SPSO Individual Decisions

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 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, a Patient Advice and Support Service (PASS) adviser, complained on behalf of their client (B) about the care and treatment provided to B's late spouse (A). A was under the care of two health boards for treatment of a concurrent bladder and colorectal cancer. C complained about the care and treatment received for their colorectal cancer. They also complained about the adequacy and conclusions reached by a Level 2 Adverse Event Review and a Level 1 Significant Adverse Event Review carried out by board A, as well as a lack of transparency under the Duty of Candour and the way that they had handled the complaint. While the bladder cancer was timeously treated, A died without having received treatment for the colorectal cancer. In responding to the complaint, the board outlined their management of A’s colorectal cancer through the regional multi disciplinary team process, having reviewed the care and treatment as a Level 2 adverse event review and a Level 1 significant adverse event review. We took independent advice from a colorectal surgeon. We found that there was a failure to provide a reasonable standard of care and treatment to A, particularly in relation to delays in initiating treatment for their colorectal cancer. We upheld this complaint. We found that the Adverse Event Review and the Significant Adverse Event Review (SAER) conducted by the board were inadequate, with inaccuracies in the timeline and unsupported conclusions. We upheld this complaint. We found that there was a failure by the board to meet their Duty of Candour obligations, and we upheld this complaint. We also found that the board’s handling of the complaint was unreasonable, and we upheld this complaint.

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.

C complained about the treatment provided to their partner (A) when they were admitted to hospital. A presented to the A&E after they woke up feeling generally unwell. A experienced weakness, lost vision, and pins and needles in their hands and feet. When assessed in the A&E, A gave a history of a three-day headache. There was a delay in A being assessed in the A&E. Given A’s symptoms, the consultant’s working diagnosis was an atypical migraine. They considered the possibility of a stroke but concluded this was less likely based on A's presentation. A was then transferred to the Acute Medical Unit before quickly being transferred to the care of the Stroke Team. A Computerised Tomography (CT) brain scan was carried out and confirmed a stroke. A further CT scan the next day confirmed that A had suffered a second stroke. C complained that there was an unreasonable failure by the A&E to diagnose that A had suffered a stroke. In addition to this, C complained that A was not provided appropriate treatment in the form of thrombolysis (medicine to get rid of blood clots in the brain) or thrombectomy (surgery to remove a blood clot or drain fluid from the brain). We took independent advice from an emergency medicine consultant. We found that an atypical migraine was a reasonable working diagnosis. We found that reasonable consideration was given to the possibility of a stroke and A’s history of diabetes was taken into account. We considered that there was sufficient reason to arrange a CT scan to assist diagnosis while A was admitted to the A&E. This was due to C’s symptoms and the diagnostic uncertainty. However, earlier imaging was unlikely to have made a material difference to the outcome. In addition to this, we noted that A had suffered a posterior circulation stroke, which is known to be challenging to identify. We concluded that there was not an unreasonable failure to diagnose A's stroke because of the atypical features of A’s presentation. In addition to this, A was

C complained that the Scottish Ambulance Service (SAS) unreasonably delayed in dispatching an ambulance for their late parent (A) and, as a result, this had an adverse impact on A’s care and treatment. C questioned why an SAS call handler initially advised them that an ambulance was not needed, when a locum GP subsequently arranged for one as soon as they learned of A’s condition. Shortly after arriving at A&E, A died following a cardiac arrest. We took independent advice from a paramedic adviser. We found that the actions of the SAS in relation to the allocation and dispatch of an ambulance for A were reasonable, based on the information, resources, and systems in place at the time. We also found that the project improvement initiatives the SAS are undertaking to mitigate the challenges with the triaging of abdominal pain are reasonable. Therefore, we did not uphold the complaint. We did, however, provide feedback to the SAS that when responding to a complaint, where possible, it would be helpful if they provided the complainant with information and explanation of any improvement initiatives that they are taking to address issues raised within the complaint. Related reading View Decision Report 202304529 as a PDF (24.4 KB) Updated: August 20, 2025

