SPSO Individual Decisions

C complained about the care and treatment provided by the board to their late parent (A). Additionally, C complained about the nursing care that A received and the boards handling of C's complaint. We took independent advice from a consultant geriatrician and a senior nurse. We found the care and treatment of A to be reasonable. We did not uphold the complaint. In relation to nursing care and treatment, we found unreasonable care in a number of areas including but not limited to, failures in wound care, a delay in administering pain relief, shortcomings in the documentation of cannulation attempts, inaccuracies in key nursing documentation, errors in medication administration and inaccuracies in fluid balance. While communication with C was compassionate and the timeframes were reasonable, the board’s investigation did not fully identify or address several significant failings in A’s care, resulting in an incomplete and unreasonable response to C’s complaint. We upheld this complaint.

C complained about the care and treatment provided to them by the board when they were admitted to hospitalwith chest pain and respiratory issues. C also complained that the board’s complaint response failed to respond reasonably to C’s concerns. We took independent advice from a respiratory adviser. We found that it was unreasonable that the board had not performed a pleural aspiration (a procedure to remove fluidfrom the space around the lungs) and had not inserted a chest drain on the day that C’s condition deteriorated in hospital. We upheld this complaint. We also found that the board’s response to the complaint was unreasonable given that they failed to identify failings in C’s care and treatment in their complaint investigation and failed to carry out a significant adverse event review (SAER). We upheld this complaint, however, we recognised that the board had accepted and apologised for failings.

C complained about the care and treatment provided to their late sibling (A) when they were admitted to A&E, and about the boards out of hours (OOH) service. A was found to have Influenza A and signs of a chest infection. A deteriorated throughout the admission to A&E with increased oxygen requirements and coughing up blood. They then had a cardiac arrest and continued to deteriorate, suffering multiple organ failure. Attempts to stabilise A failed, and A died in hospital. C also complained about the family being pressured to decide whether to have a post-mortem and that a Significant Adverse Event Review (SAER) was not carried out. The board acknowledged failings around appropriately regular observations not taking place whilst A was in hospital. However, they concluded that the overall care and treatment was reasonable given the circumstances at the time. In addition to this, the board did not uphold C’s complaints regarding the OOH service, the post-mortem, and the SAER. In respect of the care and treatment provided by the OOH service, we took independent advice from a GP adviser. We found that it was appropriate for a nurse practitioner to review A at the second of two OOH consultations the day before A was admitted to hospital. We found that the assessments and clinical decision-making, based on A’s presentation at the time, were reasonable. We did not uphold this complaint. In respect of the care and treatment provided when A was in hospital, we took independent advice from a consultant in emergency medicine. We found that appropriate regular observations did not take place. However, we considered that the overall care and treatment provided was reasonable, appropriate tests were carried out and appropriate treatment was provided, given A’s presentation at the time. As such, we did not uphold this complaint. In respect of whether the family was pressured into making a decision regarding a post-mortem, we found that communication with the family about a post-mo

C complained that their parent (A) suffered a fall while in hospital. C was concerned that bedrails and falls risk assessments were not appropriately completed prior to A suffering the fall. The board said in their complaint response that both bedrails and falls risk assessments had been carried out appropriately. We took independent advice from a registered nurse. We found that, from the evidence available to us, the falls and bedrail risk assessments carried out prior to A’s fall were limited and did not inform a comprehensive care plan. The board’s Policy for the Prevention and Management of Adult Inpatients Falling in Hospital Settings did not appear to have been followed. We upheld the complaint.

C complained about the standard of care provided to their parent (A) by the board in relation to a scan that was performed after A had been diagnosed with breast cancer. After speaking with a consultant, A and their spouse believed that A's diagnosis of metastatic cancer was certain and that A had stage 4 cancer. A and their family sought a second opinion. Another MRI scan was performed which showed no convincing evidence of metastatic disease. We took independent advice from consultants in radiology and oncology. We found that the standard of medical care provided to A was unreasonable. This was due to a failure to arrange a further review of the scan and obtain a second opinion, a failure to issue an amended report of the scan in light of A’s trauma history and an unreasonable standard of communication around the scan and the related complexities of A’s diagnosis. We upheld the complaint. We noted that the board has acknowledged and apologised for the distress, noted their failings and taken action. In light of this, we made no recommendations. Wehave asked the organisation to provide us with evidence that they have addressed the failings. Related reading View Decision Report 202401974 as a PDF (24.35 KB) Updated: May 20, 2026

