it, so the vagus nerve was cut in order to remove the lesion. Following surgery, C experienced gastroparesis (paralysis of the stomach, resulting in food and liquid remaining in the stomach for a prolonged period) and vocal cord palsy (where the vocal cords are unable to move properly). We took independent advice from an Ear, Nose and Throat (ENT) consultant. We found that the care and treatment that C received was unreasonable because there was a failure to recognise the lesion involved the vagus nerve and a failure to adequately discuss risks and consequences with C prior to listing them for surgery. We considered that it should have been made clearer to C that the surgery was likely to lead to injury or loss of function of the nerve. We also found that the events should have triggered the Duty of Candour process and that there was a failure to acknowledge the failings had occurred. Therefore, we upheld C's complaint.

C complained about the standard of medical care and treatment provided by the practice and about the way that they handled C's complaint. C attended the practice with symptoms of rectal bleeding, a change in bowel habit and abdominal pain. The practice made a routine referral to hospital but did not carry out a rectal examination. C was later diagnosed with bowel cancer. C felt that there was an unreasonable delay in diagnosing and treating their cancer. We took independent advice from a GP. We found that C's referral to hospital should have been marked as urgent given their symptoms and a rectal examination undertaken. We also found that information about C’s family history was not recorded correctly. Therefore, we upheld this part of C's complaint. However, we noted that it was unlikely that these failings would have had any impact on the treatment options or outcome for C. C also complained that the practice failed to handle their complaint reasonably. We found that the practice failed to reflect on the failings in their response to C. We upheld this part of C's complaint.

C complained about the care and treatment provided to them by their dental practice. C complained about a tooth extraction and the potential failure to fully remove the root of the tooth. The dentist performed an x-ray and examined C’s mouth but did not identify any evidence of infection or retained tooth or bone. We took independent advice from a dentist. We found that there were insufficient records relating to the tooth extraction. Based on the limited evidence available, we concluded that the care and treatment was reasonable. However, the standard of record keeping fell below the required professional standards. This was likely an isolated incident as other records provided were completed to an appropriate standard. We upheld C's complaint based on the poor record keeping but did not make any recommendations as we were satisfied the dentist had appropriately reflected on their practice. Related reading View Decision Report 202303671 as a PDF (24.21 KB) Updated: September 17, 2025

C complained about the care and treatment the board provided to their late spouse (A). A had a history of heart failure and severe left ventricular systolic dysfunction (LVSD, a severely weakened function in heart pumping) as well as other chronic health conditions. C complained about the cardiac (heart) care and treatment that A received prior to their death from cardiac failure. We took independent advice from a consultant cardiologist. We found that clinical aspects of A’s care were reasonable; however, the board’s communication was unreasonable in relation to a prescription for A’s heart medication, an echocardiogram (an image of the heart) and a possible referral to a specialist heart failure service. We upheld this part of C’s complaint on the basis of unreasonable communication. C also complained about how the board handled their complaint.We found that the board’s handling of the complaint was reasonable. We did not uphold this part of C’s complaint.

C complained on behalf of a family member (A) about the care and treatment that A received during two presentations to hospital following a fall at their home. Prior to their fall, A was fit and well and independent for activities of daily living. During our investigation the board had accepted that there were failings and had taken action to address these. This included using this case as a case study to ensure any training and development requirements were implemented, delivering training sessions on significant adverse events review and carrying out a review of the duty of candour arrangements which would include training. We took independent advice from a consultant in emergency medicine and a trauma and orthopaedic consultant. We found serious failings in A’s care and treatment and that a number of red flags (specific symptoms or signs that indicate a potentially urgent or serious underlying condition requiring immediate medical attention) had been missed in this case. In particular, we found that there was a failure to take into account relevant national guidance and to perform imaging which meant that the fractures of the vertebrae in A’s thoracic spine were undiagnosed. There was also a failure to take account of the National Institute for Health and Care Excellence guidance which the board had accepted. We found that it had been unreasonable that A had been left to sit during their second visit to hospital for a prolonged period before being assessed given their symptoms. There were also missed opportunities to complete a more thorough neurological examination with a failure to appreciate the presence of a spinal injury and to realise the significance of the signs of limb weakness and incontinence. We also found that the board failed to immobilise A while awaiting the results of a CT scan and during their transfer between hospitals. In view of the failings identified, we upheld C's complaint. During our investigation, we identified issues with the board’s h