C complained that nursing staff had failed to properly supervise their parent (A) resulting in a fall and that there was a lack of documented information about A's plan of care in the medical records. A was admitted to hospital for hip surgery following a fall at their home. A few weeks later, A fell and hit their head. This led to A sustaining a subdural haematoma (SDH, a brain injury) and A died as a result. C complained that following A’s fall there was a failure to treat A as a priority, and raised concerns that A was transferred from a trauma ward to an orthopaedic ward. C believed that A should have been transferred to another hospital, outwith the board, for surgery. In response, the board said that A’s care pre-fall had been in line with the relevant supervisory assessment. They apologised for a delay in A receiving a medical review following the fall, however, they said that nursing staff had carried out appropriate neurological observations. The board added that A was not considered suitable for surgery by surgeons and that the case had been considered at a local management team review (LMTR). We took independent advice from a consultant specialising in the care of the elderly, and an experienced nurse. We found that the documentation in A’s nursing records did not evidence that the care and interventions A received to keep them safe from harm and to support their mobility were to the standard required to prevent A falling. Additionally, we found that there were failings in relation to A’s neurological observations with a lack of proper assessment, implementation and evaluation and gaps in recording. We considered that while these measures may not have ultimately prevented A’s fall, there was unreasonable care and as such we upheld C’s complaint. We found that A’s post-fall care fell well below a reasonable level and did not meet the standards described in the board’s head injury protocol and the relevant NICE guidance for the management of head injuries.

C complained about the lack of care and treatment that the board provided in relation to not being recalled for a colonoscopy. C had undergone regular colonoscopies to monitor disease progression. C was not recalled when the next colonoscopy was due. The COVID-19 pandemic led to suspension of services with a long backlog of patients. When C did subsequently undergo a colonoscopy, this led to a diagnosis of cancer. We took independent advice from a consultant gastroenterologist and hepatologist. We found that the board failed to identify C as someone at significant increased risk that needed the procedure to be re-booked as a priority. We found that it was unreasonable that C’s colonoscopy was an overdue procedure that was not clinically reviewed. Therefore, we upheld this complaint. We also found that it was unreasonable that the board had not carried out a significant adverse event review into the matter. C also complained that the board failed to provide a reasonable response to their complaint. We found that the board’s complaint handling of C’s complaint was unreasonable, as the failure to clinically review C’s overdue procedure and failure to identify C as someone at significant increased risk, were inadequately investigated as part of the complaints process. In light of that specific failing, we also upheld this complaint.

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’s spouse (A) who had prostate cancer was admitted to the Clinical assessment unit (CAU) of the hospital following a few days of deteriorating health. During their admission, A remained in the CAU for three days before leaving the building without staff being aware of this. A contacted C in confusion and told C that they had not received food or hydration, had not been washed and had not been able to sleep. C returned A to the hospital on the condition that A was moved to a ward, which they were. The next day C was told that A had suffered an unwitnessed fall and was to be discharged to attend an oncology appointment. A also had lesions on their groin which had developed and not been cared for during their admission. A died within two weeks of being discharged. C complained to the board. The board accepted that there were a number of areas for improvement in the care and treatment that A had received, apologised and advised of actions that they would take or had taken to address these matters. C was dissatisfied with the board’s responses and raised their complaints with SPSO. The board identified further areas where the care they had provided to A had not been reasonable and advised of further actions that they would take to address these. Given this, we upheld C’s complaint that the board did not provide reasonable care to A, with specific reference to care of lesions on A’s groin and the discharge of A. We took independent advice from a nursing adviser. We found that the board, in considering how best to reflect on A’s care and treatment, had focussed too narrowly on A’s fall, that they should have considered the experience of A and their family more broadly and that relevant guidance indicates a Significant Adverse Event Review should have been carried out. We also found that there was a delay in providing a response to C’s complaints and that C had not been updated regularly while the complaints were being considered. We also found that the actions proposed an

