SPSO Individual Decisions

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 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 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 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 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

C complained on behalf of their relative (A) in relation to the nursing care and treatment that the board provided to A in hospital following orthopaedic surgery. A received nursing care in hospital before being transferred to another hospital for rehabilitation, where they died. In the second hospital, A was found to have a large wound on their foot and C complained that they had been unreasonably transferred with this. We took independent advice from an experienced nursing adviser. We found that the wound care management that A received was unreasonable. We also found that it was unreasonable for the board to transfer A to another hospital without documenting this on the transfer document and without an adequate wound care management plan in place. We therefore upheld these complaints, although we found that the board had subsequently taken action to support improvement with regards to care rounding and pressure ulcer prevention.

C complained to the partnership about the care and treatment of their late spouse (A). A suffered from Progressive Supranuclear Palsy (a rare neurological condition that can cause problems with balance, movement, vision speech and swallowing). A was admitted to a community hospital for care and support of their complex needs. C complained about unreasonable falls prevention, nutrition, personal hygiene and incident management. C was concerned that there was little information in the medical notes to show that A was being reasonably cared for. They noted that A had fallen on several occasions, that A had dirty hair, had not been washed and was not receiving enough to eat and drink. The partnership advised that A was on continuous intervention during the day and 15 minute observations at night for falls prevention, and that falls risk assessments were carried out as part of routine care, although did not provide evidence of this. They advised that Person Centred Care Plans (PCCP) were recorded in A’s records, risk assessments were completed and updated regularly and all staff were receiving personalised one-to-one training on documentation and PCCP. We took independent advice from a nurse. We found that there was insufficient evidence of falls risk assessments or malnutrition assessments in the records provided, that there were significant gaps in care rounding records and a 5 day period during which A was not offered a wash. We found this to be unreasonable and upheld the complaint.

C complained about the handling of two planning enforcement complaints which they had brought to the council in regards to Air Source Heat Pumps (ASHPs) installed at two neighbouring properties, which were affecting their enjoyment of their property due to the noise generated. C complained that the council had taken too long to determine that planning applications were required and that the council’s communication had been inconsistent and slow. C also complained that the time to determine the retrospective planning applications was too long. The council admitted that their initial handling of the enforcement complaints was inconsistent and slow. They apologised, restructured the team and provided reminders as to when planning was required for ASHPs. As regards the determination of the planning applications, they advised that they were waiting for Noise Impact Assessments (NIAs) from the applicants which were never provided. The applications were due to be determined by the Planning Committee in June 2024. However, just prior to this C commissioned their own NIA which needed to be robustly considered by Environmental Health Services. The applications were considered in February 2025. We found that given the ASHPs were potentially impacting C’s amenity, due to noise, it took the council too long to investigate the planning enforcement complaints and to decide that planning applications were required. It also took them too long to determine the planning applications. We upheld the complaint on this basis.

C complained about the care and treatment provided to their adult child (A). A had addiction issues and was admitted to intensive care with a head injury after a fall. They were later transferred to a different hospital and onto a ward after their condition improved. A received treatment from the addiction team while in hospital and following further scans and reviews, was deemed fit for discharge. A died at home shortly after discharge. C complained that the board failed to provide A with a reasonable standard of medical or nursing care. They also said that the board failed to communicate appropriately with social services or community addiction services prior to A’s discharge. We took independent advice from a consultant neurosurgeon (specialist in surgery of the nervous system, especially the brain and spinal cord) and a nurse. We found that both the medical and nursing care A received was appropriate. Therefore, we did not uphold this aspect of C's complaint. However, we found that A's discharge did not adequately consider their vulnerability and whether A would be safe in the community. We considered that the board did not communicate appropriately with social services and addiction services. Therefore, we upheld this part of C's complaint.