C, a support and advocacy worker, complained on behalf of their client (B) about the care and treatment provided to B's late family member (A) during their admission to hospital. In particular, in relation to pain management, standard of care and communication. In response to the complaint, the board apologised for the failings identified in nursing care and communication. As a result of the failings the board had taken action. This included reiterating the importance of following the National Early Warning Score (NEWS) policy, reminding nursing staff of their obligations to comply with their code of professional conduct in the workplace, and reflecting on A’s care for the purpose of improving person centred care. B was dissatisfied with the board’s response and brought their complaint to the SPSO. During our investigation, the board accepted that aspects of A’s care and treatment should/could have been better and explained that reflection had taken place, and learning had been taken forward for the purpose of improving the level and standard of person-centred care provided to other patients. In addition, relevant staff had been given the opportunity to reflect on their communication with A’s family. We took independent advice from a consultant general and colorectal surgeon (specialist in in conditions in the colon, rectum or anus). We found that there had been a number of failings in the care and treatment A received. In particular, we found that there had been a delay in carrying out a CT scan and in diagnosing that A had a bowel obstruction. We found that this may have impacted on their management, including giving consideration to conservative/non-surgical intervention. We also found that A’s pain management had been unreasonable and that an adverse event review should have been conducted, particularly around a diagnosis of bowel obstruction and its management. In view of the failings identified, we upheld C's complaint.

C complained that the practice failed to provide them with reasonable care and treatment. C attended the practice with symptoms of an ear infection. C said that they were not prescribed appropriate medication and were unreasonably diagnosed with an outer ear infection. C felt that a swab that was taken damaged their ear. We took independent advice from a GP. We found that while their communication could have been better, the practice provided reasonable care and treatment in line with the history and information available at the time, and the relevant guidance. The evidence does not suggest that the ear swab caused C’s hearing loss and the practice's rationale for performing the swab was in line with local guidance. We found that the treatment provided was reasonable. We did not uphold C's complaint. Related reading View Decision Report 202409557 as a PDF (24.16 KB) Updated: September 17, 2025

C complained about the nursing care provided to their late parent (A) whilst in hospital. They complained about a lack of adherence to infection control, poor staff attitude and breaches of uniform policy. C also complained that A had been issued a zimmer frame without appropriate assessment and guidance, and that staff inappropriately handled A when transferring them to a hospital trolley. C also raised concerns about the management of A’s medicines. A did not receive their prescribed medications and were able to self-administer after medicine was left in their possession. Through the board’s own investigation of the complaint, they identified appropriate improvements to areas including staff behaviour, infection control, breaches in uniform policy, and moving and handling. C was unhappy with this response and brought their complaint to this office. We took independent advice from a senior nurse adviser. We found that the nursing care provided to A had been unreasonable. The board were unable to evidence basic nursing care in A’s case due to poor documentation. We identified significant failures highlighting that appropriate assessments did not appear to have been carried out for A or documented during the admissions. Therefore, we upheld C's complaint.

C complained that the board unreasonably failed to provide appropriate care and treatment to their late parent (A). A attended A&E with an injured arm after a fall at home. A was treated and sent home but was admitted to hospital a few days later with low sodium and anaemia. A was discharged after a short stay but re-attended A&E a few days later. An abdominal x-ray showed dilated loops of bowel and blood tests taken showed acute kidney injury. A’s condition deteriorated and they died later that day. We took independent advice from a consultant in emergency medicine and a consultant geriatrician (specialist in medicine of the elderly). In relation to A's first admission, we found that the management of A’s sodium levels was reasonable. However, there was a lack of accurate charting of A’s bowel movements. We also found that medications to address A’s constipation were not provided at discharge. Therefore, we concluded that the care and treatment with respect to A’s constipation was unreasonable and upheld this part of C's complaint. C also complained that the board failed to provide A with appropriate care and treatment during their second attendance at A&E. We found that there was an unreasonable delay in A being seen by a doctor on arrival. Therefore, we upheld this part of C's complaint.

C complained about the treatment provided to their late parent (A) when they attended hospital with shortness of breath and abdominal distension (swelling). Following assessment, A was prescribed a blood-thinning medication and was discharged with a plan to return for a scan within 48 hours to look for blood clots in the lungs. A deteriorated within hours of returning home. They were taken to hospital by ambulance and admitted for treatment. Their condition deteriorated significantly. Investigations revealed worsening heart failure and they died within a few days. The board initially considered sepsis to be A's cause of death but a post mortem later established this as congestive heart failure. We took independent advice from a consultant cardiologist (specialists in diseases and abnormalities of the heart). We found that it was reasonable for A to have been prescribed blood thinners and referred for a CT scan when they first attended hospital. However, on the basis that A’s clinical observations were abnormal, in particular their blood gas results, we found that A should have been admitted as they required oxygen. Therefore, we upheld this part of C's complaint. C complained that the board failed to provide appropriate care and treatment in response to A's deterioration. We were critical of the board for gaps in A’s records, meaning we were unable to establish what nursing checks were carried out on the day A deteriorated. However, we found that medical staff acted appropriately in response to A’s deterioration. A’s deterioration was a result of heart failure, leading to multi-organ failure. A’s family felt that there was a lack of clarity regarding A’s condition and what they were being treated for. The board recognised that there had been communication failings, apologised and confirmed that learning had taken place. We found that the plans for investigation and treatment were appropriate. It was reasonable for clinicians to suspect sepsis when A’s condition dete

