SPSO Individual Decisions

C complained about being de-registered from their dental practice. C also complained that the practice failed to handle their complaint reasonably. Due to a broken tooth, C phoned for an emergency appointment and was told they could attend the same day. However when C arrived, they were given a temporary substance to place over the tooth until an appointment the next day. When C later phoned the practice to explain their situation had worsened, they were told to wait until the following day. C emailed the practice to complain about the service they had received but returned the following day to have the tooth treated. A year later, C requested an emergency appointment but was told that they had been de-registered and would not be seen. We found that there was only very limited evidence to show that the de-registration letter was ever sent and that there was a delay in doing so. We found that the lack of record keeping in this case has made it difficult to assess the practice’s complaint handling. This in itself is unreasonable, given the concerns C raised. Overall, we upheld both complaints.

C complained about the medical and nursing care they received for a spinal condition. C said the care led to avoidable complications and delayed their transfer to a specialist spinal unit. We took independent advice from a consultant in orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) and a registered nurse. We found a number of failings in the nursing care C received. This included poor record keeping and a failure to manage C’s skin care appropriately. This led to avoidable pressure injuries which were a significant factor in delaying C’s transfer. In terms of medical care, we found that the ward C was placed on lacked the necessary equipment to manage a patient in their condition. We found the medical and nursing care C received fell below a reasonable standard and upheld these parts of C’s complaint. C also complained that the board failed to provide them with a reasonable standard of physiotherapy. We found that C’s physiotherapy care was of a reasonable standard and was well documented, showing regular review up to the point physiotherapy was stopped on medical advice. Therefore, we did not uphold this part of C’s complaint.

C complained about the decision to stop the anticoagulant (blood thinning) medication given to their late parent (A) and a lack of communication with the family around this decision. The practice instructed to stop the medication due to an unexplained bleed. Following this stoppage, A died from a stroke. A’s family contacted the practice to discuss their concerns about the medication but they were unable to speak to a clinician in a timely manner. We took independent advice from a GP adviser. We found that there were clear indications for A to be on anticoagulant medication and that it was unreasonable that the medication was stopped without a replacement in place. The decision to stop the medication was not fully informed. We noted that the practice did not undertake timely blood tests or communicate with A’s family and the relevant specialists. We also found failings around the administration of blood tests. The practice carried out a Significant Adverse Event Review (SAER), which we found was not in line with relevant national guidance. We upheld C’s complaint

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.

C complained about the standard of medical care and treatment provided by the board to their late sibling (A) during a long admission to hospital. A’s medical history was complex as they suffered from a number of life threatening conditions during their hospital admission and they were under the care of a number of specialities. It was not until after A died, when the post mortem was performed, that A’s cancer was identified. C said that the various clinicians should have identified A’s cancer, and that communication was not reasonable. C also said clinicians did not manage A’s pain well which was unreasonable and very distressing for the family. We took independent advice from specialists in urology (urinary system and male reproductive organs), cardiology (heart), radiology (imaging) and end of life care. We found that treatment decisions were reasonable, and that the board managed A’s pain in a reasonable way. We also found that it was reasonable for clinicians not to have diagnosed A with cancer. Therefore, we did not uphold C’s complaints. However, there were aspects of communication that the board should consider improving and we provided this as feedback. Related reading View Decision Report 202306662 as a PDF (24.41 KB) Updated: May 21, 2025

C complained about the care and treatment their parent (A) received during a hospital admission. C complained about the way episodes of agitation and aggression were managed by the board including in respect of administration of medicines; bruising to A during episodes of restraint and lack of dignity; a failure to manage their nutritional needs; and poor communication with A’s family. The board’s response to C’s complaint advised that medication had been used to settle A when other measures had been unsuccessful. The board said that A’s weight loss had been recognised and a referral had been made to the dietician, however, they had been discharged from hospital before a review could take place. It was recognised that documentation including fluid and food intake charts were incomplete and steps would be taken to ensure improved compliance. The board considered there had been good communication with A’s family, however, they apologised for the lack of empathy reported by C, which staff would be asked to reflect on for future learning. We took independent advice from a senior nurse adviser and a consultant geriatrician (specialist in medicine of the elderly). We found that there were aspects of A’s care which were reasonably managed particularly in relation to the way episodes of agitation and aggression had been managed on the ward. We found there were aspects of A’s care which were unreasonably managed particularly in relation to management of their nutritional needs, record keeping and communication. On balance, we considered the board failed to provide a reasonable standard of care and treatment to A and we upheld C’s complaint.