C complained about the care and treatment provided to their late parent (A). A was admitted to hospital and received treatment for a chest infection and pleural effusion (a build-up of fluid in the chest). A remained in the hospital awaiting discharge arrangements. During a visit to A, C was told that A's bed was needed for a more acute patient and that A would be transferred to a maternity ward as a boarder. C complained that A was not included in this conversation, and that the family felt pressured to accept an unsuitable move. They were concerned that it would negatively impact A’s care and wellbeing due to noise, disruption and the availability of equipment. The board stated that A had been identified as a patient suitable for boarding and that ward moves are necessary when there is extreme pressure on capacity. The board also considered that the care provided to A was not affected by the move. We took independent advice from a consultant specialising in acute medicine. We found that A was not considered suitable for boarding under the board's policy. We also found that there had been a failure to conduct and record a full risk assessment, and to record the reasons for this deviation from policy. There was evidence that the move caused A distress leading to a deterioration in their behaviour and acceptance of treatment. Therefore, we upheld this part of C's complaint. C also complained that the board’s complaint response focussed on allegations of aggressive behaviour from A’s family towards hospital staff. C did not consider that this accurately represented events. We found evidence of challenging behaviour documented in the available records. However, the board’s complaint response unreasonably focussed on these events, which were not ongoing. Therefore, we considered that the board failed to handle C's complaint reasonably and upheld this part of their complaint.

C complained about the council’s handling of communal repairs at a tenement in which C owned a property. Extensive work was required following a fire. The council owned the majority of properties in the building and took the lead in arranging and managing the work. During the work to repair the fire damage, extensive dry rot was identified. Work was completed around four years after the fire. The invoice C received from the council for the dry rot works was approximately £15,000 over what C had expected to pay, based on the estimates for work given two years prior. C complained about the council’s management of the repairs, including their communication. We found that the council’s communication with C during the period of works and in respect of the increasing costs was unreasonable. The council also failed to follow their own processes or act in line with their obligations under the Tenements (Scotland) Act 2004. The final invoicing included substantial costs for which C was not liable, and which should not have been included in the invoice. The council also failed to notify C of the costs of an emergency repair to the roof following a storm within a reasonable period of time, resulting in C missing the opportunity to submit an insurance claim for the costs. Overall, we found that the council’s management of communal repairs was unreasonable. Therefore, we upheld this part of C's complaint. We considered that regardless of communication issues and delays, the costs would likely have been incurred and therefore are duly payable by C. However, given the multiple failings in relation to communication and administration, we recommended that the council refund the administration fee to C. C also complained about the council's handling of their complaint. We found that the council’s complaint handling was unreasonable. The council failed to identify C’s expression of dissatisfaction as a complaint, failed to respond within a reasonable timescale or provide timely update

C complained that the advice and treatment provided by the board following their positive COVID-19 test was unreasonable. C was a kidney transplant patient who tested positive for COVID-19 in early 2022. C said that they had contacted the renal unit who referred them on to the Covid Pathway (a central unit offering treatment advice and antiviral medication for high-risk patients). C received antiviral medication from a Covid Pathway nurse but was not referred to a renal clinician or advised to stop the immunosuppressant medication they were taking. C later contacted the renal unit with concerns about diarrhoea. C was advised to stop the immunosuppressant over the weekend and was given advice on what to do if their condition worsened. C felt that they were given wrong advice about their medication and that their disease progression was more severe because of this. The board advised that they had no record of C’s contact with the renal unit about COVID-19. Their first record was 11 days later, when they spoke to a renal nurse with concerns about diarrhoea. We took independent advice from a pharmacist and a consultant nephrologist (specialist in the diagnosis, treatment, and management of kidney conditions). We found that if C had indeed phoned the renal unit initially, C should have been escalated to a clinician for medication advice. We were also critical that the nurse at the Covid Pathway had not sought advice from or referred C to the renal unit. However, we noted that the immunosuppression medication was new and the situation was fluid at the time. We noted that improvements were made within two weeks, during which, guidance was published to ensure robust advice and treatment for COVID-19 positive, immunosuppressed patients and contact details for specialist clinical units were provided to the Covid Pathway. We also considered that the COVID-19 pandemic had since largely subsided. We considered that the advice and treatment that C received was reasonable as we co

