SPSO Individual Decisions

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 that there had been a lack of neurological (of the nervous system) support for their family member (A). A sustained a traumatic brain injury (TBI) that required emergency surgery, and was transferred to the board under the care of neurology. C said that staff dismissed their concerns about A’s worsening condition and that A was being managed for their epilepsy as opposed to someone with a TBI. They also complained that there had been an unreasonable delay in identifying the disconnected shunt (a thin tube implanted in the brain to direct excess cerebrospinal fluid (CSF) to another part of the body), despite A’s symptoms. The board said that the neurology team had been managing A’s epilepsy but in the absence of a consultant in neurological rehabilitation they had been seeking to provide general support and make appropriate referrals. It was acknowledged that there was a lack of NHS services for TBI rehabilitation generally throughout Scotland. The board also said that the disconnected shunt was not necessarily the cause of A’s symptoms. We took independent advice from consultant neurologist. We found that the management provided to A was appropriate with relevant referrals made. However, given the significant head injury suffered by A, we found that the consultant neurologist could have met with them at an earlier date. The information available indicates that the first meeting did not take place until some 14 months after A’s head injury. An earlier meeting would have assisted A in terms of general support and also in managing their expectations whilst providing confidence and reassurance that their condition was being managed in the best way possible. In relation to the time taken to identify the disconnected shunt, we considered that the evidence available indicated appropriate and timely steps were taken by clinical staff. We did not uphold C's complaints. However, we did provide feedback to the board in relation to the timing of the first meeting b

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 about the care and treatment provided to their late parent (A). A had a terminal illness and was discharged from hospital to be cared for at home. A few days later, the family requested a visit from a doctor. They spoke to a doctor on the phone but it was an Advanced Nurse Practitioner that visited them at home. C was also unhappy that A was not provided with emergency medication. We took independent advice on the complaint from a GP. We found that A should have had a named and experienced clinical lead coordinating and planning their care. We found that it would have been preferable that a GP had visited A following their discharge from hospital. However, it was not unreasonable that A was visited by an ANP. We found that A should have been provided with emergency medicine. We upheld C's complaint. We noted that the practice had recognised potential failings and had demonstrated that they had taken reasonable learning and improvement action. Therefore, we made no further recommendations. Related reading View Decision Report 202309340 as a PDF (24.29 KB) Updated: June 18, 2025

C complained that the council failed to reasonably respond to reports of damp and mould in their property. C also complained about the council’s handling of their complaint. The council said that they had commissioned an independent survey of the property. They also apologised for delaying with some repairs. We found that C was responsible for helping to manage the levels of humidity and the temperature in their home by maintaining ventilation and ensuring a reasonable temperature. However, it was clear that there were a number of repairs which the council were responsible for, some of which were delayed and which have generally occurred over an extended period of time. On review, it appeared that they had only been progressed or completed as a result of C’s persistence. Therefore, we upheld this part of C's complaint. In terms of complaint handling, we found that the council acknowledged and responded to C's complaint in a timely manner. However, we found that they failed to provide a full and informed response to a later complaint. On balance, we upheld this part of C's complaint.

C complained that the practice failed to adequately investigate and/or diagnose the cause of their persistent cough. C was subsequently hospitalised and diagnosed with pneumonia while on holiday. The practice did not uphold C’s complaint. They said that they had taken reasonable action in light of C’s presenting symptoms and that C’s cough had been reasonably treated. They said that C’s final examination was normal and not in keeping with a diagnosis of pneumonia and that, therefore, there was no missed diagnosis. C remained unhappy and asked us to investigate. We took independent advice from a GP. We found that there had been a failure to adequately investigate the cause of C’s cough. In light of C’s presenting symptoms, a persistent cough and infection, we found that an in person appointment and an urgent referral for a chest x-ray should have been considered after their initial telephone presentation. We also considered that C should have been referred for an urgent chest x-ray following a second presentation, in accordance with the Scottish Referral Guidelines for Suspected Cancer. Therefore, we upheld C’s complaint.

C complained about the care and treatment that they received from the board when under the care of orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) for foot surgery. We took independent advice from an orthopaedic adviser. We found that the bones of C’s toe had been reset in the wrong position and the fixation was unreasonable. We also found that C was unreasonably managed at their first post-operative review, noting that C’s x-rays were described as satisfactory which was not the case. The decision to watch and wait was also unreasonable, as by this point a good outcome from the surgery would not have been possible based on the x-rays. We considered that it was unreasonable for the board to discharge C from orthopaedics at the next review appointment when the problem remained unresolved. There were aspect of C’s care and treatment which we found were reasonable, particularly in relation to the three further surgeries C received. However, we recognised that that these had only been necessary due to the failure which had occurred during the original surgery. On balance, we upheld this part of C’s complaint. C also complained about the board’s handling of their complaint. We found that the board’s response contained factually inaccurate information, that there had been delays in complaint handling and that there had been a failure to update C during this time. We upheld this part of C's complaint.