C complained about the board’s assessment of their parent (A) and the decision not to admit A to hospital for further assessment and treatment. C felt that the board inappropriately relied on information provided on behalf of A, rather than speaking with A directly, and that decisions were based on unreliable information. A tested positive for COVID-19 in their care home and the following day, care home staff contacted NHS24 about A’s condition and the call was passed to NHS Lanarkshire Out of Hours service. The call was triaged for a clinician to call back, and an out of hours GP contacted the care home shortly afterwards. During the call with the out of hours GP, the decision was taken not to admit A to hospital, but for care home staff to contact A’s GP the following day. A died later that day. In their response, the board explained that the out of hours GP spoke with A’s carers and concluded that an appropriate assessment was undertaken. We took independent advice from a specialist in general and geriatric medicine. We found that the assessment of A conducted over the telephone was reasonable. The record of the assessment was of the level and standard expected. We concluded that the assessment of A’s condition and the decision not to admit A to hospital at that time was reasonable. We therefore did not uphold the complaint. Related reading View Decision Report 202202757 as a PDF (24.4 KB) Updated: August 20, 2025

C complained about the care and treatment that they received from the board. C said that following gynaecological surgery, they were left with side effects including recurrent pain and the need for further treatment. C complained that the board failed to provide them with adequate care and treatment in relation to the operation. The board did not identify any failings in C’s care, but did apologise for communication failings relating to the operation. They said that C had experienced a rare complication, but that this had been recognised and treated appropriately. We took independent advice from a consultant gynaecologist. We found that C’s care and treatment during and after their operation was reasonable and noted that the complication that occurred was swiftly identified and managed. However, we also found that prior to their operation, C was not provided with adequate information about other possible treatment options, including a lack of discussion about the surgery. We also found that the surgical consent process was inadequate. The board accepted that discussions relating to informed consent and counselling to support patient decisions should be fully documented, and that this had not occurred in C’s case. The board also acknowledged the importance of discussing and documenting all potential post-operative complications with the patient, so that the patient has informed choice when agreeing to a management plan. We found that there were aspects of C’s care and treatment prior to their operation that fell below a reasonable standard. Therefore, we upheld C’s complaint.

C complained to the council that their teenage child (A)'s school had not taken reasonable action following the report of an assault on A and a report of bullying. A reported continued bullying behaviour early in the next term and measures were put in place, such as allowing A to leave classes early. Just over a week later A was involved in a pre-arranged fight with another pupil close to school grounds in school time. The council’s investigation did not uphold C’s complaints about the action taken following the report of the assault and bullying. C was dissatisfied and raised their complaints with SPSO. We found that the school did not follow their Anti-Bullying Policy following the assault on A. They did not advise C of their decision that the school could take no further action regarding the reports of bullying as there was no concrete evidence of this, and they were imprecise in how they described contact with other parents/carers to C. Therefore, we upheld C’s complaints.

C complained about the care and treatment that the board provided to A, who had long-term mental health conditions. A was subject to a Community Compulsory Treatment order (CTO, a legal order that allows a person who has been detained in hospital for treatment to be discharged and receive supervised mental health care in the community). C was A’s Named Person in respect of the CTO. A experienced a deterioration in their mental health over a short period of time, which concluded with them attending A&E and requesting hospital admission. A was not admitted to hospital and died later that night. The post-mortem believed that A may have completed suicide. The board carried out a Significant Adverse Event Review (SAER) and concluded that the outcome could not have been predicted. The SAER identified areas of good practice but also some learning points. These centred on missed opportunities to refer A to addiction services and paper notes from the Forensic Community Mental Health Team (FCMHT) not being accessible by other services. C complained to the SPSO as they felt that there were failings in the care and treatment provided to A that contributed to their death. In addition to this, C complained that the board did not communicate with them reasonably, given that they were A’s Named Person. We took independent advice from an adviser with a background in forensic psychiatric nursing. We found that the overall care and treatment provided to A in respect of their mental health was reasonable. We considered it clear that access to the FCMHT records across services would have been preferable. This would have assisted the clinical decision-making when A presented to A&E. However, we found that there are no standard guidelines or requirements for the sharing of records across NHS services in Scotland. Based on A's presentation and what was known to clinicians at the time, we found that the care and treatment provided by the board was reasonable. Therefore, we did not uphold th