C complained about the care and treatment provided to their parent (A). A was assessed by a junior doctor in A&E who ordered various tests and investigations. A was later moved to the acute assessment unit and diagnosed with a perforated bowel. A underwent emergency surgery and developed sepsis. C complained that there was a delay in identifying A’s condition. They said that the board focussed on potential cardiac issues rather than an abdominal cause. C considered that this delay resulted in a worse outcome for A. The board acknowledged that a more senior doctor may have identified the cause of A’s symptoms quicker. However, they said that the care provided was reasonable. They also noted that this this complaint had resulted in learning and ongoing development. We took independent advice from an emergency medicine consultant. We found that there were a number of red flags in A’s presentation that should have raised the possibility of significant abdominal pathology. It did not appear that A was reviewed by a senior clinician. We also found issues in the documentation. No intimate examination was recorded in the records and there was a lack of documentation around the interpretation of an x-ray. Overall, the initial assessment process led to a delay in the diagnosis of acute bowel perforation which is likely to have had a significant effect of the outcome for A. Therefore, we upheld C’s complaint

C complained about the care and treatment provided to their late spouse (A). C complained that A had an infected toe which remained unresolved despite undergoing several months of treatment. A was diagnosed with oesophageal cancer but was unable to start chemotherapy treatment because of the ongoing infection. C said that A experienced significant pain during this time and that there was a failure to reasonably coordinate A’s care needs. We took independent advice from a consultant orthopaedic surgeon (specialist in treatment of diseases and injuries of the musculoskeletal system) and a consultant clinical oncologist (specialist in the diagnosis and treatment of cancer). We found that the board had provided reasonable care and treatment to A over several admissions when each one was considered in isolation. However, on one occasion, we found that an MRI scan result was not correctly reported at the time. This resulted in A receiving lesser surgery than they would otherwise have received. We also found that the board had failed to report the incident in line with Duty of Candour legislation, or undertake an internal review process to learn from the event. We found that a more coordinated approach to A’s care may have provided a proper overview of their care needs (including pain) which were known to be complex given the number of specialties involved in A’s care. Therefore, we upheld this part of C’s complaint. C complained that the board’s handling of their complaint was unreasonable. We found that the board kept C reasonably informed of delays.However, they did not accurately describe the failing with the MRI scan or acknowledge the impact this had on A’s surgery and treatment plan. There was also a failure during the complaint process to initiate relevant reporting and investigation processes in relation to the MRI scan reporting when this became known. Therefore, we upheld this part of C’s complaint.

C complained that the board failed to provide reasonable personal care and treatment to their sibling (A). A was admitted to hospital to initiate and titrate Clozapine (an antipsychotic drug used to treat schizophrenia and other psychotic disorders). A had a history of diabetes and experienced episodes of incontinence which placed A at greater risk of infection. C complained that the discharge letter did not mention a pressure sore which was treated by A's GP upon discharge. This could have resulted in A’s Clozapine treatment being temporarily suspended. We took independent advice from a mental health nurse and from a wound-care specialist nurse. We found that A’s feet were examined following concerns raised by C. However, no treatment was prescribed and the doctor's advice about caring for A’s feet was not passed on to C. We found that there was no conclusive evidence to determine whether A had a pressure sore or an ulcer which might have impacted on A’s Clozapine treatment. We also found that it was reasonable for the board to conclude that the wound A had was not a pressure ulcer. However, the board failed to evidence that relevant assessments relating to pressure ulcer risk and skin inspections were carried out. We also found that there was no person centred care plan in place to identify A’s needs in relation to activities of daily living, including personal hygiene. We found that the immediate discharge letter was dated the day after discharge which suggests it was not available to C at the point of discharge, or on the same day, when it should have been. Therefore, we upheld C’s complaint.