C complained about the board’s decision not to provide thyroid chondroplasty (a surgery to reduce the size of the Adam’s apple) as part of their gender affirming treatment. The board explained that though they used to have surgeons who could carry out this surgery, they no longer do. They said that the Scottish Government does not fund thyroid chondroplasty and therefore they cannot recruit surgeons for the purpose of performing the surgery and are prevented from using public finances to fund it. We found that there is no obligation for the board to provide thyroid chondroplasty on the basis of Scottish Government protocols. However, protocols state that health boards should ensure they have clear documentation on what is available to their patients and have local policies in place regarding access to them. We gave feedback to the board on this point, but ultimately did not uphold C’s complaint. C also complained that when they were in the process of having hair removal prior to gender reassignment surgery, the board stopped providing this service. Because hair removal at the site of surgery is a requirement, C had to pay for the hair removal to be completed privately. During the course of our investigation, the board accepted that they had not been clear to them at the point of C’s complaint that it is the responsibility of the health board where the patient lives to arrange hair removal prior to gender reassignment surgery. The board apologised for the failure and financial inconvenience caused and offered to reimburse C for the laser hair removal. We upheld the complaint and made no further recommendations. Related reading View Decision Report 202311694 as a PDF (24.62 KB) Updated: May 21, 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 on behalf of their late partner (A) who died from a stroke caused by a blood clot. A was admitted to hospital with seizures after collapsing at home and sustaining a head injury. A couple of days later A was identified to have had a stroke, and they died the next day. C complained that an MRI scan was not carried out in order to verify the cause of A’s seizures (a blood clot), in a timely manner to enable acute stroke interventions. We took independent advice from a consultant in intensive care medicine and a consultant stroke physician. We found that receiving a CT head scan when A first presented was appropriate. A working diagnosis of seizure was reasonable at that time. We found that it was reasonable that time critical acute stroke interventions were not indicated, and therefore an MRI was not indicated. A repeat CT scan did not show any significant changes from the initial scan. We noted that an MRI scan at this point would have been unlikely to have altered A’s immediate management. C was concerned that placing A in a medically induced coma masked the progression of the stroke, however, we found that this action was in keeping with guidelines. We considered that the clinical management of A was reasonable. Therefore, we did not uphold C’s complaint. Related reading View Decision Report 202302038 as a PDF (24.47 KB) Updated: May 21, 2025

C complained on behalf of their parent (A) about the care and treatment they received from the board following neurosurgery (surgery performed on the nervous system, especially the brain and spinal cord). C complained that the board did not provide follow-up care to A and they were not referred to oncology (cancer specialists) for further treatment. C said that A required further surgery to treat recurrent disease a few years later as a result. The board’s complaint response explained that an administrative error had occurred which had led to A not receiving follow-up care from neurosurgery or a referral to oncology. The administrative error had been managed via staff training to prevent it from happening again. In response to our enquiries the board confirmed that no internal review, such as a Serious Adverse Event Review (SAER), had taken place. We took independent advice from a neurosurgery adviser. We found that it was unreasonable that A had not received the planned clinical follow-up after their surgery. It was also unreasonable that SAER or Duty of Candour guidance had not been followed in this case. As such, we upheld C’s complaint.

C complained that the board failed to provide their late relative (A) with reasonable nursing care whilst in hospital. C told us that they felt nursing staff did not take A seriously when they reported pain, that information given was not passed to medical staff as agreed, and that A was left feeling abandoned and ignored. The board said that A was admitted with a blockage in their bowel which was likely caused by bowels being stuck together after a previous operation. A underwent surgery to free the bowel and was cared for initially in the surgical high dependency unit. The board said that due to A’s co-morbidities, A began to experience worsening symptoms, including very advanced heart failure and respiratory issues. The correct diagnosis was made for heart failure and A was receiving correct treatment for this. We took independent clinical advice from a specialist nurse practitioner. We found that the nursing notes were completed to an acceptable standard with the exception of the infection control documentation. The board’s infection prevention control team identified and documented some issues with the documentation relating to a possible clostridium difficile infection (a type of bacteria that can cause a bowel infection). The nursing notes indicated a lack of recording and documentation of when A’s bowels had moved and there were no stool charts completed. There was a non-compliance of the completion of clostridium difficile infection paperwork. We considered that this indicated a lack of understanding in nursing staff of the importance of the infection control guidance and that the process was not followed or recorded appropriately. This indicates that the management of infection control in A’s care was unreasonable. We found that there was no evidence that matters raised by the family were recorded in the notes, or escalated to medical staff as the family thought. We also found that other documentation was incomplete, specifically, the ‘Getting to Know Me’