C complained about the care and treatment of their late parent (A) following an admission to hospital with a hip fracture, and about the communication surrounding this. C raised concerns about A’s fitness for discharge, including a lack of rehabilitation in hospital and length of wait for community rehabilitation, as well as a lack of support with food and fluid intake, and a lack of adequate skin care. C also raised concerns about a lack of engagement with them as A’s next of kin and power of attorney. We took independent advice from a consultant orthopaedic surgeon and a registered nurse. We found that A’s discharge was medically reasonable, and that the level of input from therapists was reasonable. The board acknowledged shortcomings in communication with C around their discharge, and a failure to document the nursing handover with the care home. The board also apologised that the target timescale for community rehabilitation was not met. We found that there were unreasonable failings in the nursing documentation, person centred care, and pressure care that A received. A’s person centred care plan was not completed, and a documented instruction that A required full assistance with nutrition and hydration was not adhered to. We identified frequent gaps in skin inspections and repositioning, and inconsistent completion of a pressure ulcer risk assessment. The relevant foot care did not take place in light of A’s diabetes, and there was no referral to podiatry when pressure damage to A’s heel was discovered. We were concerned to note that A’s nutritional needs were not met, and that there was a failure to protect A from pressure damage. We upheld this complaint. We also identified inconsistencies in the board’s complaint responses and noted that important failings were overlooked. We made recommendations to the board to address these.

C complained about care and treatment provided to them by the board in relation to diagnosis and treatment of prostate cancer. C had concerns about medical treatment both prior to and after surgery, and about nursing care when they were in hospital following surgery. We took independent advice from a urologist and a nurse. We found that overall, medical care and treatment had been reasonable and did not uphold these aspects of C’s complaint. However, in relation to nursing care, we found that C’s needs and risks were not properly assessed, resulting in a lack of person-centred care planning and implementation. We upheld the complaint about nursing care.

C complained about the care and treatment given to their partner (A) while in hospital, which they believe led to A's death. In response to the complaint, the board acknowledged and apologised that communication with C had not been effective. However, A had been aware of the severity of their diagnosis and prognosis and was able to make their own decisions and all communication had been with them. We took independent advice from a consultant in acute and general medicine. We found that, while significant parts of A’s care and treatment had been reasonable, there was a delay in the diagnosis and initiation of cancer treatment. In terms of the Scottish referral guidelines for suspected cancer, patients referred via the urgent suspected cancer pathway should receive their first treatment within 62 days of receipt of the referral, which did not happen in this case. We also found that there were unacceptable delays in relation to acting upon the results of the PET scan and a delay in A’s subsequent diagnosis. In addition, we found that at the time of A’s death a morbidity and mortality meeting (M&M) had not taken place. However, the board confirmed that a new M&M process had been implemented so that all deaths were reviewed through this process. We upheld the complaint. During our investigation, we identified issues with the board’s handling of the complaint. We made a recommendation to the board to support improvement of their complaint handling.

C complained about the care and treatment of A, who had a background of complex medical conditions, including a history of diabetes, heart disease, chronic kidney disease and cardiorenal syndrome (a chronic disorder and imbalance of the heart and kidney function). A was admitted to hospital three times over the course of approximately eight weeks. A had surgery for a fractured hip. After surgery, A developed bilateral non-arteritic anterior ischaemic optic neuropathy (NAION, a rare condition that causes sight loss). C complained about the medical and nursing care that A received. We took independent advice from a consultant renal physician (a specialist in kidney conditions), a consultant ophthalmologist (a specialist in eye conditions) and a cardiac nurse (a nurse who specialises in heart conditions). We found that the board provided reasonable medical care to A over the course of their three admissions. Therefore, we did not uphold this part of the complaint. We found that on one occasion, A was unreasonably recorded as being able to attend the toilet independently overnight, when A had an accident. In all other aspects, the board provided reasonable nursing care to A. Therefore, on balance, we did not uphold this part of the complaint. Related reading View Decision Report 202310591 as a PDF (24.41 KB) Updated: July 23, 2025