C complained about the care and treatment provided to their spouse (A). A had a history or recurring urinary tract infections (UTI's) and was self-catheterising. The board gave A an indwelling (long-term) catheter to be changed every three months. Over the next several months, A attended A&E five times before being admitted and diagnosed with bladder cancer. C complained about the lack of arrangements to change A’s indwelling catheter, that requests for appointments were ignored and that A was only admitted after multiple visits to A&E. We took independent advice from a consultant urologist (specialist in the male and female urinary tract, and the male reproductive organs), consultant in emergency medicine and a medical director specialising in palliative care. We found that, as the indwelling catheter was a trial, the board should have followed up with A on their progress. There was also unreasonable delays in A being seen by urology and in being advised of their cancer diagnosis. While it was reasonable that A was not admitted by A&E for examination sooner, the board acknowledged that there was a missed opportunity. Therefore, we upheld this part of C's complaint. C also complained that A’s cancer diagnosis, discharge and care arrangements were not clearly explained. We found that the board made reasonable efforts to explain the cancer diagnosis to C and A. However, they did not reasonably communicate how they might manage once A was discharged home, and about the challenges associated with A reaching end of life. Therefore we upheld this part of C's complaint. In relation to complaint handling, we found that the information provided to both C and this office was inaccurate in places and incomplete. Therefore, we made a recommendation to improve the board's complaint handling.

C complained that their late partner (A)’s discharge from hospital was unreasonable. A was admitted to hospital with pneumonia and was discharged after ten days. Less than two weeks after discharge, A collapsed and was readmitted to hospital. A died a few days later. C questioned whether A had been fit for discharge. They also raised concerns about not receiving adequate education on the new medications that A was prescribed on discharge. The board noted that A’s infection had improved with antibiotic therapy and that they had been stable and well enough for discharge home. They explained the rationale for the medications that A had been prescribed and apologised that medical staff did not have a better discussion with them at the time of A’s discharge. We took independent advice from a consultant in acute and general medicine. We found that A's oxygen levels had been stable and their discharge was clinically reasonable. However, we noted that A's sodium level had been low during their admission but had improved on discharge. We found that no follow-up arrangements were made to ensure that A's sodium level was continuing to improve after their discharge. The working diagnosis on A's readmission was that they had had a seizure due to low sodium which led to hypoxia (deficiency in the amount of oxygen reaching the tissues) and cardiac arrest. It is possible that the fall in A's sodium level could have been detected had there been follow-up to re-check this. Therefore, we upheld C's complaint. We also noted a discrepancy between the working diagnosis on A’s re-admission and the recorded cause of death on the death certificate. This was not identified by the board. Therefore, C was not provided with a coherent narrative of events surrounding A’s death and we made a recommendation to address this.

C complained about the care and treatment provided to their parent (A) during an admission to hospital. C complained that the board had failed to manage placement of a nasogastric tube (NG) correctly and did not act timeously on signs of a complication. C said that the board failed to carry out an adverse event review of this event. C complained that the board dismissed A’s known diagnosis of myasthenia gravis (a rare long-term condition that causes muscle weakness) too quickly and failed to arrange a neurology (speicalism concerned with the diagnosis and treatment of disorders of the nervous system) review. Finally, C said that the board did not maintain A's privacy or dignity when providing end of life care and communication with the family was poor. The board apologised for failures in A’s care in respect of the NG tube insertion and for aspects of their communication. The complication which occurred with the NG tube was a rare but known complication of the procedure. The board said that A’s case had been reviewed at a Mortality and Morbidity (M&M) meeting and points of learning had been identified. We took independent advice from a consultant neurologist (specialist in the diagnosis and treatment of disorders of the nervous system), a consultant gastroenterologist (specialist in the diagnosis and treatment of disorders of the stomach and intestines) and a consultant respiratory physician (specialist in conditions affecting the lungs). We found that there were aspects of A’s care which were reasonably managed including the review by neurology, the decision to site the NG tube, the end of life care provided to A and the review of the admission undertaken by the M&M meeting. However, we found that the chest x-ray undertaken after insertion of the NG tube was unreasonably delayed. Therefore, we upheld this part of C’s complaint. However, we noted that the board had recognised this failure as part of their own review of C’s complaint. C complained that the board fai