C was assessed for the purpose of diagnosing gender incongruence, over a period of two years. Gender incongruence was diagnosed and C started gender affirming hormone treatment (GAHT). Less than a year later, due to new information which had come to light, the diagnosis was removed, treatment withdrawn and C was discharged from the gender clinic. C complained that they had not been informed at the time of diagnosis that it could be removed or treatment withdrawn. C did not consider that the information was new, as it had previously been available to clinicians. C noted that no-one had discussed this information with them and it appeared that the multi-disciplinary team (MDT) had inappropriately made the decision based on risk rather than clinical assessment. The partnership advised that information was presented to the MDT, which placed doubt on the diagnosis. Subsequently the MDT recommendation was to revoke the diagnosis and advice was given to the GP to withdraw GAHT. We took independent advice from a consultant psychologist specialising in gender. We found that the partnership should have carried out and documented a further assessment of C to consider whether the information changed the diagnosis, prior to making a decision. We upheld the complaint.

C complained about the care and treatment provided to their family member (A) during their admission to hospital, following a fall at their home. A was admitted to hospital after falling unwell, and for management of their underlying heath issues. A was discharged but had to be re-admitted to hospital two days later. C raised concerns that A did not receive appropriate care and treatment during their admission, that they should not have been discharged and that medical staff did not properly communicate A’s care plan during the admission. In response to the complaint, the board explained that staff were aware of, and managed, A’s pre-existing health conditions and that appropriate investigations were undertaken to investigate their symptoms. A’s weight loss during admission was noted and the board explained monitoring of this aspect of their care could have been better. The board explained that A was assessed as being medically fit for discharge and this was discussed with family. We took independent advice from a consultant in the care of the elderly and from a registered nurse. We found that whilst the general management of A’s underlying health conditions and symptoms was reasonable, in the initial days of their admission A was administered within correct medication and there was a missed opportunity to perform an x-ray to investigate A’s symptoms. For these reasons, we found that A’s care and treatment was unreasonable. We also found that medical staff failed to recognise the status of A’s family members as Power of Attorney, and did not appropriately communicate with A or their Power of Attorney with respect to their care. The communication with A and their family was unreasonable. We upheld this complaint. Finally, we found that appropriate assessments were carried out to determine A was fit for discharge and we did not uphold this complaint

C complained about the care and treatment provided to their adult child (A) by the partnership. A had received care from mental health services for several years prior to their death by suicide. C complained that the partnership failed to reasonably share information with A’s family and failed to involve them in A’s care. C also complained about the HSCP’s complaint handling. We took independent advice from a consultant psychiatrist. We found that the partnership had failed to evidence that there was any discussion with A about sharing information with their family or involving family in care and treatment, including risk assessment. We considered that not to have had this discussion, or to have had the discussion and failed to document it, was unreasonable. We upheld this aspect of C’s complaint. We found that there were delays in the partnership responding to C, and that they did not answer all points of the complaint. We upheld this complaint about complaint handlings.

C complained about the care and treatment provided to their late parent (A) who was diagnosed with lung cancer. C considered that there had been missed opportunities to diagnose A earlier, and that as a result A was denied appropriate care which may have affected their outcome. C also complained that the cause of death determined by the board was inconsistent with A’s diagnosis. Additionally, C complained that the cause of death was amended at a later date, which caused them to doubt the accuracy of the board’s conclusions. In their complaints response, the board stated that X-rays conducted earlier in the year had been reviewed and that radiologists were in agreement that A’s disease could not have been identified earlier. The board had also apologised that the cause of death had initially been determined to be hospital acquired pneumonia, and that this had now been corrected to community acquired pneumonia with lung cancer as the major contributing cause. We took independent advice from an experienced respiratory consultant. We found that it was not unreasonable that A’s cancer had not been detected on earlier X-rays. However, a decision to downgrade a GP’s referral from ‘urgent suspicion of lung cancer’ to ‘new urgent’ created delays in investigations of approximately four weeks, and likely longer had A not been admitted to hospital unrelated to the referral. Further delays of around three weeks were also apparent between the final investigation and the final multidisciplinary team (MDT) discussion. We also found that it was unlikely that there would have been a different outcome for A due to the nature of A’s illness. As such. we upheld C’s complaint. Regarding the cause of death, we found that the cause of death had been correctly identified in line with the available information and that whether the pneumonia had been hospital or community acquired was a technicality that was less significant than the overall conclusions. Based on this, on balance, we did not