C was Power of Attorney (POA) for the patient (A). C complained about the care and treatment that A received in hospital. A suffered two falls, resulting in five fractured ribs. A also acquired pressure sores, contracted pneumonia and died shortly after discharge. C that they were not timeously informed of the falls or A’s deteriorating health. C also complained about the board's handling of their complaint. The board advised that A was assessed by a doctor after both falls and pain medication was increased. Due to ongoing pain, x-rays and a CT scan were taken weeks later which showed the injury. The board advised that treatment would have been the same if they had known of the injury earlier. The board also noted that they had increased care rounding following the falls and provided a pressure relieving mattress. They acknowledged that on some occasions care rounding had been delayed due to clinical pressures. The board apologised that A had developed pressure sores and that they had not communicated effectively with C. They advised that staff had been reminded of falls guidance, pressure ulcer guidance and to contact POAs and next of kin. We took independent advice from a nurse. We found that the board had not regularly evaluated the risk of falls before A fell and did not appropriately review A after their falls. We found that they had not sufficiently managed the risk of pressure ulcers and did not appropriately manage the pressure ulcers once they had developed. We also considered that POA documentation was not correctly filled in on admission and that C had not been appropriately updated regarding important health matters or A’s falls. We found that the complaint response had taken too long, that C had not been regularly updated and that the complaint investigation could have been more thorough. We upheld all aspects of C's complaint.

C complained about the care and treatment that their sibling (A) received whilst in hospital following a fall. C also raised complaints about communication issues with the board. The board accepted that there had been poor communication with A’s family but did not indicate any concern regarding the care and treatment of A. C and their family were dissatisfied with the board’s responses and brought their complaints to the SPSO. We took independent advice from a nursing adviser. We found that A did not receive timely medical intervention due to documentation and assessment gaps, particularly in relation to A’s positioning, their need for increased oxygen support, falls prevention and support for hydration. We upheld this part of C's complaint. In relation to communication and complaints handling, we found that the board did not respond within reasonable timescales. We also found that it was unreasonable that the board did not apologise for the time taken to provide their response, that they did not take action to prevent any recurrence, that they included an inaccurate statement and that they did not respond to all of the complaints that they had clarified with C. We upheld these parts of C's complaint.

C is a council tenant and lives with their family. C complained that the property they were living in suffered from significant problems with damp and mould. C believed that the conditions in the property were adversely affecting the family’s health and damaging their possessions. It was acknowledged by the council that C had been raising concerns for some time. Although the council had carried out works and surveys on C’s property, damp problems remained. We found that the primary cause of damp had not been identified and the council accepted further works were required, and that the time taken to address the problem had been excessive. We found that the council could not evidence that they had considered the impact on C of their living conditions and it was not clear that the property was treated as a priority in line with the council’s revised damp and mould policy. We upheld C’s complaint that the issues with their property had not been dealt with reasonably.

C complained that the association did not respond reasonably to their reports of anti-social behaviour from a neighbour. We found that the association unreasonably concluded that a number C’s reports did not amount to anti social behaviour (ASB). We also found that the reports that the association did consider to include ASB were not dealt with in line with the guidance and policy documents that the association provided. This included failures to acknowledge reports, reasonably complete forms, undertake checks of previous incidents, undertake (or make proper records of) interviews and log reports within a reasonable time. We found that the association provided inaccurate information to C about their use of CCTV footage in the investigation of reports of ASB and did not reasonably respond to C’s complaints about the handling of the ASB reports. We upheld this part of C’s complaint. C complained that the association did not take reasonable action to address issues regarding an allocated parking bay for their property. When C accepted their tenancy they understood it included a dedicated disabled parking bay but this was being regularly used by others. The association told C that numbered parking bays are not included or detailed as part of individual tenancies but continued to explore options to indicate the bay was for C’s use. We found that the association took an unreasonable length of time to substantively respond to the parking bay issues C raised. We upheld this part of C’s complaint. C complained that the association did not take reasonable action to address issues with their heating and hot water systems. We found that the length of time C waited for repairs to the heating and hot water system was unacceptable. We also found that the association had unreasonably concluded C’s complaints had been resolved before the effectiveness of an intended repair had been confirmed. We upheld this part of C’s complaint.