C complained about the care and treatment provided to their spouse (A) when they attended A&E. A had fallen from a height and injured their shoulder. A was x-rayed and diagnosed with a soft tissue injury to the shoulder and a minor head injury. A was discharged home and advised to use regular simple pain relief for the shoulder injury. A was later diagnosed with a rotator cuff injury which required an operation. C said that A should have been correctly diagnosed by the doctor in A&E and that the delay left A in significant pain and distress. We took independent advice from a consultant in emergency medicine. We found that A should have been reviewed by a senior doctor before discharge. We also found failings in relation to a lack of follow-up and record keeping. Therefore, we upheld C’s complaint. We also found that C’s complaint was not handled reasonably as there were clear inaccuracies in the board’s complaint response and no reflection on the failings. We made a recommendation to address this.

C’s elderly spouse (A) spent approximately ten weeks in hospital. While in hospital, A fell on two occasions. C complained about the medical, nursing and physiotherapy care and treatment provided by the board. We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). We found that the medical care after A’s falls was reasonable. We found that the board had taken reasonable and proportionate actions to acknowledge, apologise for and support learning and improvement regarding the provision of pain relief and a delay in reviewing an x-ray after A’s first fall. We found that the board did not reasonably handle A’s prescriptions for haloperidol (a sedating medication) or codeine (a type of painkiller). On balance, we upheld this part of C’s complaint. We took independent advice from a registered nurse. We found that the care and treatment regarding A’s falls was unreasonable, as a mechanical aid should have been used to assist A from the floor, and risk assessments and care plans should have been updated. We found that A should have been more closely supervised prior to their second fall. We also found that the board’s post-fall protocol was not reasonable in its current form. Finally, we found that A’s hygiene needs were not reasonably met in hospital. The board had taken some action to support learning and improvement regarding the management of falls. On balance, we upheld this part of C’s complaint. We took independent advice from a physiotherapist. We found that the care and treatment provided to A was reasonable, and physiotherapy sessions were appropriate, timely and sufficient, considering A’s clinical presentation. We did not uphold this part of C’s complaint. Additionally, we found that some points of the board’s complaint response were incomplete and made a recommendation to address this.

C suffered with lower back and right hip pain. C complained about the care and treatment provided by the practice in relation to their diagnosis of Hip Osteoarthritis. C said that despite raising concerns with the practice, they failed to take appropriate action to ensure C’s symptoms were further investigated. We took independent advice from a qualified GP. We found that the management of C’s symptoms was reasonable and appropriate steps were taken to investigate C’s symptoms. We did not uphold this aspect of the complaint. With respect to the handling of C’s complaints, we found that the practice’s complaints handling procedure was not compliant with current requirements. We also found that, whilst their complaints response demonstrated that they had investigated the complaint, the practice unreasonably failed to provide further response to C’s subsequent communications or the communications from our office. We therefore upheld this aspect of the complaint.

C complained about the care and treatment provided to their late spouse (A) for cardiac amyloidosis (the abnormal build-up of a protein (amyloid) in the heart). C complained about delays in referrals, diagnosis and treatment. The Board did not uphold the complaint and considered that there had been no delay in referring A to an appropriate specialist or in their diagnosis and treatment. C was unhappy with this response and brought their complaint to this office. C also complained that the board had failed to adequately investigate and/or respond to their complaint. We took independent advice from a consultant cardiologist (specialist in diseases and abnormalities of the heart) and a consultant haematologist (specialist in blood and bone marrow). We found that A’s cardiology care and treatment was reasonable. However, we also found that there was an unnecessary delay in referring A for specialist haematological treatment and that this treatment was poorly documented. Additionally, we found that the communication with A’s family about A's treatment could have been better. We upheld this part of C’s complaint. As these failures were not identified by the board, we found that the board had failed to adequately investigate and respond to C's complaint. We upheld this part of C's complaint.