C complained about the lack of care and understanding for their parent (A) who died in hospital. C referred to incorrect information being passed to the family and the lack of notes and records of events which occurred during A's admission. C said that while the board replied with some apologies and acknowledgement that errors were made, they did not fully explain the actual events that happened in the lead up to A's death. Having sought initial advice, we agreed to investigate the care and treatment provided to A and the board's communication with the family. Related reading View Decision Report 202402836 as a PDF (24.04 KB) Updated: August 20, 2025

C complained about the care and treatment provided to their late parent (A) by a GP Practice. Following a road traffic accident, A was found to be in atrial fibrillation (a type of heart rhythm where the heartbeat is not steady). The hospital asked the GP to review A for anticoagulation (medication to prevent blood clots from forming or growing) once their injuries had resolved. Several weeks later A had an appointment at the practice and was referred for a 24-hour ECG (a medical test that records the heart’s activity over a 24-hour period). Before the results could be assessed by the practice, A suffered a stroke. C complained that the practice unreasonably delayed in initiating anticoagulant therapy. We took independent advice from a GP. Following our initial enquiries, the practice provided additional explanation regarding the complexity of the decision making as to whether to prescribe anticoagulation to A, and the reasoning behind their decision to wait for the results of the 24-hour ECG. Following this additional explanation, we considered that the practice’s position and treatment plan was reasonable. We therefore did not uphold the complaint. However, we noted that not everything the practice had said in their further explanation was documented in the medical records and we provided feedback to the practice on this point. Related reading View Decision Report 202408315 as a PDF (24.47 KB) Updated: August 20, 2025

C complained about the care and treatment provided to them in relation to their health in prison. C experienced difficulties in relation to their medical needs, including staff not attending when C requested, not receiving their medication, lack of communication and that the complaint response did not answer all of C’s concerns. We took independent advice from a qualified GP. We found that the board seemed to lack appreciation that without medication for stomach acid, C would be left very symptomatic and sore and that they failed to supply the alternative medication to C when it was due. Once the medication had been obtained, they failed to locate C within the prison to give them the medication and failed to follow protocol to store the medication for reissue. We found that the board failed to communicate the problem with their medication to C and failed to reach a solution about C’s missing medication. We also found that the board failed to attempt to reach a solution about the poor communication between them and the Scottish Prison Service (SPS). Therefore, we upheld this complaint. We acknowledged that the board had taken learning and improvement action in relation to a number of these failings. C also complained that the board unreasonably failed to respond to all of C’s concerns in their complaint response. We found that the board’s first complaint response was unreasonable, and while the second response was generally reasonable, the length of time it took for the board to issue this was unreasonable. On balance, we upheld this complaint. We also acknowledged that the board had taken some learning and improvement action in relation to these matters going forward.

C complained about the care and treatment provided to their late parent (A) by a GP Practice when A was a resident in a care home. Care home staff had reported that A was agitated and unsettled, possibly in pain and with poor sleep at night. The practice requested that care home staff take a set of observations (temperature, oxygen saturation, pulse, blood pressure) and obtain a urine sample. When observations were later taken by care home staff, the practice advised that they were all normal, thereby giving a NEWS Score (a tool used to quickly determine the degree of illness of a patient and identify acute deterioration) of 0. They said that no visit was indicated at that time and queries about medication for agitation would be discussed on the next GP round to the care home. C was of the view that the report of agitation and confusion should have led to GP review. We took independent advice from a GP. We found that the care and treatment provided to A was unreasonable, as A had delirium until proven otherwise and should have been seen and assessed for this. We also noted that the practice appear to have relied on a NEWS score to decide no visit was needed, but NEWS is not validated for use in primary care. We therefore upheld the complaint. During the course of our investigation the practice carried out a Significant Event Review. As a result, they had developed a protocol, to be used alongside physiological measurements, for assessing delirium in the care home setting and had shared and discussed this with the care home. We considered these actions to reasonably address the failings in this case, so aside from apologising to C, we made no further learning and improvement recommendations.