C complained about the standard of surgery and post-operative care that they received when they had an elective operation for a long standing hernia (when part of an organ protrudes through your muscle wall). During the procedure the bowel was punctured resulting in an injury and transfer to another hospital. C said that the small hernia was manageable without an operation, and complained that they had not been told about all the risks and about inadequate care post-surgery. We took independent advice from a consultant general and colorectal surgeon. We found that it was reasonable to offer C an elective repair of the hernia and for this operation be to done by the consultant surgeon. However, more regard should have been given to whether C was at an increased risk due to their BMI. We found that the board failed to provide informed consent at an appropriate time which meant that the risks of surgery were not effectively communicated to C. We also found that the consent process for C did not meet published guidelines. Therefore we upheld this complaint. We found that post surgery, recognition and escalation to start Patient Controlled Analgesia was appropriate, and that C responded well to this pain relief. The timing of the CT scan was reasonable. Following escalation to clinical care specialists and treatment, C was transferred for further care which was also reasonable. We therefore did not uphold this complaint. We provided feedback that consideration should be given to the preoperative risk assessment being carried out at consultant level and that referral to specialist weight management is available for patients who require incisional hernia repairs electively.

C complained about their experience at the primary school of their child (A) who has additional support needs. C requested independent mediation with the school and a Co-ordinated Support Plan (CSP) for A. C complained that the council failed to reasonably handle these requests, and that they did not reasonably apply their Unacceptable Actions policy in C’s case. The council said that an internal mediation process had been put in place and a member of staff was mediating with C on behalf of Education Services. The council said that this went well, so there was no requirement to involve an independent mediator. We found that C was not reasonably informed about the start of the internal mediation process. The council acknowledged that there was a slight delay in handling C’s request for a CSP. We found that the council failed to meet the eight-week timescale for responding to requests for CSPs, as set out in the council’s policy and statutory guidance. We also found that the council did not reasonably inform C that they had the right to make a reference to the Additional Support Needs Tribunal The council said that the Unacceptable Actions policy has been applied correctly. We found that the council failed to provide C with a warning letter prior to restricting C’s contact, and that there was a delay in the council’s response to C’s appeal of the decision to apply the Unacceptable Actions policy. Additionally, we found that the council should have referred to relevant policies and guidance in investigating C’s complaints about their request for a CSP and the application of the Unacceptable Actions policy. Therefore, we upheld C’s complaints.

C, a tenant of Albyn Housing Society Ltd, reported antisocial behaviour (ASB) from a neighbouring family who were also tenants of the association. The ASB related to an overwhelming and pervading smoke and smell as a result of the neighbouring family’s cannabis smoking. The association reported having visited the family and the volume and frequency of smoke and smell reduced. Over the next several months, C made three further reports of the same ASB recurring, including reporting deterioration in their own and their family’s respiratory health. On each occasion the association reported visiting, or attempting to visit, the neighbouring family it resulted in temporary reductions in the volume and frequency of smoke and smell. When C complained that the association had not responded reasonably to the reports, the association’s response indicated that they considered that they had taken reasonable action. C felt that they had no option but to end their tenancy and raised their complaints with SPSO. We found that the association did not progress matters in line with a number of parts of their ASB Procedure regarding administration, categorisation and investigation of reports of ASB, subsequent review of progress, consideration of possible solutions to the reported ASB, or taking into account how the situation had developed over a number of months. The association did not explain to C that evidence and corroboration was required to enable them to take action, and they did not follow through with their belated requests that C keep a log of dates and times when issues arose. The association also failed to keep reasonable records of the actions that they did take or pursue and fulfil actions they indicated they intended to take. We upheld C’s complaint.