C, an advocate, complained on behalf of their client (A) about the social care assessment carried out by the council, and the council’s handling of A’s complaints. A has several long-term health conditions and requested a social care assessment due to concerns about gaps in their care arrangements. The complaints raised regarding the assessment included the timescales taken for completion of the assessment, whether A’s needs were fully and reasonably assessed, whether legal standards and good practice were appropriately taken into account, and whether the conclusions of the assessment were reasonable. We took independent advice from a social work adviser. We determined that the social care assessment was unreasonable. This was because it was not carried out within a reasonable timescale, risks ratings appear to have been changed from ‘substantial’ to ‘moderate’ without explanation, and there was evidence on file to suggest that A’s financial means may have been a factor in assessing their needs and risks. Therefore, we upheld this part of C's complaint. We also found that the council’s handling of A’s complaint was unreasonable, as they failed to appropriately log and respond to complaints, failed to contact A to discuss the complaints, failed to read documentation provided by A prior to a complaint meeting, and failed to respond to C and A’s outstanding concerns. We upheld this part of C's complaint.

C complained about the medical care provided to their late parent (A) by the board when they were admitted to hospital. We took independent advice from a consultant in emergency medicine. We found that there should have been better communication between the medical, nursing, and other allied health professional staff in relation to bruising found on A. We found that medical staff failed to take note of the physiotherapy findings of bruising and to document the presence of any significant injury. We also found that medical staff should have prescribed a second antibiotic at the time of A’s admission, that an assessment using arterial blood gas analysis should have been carried out before A’s transfer to the critical care unit and that the mental health team failed to assess A’s delirium, or prompt medical staff to consider this. Finally, we noted that the cause(s) of A’s death should have been recorded in more detail on the death certificate. Therefore, we upheld this part of C's complaint. C also complained about the nursing care that the board provided to A. We took independent advice from a nurse. We found that nursing records, in particular, risk assessment and care planning documents, were not always completed to the required standard or frequency. We also found that A did not receive a reasonable standard of person centred care in relation to their fluid intake and nutritional support and there was poor and inadequate support provided to assist A with their personal hygiene. Nursing staff should also have identified earlier the bruising on A’s body and ensure A had timely access to their medications.Therefore, we upheld this part of C's complaint.

C complained that the board failed to consider their request for bariatric surgery reasonably. C also complained that the board failed to handle their complaint reasonably. C suffers from complex physical and mental health issues. They were referred for bariatric surgery by the clinicians treating their medical conditions. C attended a number of assessment appointments to determine their suitability for surgery. C was concerned by the assessment process and asked to see the report being submitted to the Multi-Disciplinary Team (MDT) meeting but this request was refused. C was not accepted for surgery. C received a copy of the assessment report through a subject access request. C was told by the board that they would accept a complaint from C if their complaint was made within 12 months. C complained a few months later. The board delayed in acknowledging and responding to the complaint but met with C to agree how the complaint would be handled. The following month, the board wrote to C stating that they would not investigate the complaint, because it had been submitted outwith the time limit for investigation. We took independent advice from a consultant psychologist. We found that C should have been allowed the opportunity to provide feedback on the assessment process before it was discussed at an MDT. C had been promised an appointment to do this, but the appointment was not made. However, we considered that the assessment itself had been reasonable. Therefore, we did not uphold this part of C's complaint. In relation to complaints handling, we found that C was not properly informed about the process that the board intended to follow and was repeatedly given the impression that the case would be investigated. The board did not demonstrate how it had determined C’s complaint was out of time. Therefore, we upheld this part of C's complaint.

C complained that their GP practice failed to provide them with reasonable care and treatment. C attended the practice with loss of appetite, vomiting, concentrated urine, poor fluid intake, a temperature of 38.7 degrees, and a high heart rate. C was prescribed antibiotics and given advice on what to do if their condition worsened. C’s condition deteriorated and they attended the practice again. C was referred for a chest x-ray and diagnosed with empyema (pockets of pus that have collected inside a body cavity). C’s condition was life-threatening and they remain impacted by it. In their response to the complaint, the practice arranged an independent review of C's treatment by a respiratory consultant. They noted that C had a significant tachycardia (heart rate exceeding 100 beats per minute at rest). The practice said that this could have been discussed with the Acute Medical Unit at the time. However, it was likely that they would have advised to treat C at home rather than to admit them. We took independent advice from a GP. We found that C’s presentation and clinical examination findings were suggestive of pneumonia at least, and indicated that they were at high risk of sepsis. We found that C should have been admitted to hospital rather than sent home with antibiotics. Therefore, we upheld C's complaint. During the course of our investigation the practice confirmed further reflection and learning. We were satisfied that in doing so they had appropriately addressed the failings in C’s care.