C complained that the practice failed to handle their telephone call reasonably. C called the practice while being discharged from hospital to speak to a GP about an urgent review of their GP prescribed medication. In particular, regarding the safe discontinuation of pregabalin (an anti-epileptic drug that can also be used to treat nerve pain and anxiety) following surgery. We found that the call did not address C’s concern that C needed advice about how to safely discontinue GP prescribed medication. C was also not told that further fit notes could be accessed by requesting one through the practice website or that they needed to wait until they had received a discharge letter so that the pharmacy team and the GP had the correct information. C was not informed that they could call for a same day triage appointment on their discharge from hospital. Although C was offered a routine appointment which is consistent with the practice’s policy on GP access, C was not given the chance to say whether they wanted to accept this before the call was terminated by the practice. We found that no offer was made to send a message to a GP informing them of the problem, to be actioned by the GP as and when appropriate. No explanation was provided to C about why their request to speak to the Practice Manager was refused and no consideration was given to requesting someone else (such as the Team Leader) to call C back. Therefore, we upheld this part of C’s complaint. C also complained that the practice failed to handle their complaint reasonably. We found that the complaint response did not address all the issues that C raised. The response also made statements about what C was told that were not supported by the recording of the telephone call to the reception team. We upheld this part of C’s complaint.

C, an advocate, complained on behalf of A. A had been detained by the board under mental health legislation. C complained as to whether the board had taken steps to address the acknowledged deficiencies in discharge planning experienced by A, and whether A's personal belongings were securely stored in a way which allowed patients to access them. The board said that there was evidence of discharge planning, however they accepted that A’s need for district nursing care was omitted. The process had been reviewed, and the board were happy to provide a report to demonstrate progress had been made. The board said that patients’ rooms were lockable and while staff had the keys for rooms, patient access was not restricted, beyond the need for staff to open and close rooms for individuals. Restricted items were stored separately, and patients would be supported by staff in accessing these. We took independent advice from a mental health clinical adviser. We found that the board’s response demonstrated that they were taking reasonable steps to review the discharge process. However, we found that A’s discharge planning did not include the district nursing team. We upheld this aspect of the complaint but made no recommendations. We found that the board’s approach to the storage of possessions was reasonable. We did not uphold this aspect of the complaint. Related reading View Decision Report 202401449 as a PDF (24.45 KB) Updated: July 23, 2025

C gave birth involving a forceps delivery (where a medical instrument is used to assist birth) and suffered a fourth-degree perineal tear (significant injury to the area between the vaginal opening and anus). C had surgery to repair the perineal tear and again to have treatment for retained placenta (where some placenta remains in the womb after birth). C complained about the maternity care and treatment in hospital, the board’s communication with C in hospital and the board’s handling of C’s complaint. The board apologised for poor communication during the birth and said that they were carrying out actions to improve management of obstetric and anal sphincter injury and obtaining consent for instrumental birth. We took independent advice from a consultant obstetrician. We found that the maternity care and treatment provided to C during the time of the birth was reasonable. We did not uphold this aspect of the complaint. We found that the board’s communication with C when C was in hospital was unreasonable. Though the birth situation was urgent, it was not an emergency, and a fuller discussion should have taken place with C regarding the forceps delivery. We upheld this aspect of C’s complaint. We found the actions that the board said they were carrying out were reasonable in response to the failing in communication. We found the board’s complaints handling was unreasonable, because C’s initial complaint was not reasonably progressed, the scope of the complaint investigation was not agreed with C, the board’s response to the complaint was not reasonably clear, and there were regular and significant delays in the board’s communication with C regarding the complaint. We upheld this aspect of the complaint.