A & B complained to the council about their handling of their claims procedure in relation to the Trams to Newhaven project. A and B were unhappy with the council’s response because they considered that the council failed to appropriately address and investigate their complaint and that relevant issues were not given due consideration. A and B complained to the SPSO. After an initial review, we considered that the council had failed to engage with A and B to specify their complaint. We also considered that the council had opted to summarise what they regarded as the issues of complaint without obtaining A and B’s agreement to this. As the council had not fully addressed or clearly responded to all of A and B’s concerns, we directed that they should provide an additional response. The council provided A and B with an additional response and apologised to them for failing to adequately address their complaint. A and B then complained to our office that the council failed to investigate their complaint in accordance with their complaints handling procedure (CHP). During our investigation the council acknowledged that A and B’s complaint was not fully responded to and was not handled in accordance with their CHP. We also considered that the council failed to act in line with their CHP when initially investigating and responding to A and B’s complaint. We upheld the complaint. The council informed us of the learning that they identified from A and B’s complaint and their wider experience of the Trams to Newhaven project. We considered this to be an example of good practice.

C’s adult child (A) had been referred to the board's Community Mental Health Team (CMHT). A had some contact with both psychiatry and psychology services over the next few weeks. A later died. The board commissioned a Significant Adverse Event Review (SAER) into the care provided to A. In the SAER it was concluded that, following an initial face-to-face assessment by Community Psychiatric Nurses (CPNs), a further face-to-face consultation should have been arranged and that not doing so compromised the care provided to A. C complained to the board about the care and treatment provided to A, and communication during the SAER process. We took independent advice from a psychiatry adviser. We found that the SAER conclusion regarding face-to-face consultation of A was reasonable. We also found that no evidence of a contemporaneous record of the examination carried out by a consultant psychiatrist had been provided and that the record that had been provided does not indicate a comprehensive Mental State Examination (MSE) was undertaken at this time. We found that this was unreasonable given the other evidence available of A’s presentation at this time. Given this, and the conclusion of the SAER that the care and treatment of A had been compromised, we upheld C’s complaint about the care and treatment provided to A. C’s concerns about the SAER process originated in the delays and lack of communication throughout the process, and the failure to provide a final copy of the SAER. We found that the SAER in itself was reasonably thorough but are concerned that no contemporaneous record of the MSE was identified by the SAER. We found that the extended timescale for completion of the SAER and the board’s communication with A’s family, which did not include regular or on-going communication and was subject to a lack of clarity around the status of the SAER report that continued for a period of years, was unreasonable. We also considered that during the SAER process, A's family were

C raised concerns about the care and treatment provided to their sibling (A). A underwent a series of hospital admissions, suffering from bleeding from their bladder, following radiotherapy. During these admissions, the majority of communication between the board and the family was with A’s partner (B). A was initially expected to recover from the radiotherapy but was admitted and discharged repeatedly, with some readmissions happening a matter of hours after A was discharged. A continued to deteriorate and died in hospital. C believed that A was not provided with an adequate standard of urological or nursing care. They felt that A was not provided with appropriate treatment and that they were not reviewed properly by other medical specialties, given the complexity of their case. C was also concerned that A was not provided with adequate nursing care. C believed that the board had not acknowledged systemic failings which impacted on A’s care, wellbeing and adversely affected the outcome of their treatment. We took independent advice from a consultant urologist and a registered nurse. We found that A’s urology care fell below a reasonable standard, as did their nursing care and we upheld these aspects of the complaint. We found that A was reviewed appropriately by other medical specialties and this aspect of C’s complaint was not upheld. Finally, the opportunity to perform surgery on A was missed and this contributed to A’s deterioration. It was not possible, however, to determine whether A would have survived if their care had been different. The board failed to transfer A to a different consultant or offer a second opinion when this was requested and they failed to communicate reasonably with A’s family about their care. We upheld these aspects of the complaint.