C complained about the care and treatment given to their late sibling (A) by the board. A, who had a history of addiction issues and Chronic Obstructive Pulmonary Disease (COPD, a group of lung conditions that cause breathing difficulties), was admitted to A&E after overdosing on non-prescription drugs. A was treated for the overdose and was discharged to C’s care. A died the following day. C complained that the board inappropriately discharged A and that the treating doctor had failed to communicate adequately with them. The board did not identify any failings in A’s care, but did apologise that A was discharged with a cannula in place. The board also apologised for communication failures with C. C remained unhappy and brought their complaint to us. We took independent advice from a consultant in emergency medicine. We found that A was monitored for approximately 12 hours before discharge. This is the minimum period recommended by Toxbase (the primary clinical toxicology database of the National Poisons Information Service). However, we found that A would have required observation over and above this minimum period. This was because of A’s history of acute seizures, intoxication with opiate drugs and their complex medical history. In the circumstances, we found that it would have been reasonable for A to have remained as an in-patient to enable a greater period of medical observation. Therefore, we considered that the decision to discharge A was unreasonable. We upheld C's complaint.

C had a bilateral total knee replacement surgery, which was carried out by another organisation. Approximately three weeks after their surgery, C was admitted to a hospital within Forth Valley NHS Board following a fall. Approximately three weeks after C’s discharge, C had surgery to repair a tendon in their right quadriceps (thigh muscle), which was carried out by another organisation. C complained about the care and treatment that they received in hospital during their admission and the care and treatment that they received from the outpatient physiotherapy service over the next six months. The board said that the presentation of C during their hospital admission was a common presentation following knee replacement surgery and very similar to the presentation for an injury to the quadriceps. The board said that the outpatient physiotherapy guidance was followed when treating C. We took independent advice from a consultant orthopaedic surgeon (specialist in the treatment of diseases and injuries of the musculoskeletal system) and a physiotherapist. We found that the board failed to consider a right-sided quadriceps tendon injury when C was seen by a consultant in hospital, failed to reassess C during their admission and failed to escalate C when C did not progress when in hospital. On this basis, we upheld this part of C’s complaint. In relation to the physiotherapy service, we found that the exercises C received were in line with post-operative guidance and that physiotherapists followed protocols for treating C. We did not uphold this part of C’s complaint.

C complained on behalf of their partner (A) about the care and treatment provided to A by the board when they presented to the obstetric triage department 25 weeks’ gestation with pain and abdominal tightening. A was assessed as having Braxton Hicks (when the womb contracts and relaxes during pregnancy, also known as ‘false labour’) given advice on what to do if their condition worsened, and discharged. Four weeks’ later A suffered preterm prelabour rupture of the membranes (PPROM) and their child was delivered prematurely. C complained about the care and treatment provided to A as they considered the assessment at 25 weeks’ gestation was a missed opportunity for further investigation or follow-up. The board’s complaint investigation identified that according to local guidelines, A should have been reviewed by a more senior doctor. However, they were of the view that it was unlikely that this would have led to a different outcome. We took independent advice from a medical adviser. We found that while there were some areas for potential improvement, overall the care and treatment provided to A was reasonable. We therefore did not uphold C's complaint, though we did provide feedback to the board according to the adviser’s comments. Related reading View Decision Report 202400979 as a PDF (24.45 KB) Updated: June 18, 2025

C complained that the council unreasonably failed to follow relevant processes and procedures in managing and responding to bullying behaviour experienced by C's child (A). C also complained about the way the council handled their complaint. In response to C's complaint, the council confirmed that the school had taken appropriate action in responding to incidents and had investigated C's complaint reasonably. C was dissatisfied with the council’s responses and brought their complaint to this office. We found that the school had not consistently recorded incidents reported in pastoral and other recording systems. Therefore, it was not possible to determine with any certainty what actions the school took in response to concerns and the impact those actions were having both on A and any perpetrators of bullying behaviour. We also found that the council failed to reasonably investigate aspects of C’s complaint. Therefore, we upheld C's complaints.