C complained that the Scottish Prison Service (SPS) failed to appropriately investigate their lost property claim. C submitted a claim for lost items which went missing during a transfer to another prison. C complained about the handling of the claim, including the timescale for receiving a decision. C maintained that three bags of property were missing, whereas the SPS concluded that only one bag was unaccounted for. This office does not provide a route of appeal, and it was not our role to assess what property was missing or what compensation should be offered. Our focus was on the administrative handling of the claim, including whether the SPS assessed all relevant information and provided a clear explanation as to how they reached the conclusion that they did. The evidence we received from the SPS of their assessment of the claim was difficult to follow. It was unclear to us how they concluded that one bag of property was unaccounted for. We found that this was based on a bag seal check eight months after C’s prison transfer. C noted in the claim that much of the missing property had been kept in storage at their previous prison and was not in their possession (‘in use’). The SPS said that C packed their own property prior to the transfer. It was not clear from the records what items C had ‘in use’ at their previous prison, and there did not appear to be a method in place for itemising ‘in use’ items packed from a prisoners cell prior to being placed within a sealed bag for transfer. C also alleged that some items were damaged during the transfer and we found no evidence that the SPS assessed this part of C's claim. The SPS communicated their final position more than three years after C initially raised matters following their prison transfer. It was not clear why this took so long. Therefore, we upheld C's complaint.

C complained about the care and treatment provided to their parent (A) during two admissions to hospital. Both admissions were due to concerns about A's lungs. A was admitted to hospital for a third time and was diagnosed with empyema (pockets of pus) in their left lung. C complained that this was missed during A's first two admissions and that A was unreasonably discharged from hospital on both occasions. We took independent advice from a consultant who specialises in both respiratory and general medicine. We found that there was no evidence that empyema was present during the two admissions. However, there were missed signs that indicated the potential for empyema to develop. In particular, the presence of high C-reactive protein (CRP, an indicator of inflammation in the body) during the first admission and the recent history of pulmonary and pleural infection at the time of the second admission. We considered that it would have been reasonable for the board to carry out further investigation during A's admissions to hospital. We concluded that the board did not take reasonable steps to establish whether there was an evolving infection or potential for empyema to develop. Therefore, we upheld this part of C's complaint. In respect of A's first admission, we found that A was clinically well enough to be discharged. However, there was a failure to recognise the significance of the raised CRP in the context of A's presentation, and to consider further assessment on this basis. Therefore, we upheld this part of C's complaint. In respect of A's second admission, we found that A was clinically well enough to be discharged. In contrast to the first discharge, A's CRP was not as significantly high and was shown to be declining. As such, there was less indication that A would benefit from remaining in hospital. Therefore, we did not uphold this part of C's complaint.

C complained about the care and treatment that their adult child (A) received from the practice following their discharge from hospital. C complained that A had struggled to get an appointment with a GP and that the practice failed to provide a reasonable standard of care in relation to pain management, A’s mental health needs, and follow-up with the health board. The practice said that they were short-staffed and had been working on an emergency-only basis at the time of the complaint. When A had enquired about seeing a GP, there had been no indication that an emergency appointment was required. A was advised to phone again the next day or to attend A&E. In respectof A’s pain, the practice said that the discharge medication had been managed in accordance with their policy and in recognition of the nation-wide shortage of the drugs prescribed. A was given an appointment to discuss pain when they reported that the medication was not working and a prescription for nerve pain was given. In reference to A’s mental health, the practice said that this was discussed during a phone appointment. However, A had breached the practice’s zero tolerance policy during the conversation. A was issued with a warning letter after the incident but was not removed from the practice (as would be policy) in recognition of the mental health difficulties that they were experiencing. This incident was reviewed as a part of a Significant Event Analysis Review (SEAR) and the practice identified learning to manage this type of occurrence in the future. In respect of A’s follow-up with the health board, the practice confirmed no post-discharge requests had been made and that it was the responsibility of the hospital to issue clinic appointments. We took independent advice from a GP. We found that the practice had reasonably managed the discharge prescription for pain medication. While A had been appropriately directed to other services when no appointments were available, we found that the messa