C complained about the practice’s treatment and diagnosis in respect of issues C had with their leg over a period of 18 months and being diagnosed with deep vein thrombosis (DVT). In C’s view, the practice missed various opportunities to diagnose DVT or refer onwards to an appropriate specialist. C also raised concerns about the general treatment that they received from when they presented with a lesion on their left leg. The practice had acknowledged that there was a delay in diagnosing C’s DVT. However, there remained uncertainty regarding when the practice should have diagnosed a DVT or explored the possibility of this diagnosis. We took advice from an independent GP adviser. In respect of the DVT, we found that this was a more difficult case of DVT to diagnose. However, there were signs that the practice unreasonably missed. C attended a consultation after they had been on a flight. We found that, from this point onwards, there was an unreasonable failure to fully take into account risk factors and symptoms pointing to an alternative diagnosis of DVT. There were also missed opportunities to carry out appropriate investigations that would have supported or ruled out such a diagnosis. We considered that there was less certainty over whether the DVT was present prior to C’s flight. We upheld this complaint. In respect of the more general care of C’s leg, we found that this was initially of a good standard. However, this became less reasonable as the months went on and C’s symptoms persisted. We found that, at a certain point, the practice were not treating C’s symptoms proactively. We also considered an apparent absence of a dermatology referral, despite C’s records indicating that this was part of the treatment plan. For these reasons, we upheld this complaint.

C complained about the care and treatment that their adult child (A) received from the board during three admissions to hospital with non-epileptic seizures. A is a prisoner and has a learning disability and autism. C is A’s welfare guardian. In terms of the guardianship order in place at the time relevant to the complaint, C was granted the power ‘‘to consent or withhold consent to medical or dental treatment and to require the Adult to comply with such treatment and to administer such medications as may be prescribed for the Adult’ and ‘To decide and approve the appropriate level of health and social care for the Adult". C complained that they had not been appropriately involved in A’s care, despite holding the guardianship order. C complained that the board gave non-emergency treatment to A knowing that they were deemed to lack capacity to make that kind of decision. We took independent clinical advice from a neurology adviser, who referred to the Adults With Incapacity (Scotland) Act 2000 (AWI), the code of practice for practitioners and relevant guidance. We noted that A’s presentation was complex. We found that the board carried out appropriate investigations and provided reasonable care and treatment during each of A’s admissions. We did not uphold this aspect of C’s complaint. We found that when C raised the matter of guardianship with the board during a telephone call, the board ought to have done more to explore this further. Guardianship paperwork should have been included in A’s records, with AWI paperwork completed appropriately for each admission. Whilst it was appropriate for the board to carry out emergency treatment without consulting the guardian, C ought to have been consulted in relation to all non-emergency treatment. We upheld this aspect of C’s complaint.

C complained about the care and treatment provided to their adult child (A) by the board. A had received care from mental health services for several years prior to their death by suicide. C complained that the board failed to reasonably share information with A’s family and failed to involve family in A’s care. C also complained about the board’s adverse event review process, and their complaint handling. We took independent advice from a consultant psychiatrist. We found that the board had failed to evidence that there was any discussion with A about sharing information with their family or involving family in care and treatment, including risk assessment. We considered that not to have had this discussion, or to have had the discussion and failed to document it, was unreasonable. The board told us that records were kept briefer than they would normally, because A was an employee of the NHS and was concerned about their records being kept confidential. We did not consider this to be a reasonable position to take, as all patients, including those who are NHS staff, should be confident that their records will be kept confidential. We considered it unreasonable that the board had not addressed this concern. We upheld C’s complaint about information sharing and involvement of family. In relation to the adverse event review process, we found that the board had not appropriately taken account of C’s view on the scope of, and information to be contained within the review, and because it did not identify the failings in care. We upheld this aspect of the complaint. Finally, we considered the board’s handling of C’s complaint to be unreasonable. This was because answers to multiple questions about care and treatment were responded to using generic and repetitive phrasing, the complaint response contained several inaccuracies and C was not made aware that some aspects of the complaint could only be responded to by another organisation until the final complaint response,. We

C complained in relation to their late child (A) and the actions of the social work services. A suffered from significant and life-limiting health conditions. During the final months of A’s life, a number of healthcare and education professionals raised concerns about C’s approach to A’s medical needs and care. Social workers made contact with C and initiated a child protection investigation, which ultimately did not establish child protection issues. C complained that contact that they received from the partnership, both via the phone and in person, was harassing and unreasonable. C considered that the partnership failed to recognise that the reports of other agencies were inaccurate, and harassing in nature, and had displayed bias by ignoring C’s views in this regard. We took independent advice from an experienced social worker. We found that it was evident that healthcare professionals had been concerned about A and had notified social workers of these concerns. In making enquiries and initiating a child protection investigation, social work services had followed the process set out in the National Guidance for Child Protection and in doing so had acted appropriately. While we recognise the difficult circumstances involved, I did not uphold C’s complaint. Related reading View Decision Report 202401251 as a PDF (24.43 KB) Updated: April 30, 2025