C complained about the care and treatment provided to their parent (A) in relation to a number of hospital admissions. C complained that A was discharged without clear advice as to whether they had sepsis, and how to manage A’s condition. C also said that the board did not provide a discharge letter. C complained that when A attended hospital four days later, they should have been admitted rather than being sent home with oral antibiotics. Lastly, C said that when A was readmitted to hospital the following month, a day passed before they were seen by a consultant. We took independent advice from a consultant urological surgeon (specialist in the male and female urinary tract, and the male reproductive organs). We found that, while A received appropriate care during their initial admission, the board's communication around A's sepsis was unreasonable. They also did not provide an interim discharge summary. In relation to A's second discharge, we found that A's symptoms raised the possibility of a complicated kidney infection. Therefore, we considered that discharging A with oral antibiotics was unreasonable. A should have received treatment with IV antibiotics and consideration should have been given to admission, which may potentially have prevented the need for A to be admitted the following month. We upheld these parts of C's complaint. Finally, we found that A's condition when they were readmitted did not meet the criteria for an urgent consultant review. Therefore, we did not uphold this part of C's complaint.

C complained that Everflow failed to bill them accurately for their water consumption and failed to communicate reasonably with them about their account. C believed that Everflow had breached their contract with C. Everflow did not accept this, noting that the bill increase was primarily due to increases in wholesale costs.They also said that C’s water usage fluctuated across the year resulting in uneven charges. We found that there was evidence meter readings were being recorded on C’s account in line with Everflow’s obligations as a Licensed Provider. However, the rateable value for C’s property appeared to be inaccurate. This should have been resolved or explained during the complaints process. Therefore, we upheld this part of C's complaint. In relation to Everflow's communication with C, we found that C was sent letters about Everflow’s debt collection process. These letters were unclear and inaccurately reflected the legal process in Scotland. They also did not reflect the fact that C was making payments on their account and emailing Everflow about it. Therefore, we upheld this part of C's complaint.

C complained about the obstetrics (specialists in pregnancy and childbirth) care and treatment that they received from the board during and after the delivery of their baby by planned caesarean section. C said that there was a delay in diagnosing retained products of conception (tissue that remains in the uterus after a pregnancy) which led to infection. C also said that they were kept nil by mouth (not allowed to consume food or drink by mouth) for over 30 hours as their surgery for evacuation of the retained products kept being delayed. We took independent advice from a consultant obstetrician and gynaecologist. We found that some aspects of C’s care and treatment were reasonable. However, a doctor should have attended when C passed a large clot. There was also a misunderstanding between C and a doctor regarding how long they would be kept nil by mouth for before their evacuation procedure. We also found that the board failed to address C’s concerns about the conduct of a sonographer (specialist in the use of ultrasonic imaging devices) in their response to the complaint. Therefore, we upheld C's complaint

C complained about the nursing and medical care and treatment provided to their parent (A) when A was in hospital following a hip fracture. A had surgery for the fracture but was diagnosed with a number of illnesses while in hospital and died. We took independent advice from a nursing adviser and consultant geriatrician (specialist in medicine of the elderly). In relation to nursing care, we found failings with A's nutrition, pressure care, person centred care planning, and documentation. We upheld this part of C's complaint. In relation to medical care and treatment, we generally found this to have been reasonable and did not uphold this part of C’s complaint. However, we provided feedback to the board regarding starting oral nutrition supplements in line with Scottish Hip Fracture Guidance. Finally, we found that there were delays in the handling of C's complaint and the board failed to fully address of all C's concerns. The board had acknowledged these failings and taken action to address them. Therefore, we upheld this part of C's complaint but made no further recommendations in this regard.

C complained that the council unreasonably failed to carry out and progress police checks for two individuals who have contact with their grandchild. After notifying the council of our investigation, they agreed to provide C with a fuller apology and assurance that this would not happen again. C was happy with this outcome. Therefore, we closed the complaint as resolved. Related reading View Decision Report 202311539 as a PDF (23.94 KB) Updated: June 18, 2025

C complained that the council failed to deal with concerns that they raised about alleged anti-social behaviour (ASB) involving a neighbour. During our investigation, we considered whether or not the council had followed their anti-social behaviour policy (ASB policy) in relation to their handling of C’s concerns. We found that the ASB service had appropriately responded to C’s first two calls. However, we found that C raised further concerns with the housing team via email, and no evidence was provided by the council to indicate that this information was appropriately passed on to the ASB service for their consideration. The council also failed to provide this office with evidence that they had contacted Police Scotland in relation to the incidents reported by C. We also found that the council failed to keep C informed and up-to-date. Therefore, we upheld this part of C’s complaint. C also complained that the council failed to handle their complaint reasonably. The council accepted that there were failings in relation to timescales and acknowledgement of C's complaint. We found further failings relating to timescales, communication and record-keeping. Therefore, we upheld this part of C’s complaint.

C complained on behalf of their client (B) about the care and treatment given to B's late parent (A). A was admitted to hospital and discharged a few days later. A was readmitted the next day and died the following week. B had concerns around A's diagnosis and said that they should have been consulted given that they held Welfare Power of Attorney (Welfare POA). C also complained that the board's communication with B was unreasonable. The board said that A was treated for infection with broad spectrum antibiotics. A was discharged after their first admission as it was deemed appropriate and clinically safe to do. The board said that during A’s second admission a lumbar puncture procedure was indicated. They acknowledged that an Adults with Incapacity (AWI) certificate was in place and that during that time, Welfare POA rights were in effect. However, the board said that when the AWI certificate was revoked, the Welfare POA did not maintain the ability to make decisions on the patient’s behalf. In relation to communication, the board apologised that B found the manner of staff to be abrupt and explained that the situation was urgent. We took independent advice from a consultant physician in medicine for the elderly. We found that A received appropriate care and treatment. Appropriate investigations were carried out and various diagnoses were considered during A’s treatment. However, the board did not seek appropriate informed consent from B for a medical procedure when the AWI certificate was in place which was unreasonable. We found that the content of the communication recorded in the medical notes was reasonable. However, the tone of communication lacked sensitivity and respect of B and their role as the Welfare POA. Therefore, we upheld C's complaints.

C, an advocacy worker, complained on behalf of their client (A) who is the kinship carer of their grandchild (B). B came to live with A from England. C complained that the council failed to assess A in relation to the kinship care arrangement in place for B and failed to respond to A's complaint about entitlement to kinship care allowance. C was seeking backdated kinship care allowance for A. The council stated that it was the responsibility of the authority in England as they were the ones who placed B in A's care. After obtaining initial social work advice, we opened the complaint at investigation. In response to the complaint notice letter, the council agreed to apologise to A, make a backdated kinship care payment of £17,559.26 and make future monthly payments. They also agreed to update their kinship care allowance policy/procedure. C was satisfied with this response and we closed the complaint as resolved. Related reading View Decision Report 202405671 as a PDF (24.2 KB) Updated: June 18, 2025

C complained about the council’s decsion to build a prison facility next to their and others’ property. C’s complaint covers the council’s planning and environmental health services. Regarding the planning process, C considered the council had failed to safeguard neighbouring residents when granting planning permission. C said the council did not consider the proximity of the houses to the prison and the soil type present on the site. They also felt that a Noise Impact Assessment should be carried out. C said this resulted in damage to property, issues with noise and vibration, and the loss of house value. We took independent advice from a planning adviser. We concluded that the council had carried out their planning obligations, in line with relevant legislation, guidance and policies. We recognised that C disagreed with the council’s position but concluded that the council handled the planning applications reasonably. Therefore, we did not uphold this part of C’s complaint. In respect of the environmental health service, C said that the council failed to safeguard them during the construction of the new facility. They explained that they experienced noise and vibration issues. C said these vibrations caused visible damage to their property. We found that the council’s environmental health service acted reasonably in response to concerns raised by C. It was for the council to decide whether the threshold was met for noise and vibration from the construction site to be considered a statutory nuisance. We were satisfied that the council had provided reasonable explanations for why this threshold was not met. Therefore, we did not uphold this part of C’s complaint. Related reading View Decision Report 202202657 as a PDF (24.55 KB) Updated: May 21, 2025

C complained that the council unreasonably failed to assess their housing application in accordance with their policies and procedures. C and their partner had two children and shared their bedroom with the youngest child. C submitted a request for rehousing. The council awarded C a priority band 2 (with 1 being the highest and 4 the lowest). C then submitted medical information regarding their mental health to support their application for rehousing. However, the council advised C that they did not meet the criteria for a band 1 priority and that their current award of band 2 was correct and in line with the allocation policy. C submitted an appeal, along with a further supporting letter from their mental health nurse. The council responded stating C’s current band 2 status was deemed appropriate and in line with the established policy guidelines. We found that the council’s position was not in line with the allocation policy. We were concerned by the council’s statement that band 2 was correct, that there would be no band 1 award on the basis of mental health and that they had been applying this reasoning consistently. Their policy states that Band 1 is awarded to those applicants whose home is causing significant problems due to a physical, medical, or mental health problem or disability. We also found that C did not receive timely responses from the council. Their responses were delayed and C had to chase several times for a response. Therefore, we upheld C’s complaint.