C complained about the care and treatment that they received in A&E, and the subsequent handling of their complaint by the board. C initially attended the A&E with vomiting, diarrhoea and abdominal pain. Although C and their partner raised the possibility of appendicitis, this was dismissed. C was diagnosed with gastroenteritis and discharged without a full abdominal examination or review by a senior clinician. The following day C’s condition deteriorated, and C was found to have a ruptured appendix and septic shock, requiring emergency surgery, ventilation, and a prolonged hospital stay. We took independent advice from an Advanced Nurse Practitioner. We found that the care and treatment that C received was unreasonable because a thorough abdominal examination was not carried out by a senior decision maker and documented to exclude appendicitis as a differential diagnosis, prior to discharging C. It was also unreasonable that the board did not initiate an Adverse Event Review at an earlier stage. We upheld C’s complaint. Regarding complaint handling, we found that the board failed to provide a response addressing all issues raised and did not give C a revised timescale for their delayed response, contrary to the NHS Model Complaints Handling Procedure. We upheld C’s complaint about the board’s complaint handling.

C complained about the care and treatment provided to their late parent (A) by the board. A, who was diabetic, had been diagnosed with conditions including Myasthenia Gravis (an autoimmune disorder causing muscle weakness). A was admitted to University Hospital Crosshouse (UHC) as an in-patient four times, initially with a diabetic foot ulcer. This deteriorated over the course of time leading to infection, surgery and amputation. A died during their fourth admission. The board partly upheld C's complaint and identified failures in A’s care, particularly around the administration of medication for the treatment of Myasthenia Gravis and around communication with A’s family. They identified learning and improvements. C remained unhappy and asked us to investigate. C complained that A had been provided with inadequate care and treatment as a podiatry out-patient and as an in-patient at UHC. C also complained that the board had failed to adequately investigate their complaint. We took independent advice from a consultant vascular surgeon. We found that the out-patient podiatry care provided to A was reasonable and did not uphold this complaint. However, while we found that, overall, A’s care and treatment was reasonable during their in-patient admissions, there were failings in relation to A’s Myasthenia Gravis medication and in communication with A’s family. We upheld this complaint and recommended that the board provide us with evidence of the implementation of the learning and improvements they had previously identified. We found that the board’s investigation of C’s complaint was reasonable. However, we were critical of the time taken to respond to the complaint and of the board’s failure to keep C regularly updated on the progress of their investigation. We noted that the board had accepted this and identified learning and improvements. We made no further recommendation for action. Related reading View Decision Report 202309740 as a PDF (24.71 KB) Updated: March 18,

C complained about the care and treatment that their spouse (A) received from the board during admissions to Dr Gray’s Hospital (Hospital A) and Aberdeen Royal Infirmary (Hospital B). A was admitted following episodes of vomiting blood and received treatment for gastric varices (enlarged blood vessels in the stomach lining). C complained that the board did not investigate or treat A’s condition timeously, and that treatment was only given when their condition deteriorated. C complained that an oesophageal perforation occurred as a complication of a procedure to stop bleeding. C also complained about aspects of nursing care at Hospital B. We took independent advice from two advisers, a consultant hepatologist, who provided advice on the medical care and treatment, and a senior nurse, who provided advice on the nursing care and treatment. In relation to Hospital A, we found that there were aspects of A’s care which had been reasonably managed. Specifically, a recognised tool was used to assess the severity of the upper gastrointestinal bleeding which had occurred. However, there were aspects of A’s care which we considered unreasonably managed. In particular, having identified A as being at high risk of bleeding, there were delays in acting on this result, arranging diagnostic endoscopy, and making a timely referral and transfer to Hospital B for ongoing treatment. On balance, we upheld C’s complaint about Hospital A. In relation to Hospital B, we found that it was reasonable to seek specialist advice about the treatment of A’s condition from another health board. While a complication had occurred when inserting a tube to control bleeding, we found that the management of this was reasonable. We also found that Hospital B had reasonably acknowledged the nursing care incidents which had occurred and taken appropriate steps to learn and improve from them. However, there were aspects of A’s care and treatment which were unreasonably managed by Hospital B. In particular, h

C complained on behalf of their adult child (A), who underwent septorhinoplasty surgery (to improve the function and appearance of the nose) after a rugby accident. C complained about the care and treatment provided to A following the procedure. C had all skin sutures and brace, seven days after surgery, as per the clinic letters. A developed a post-operative infection and was reviewed again 12 days after surgery, when a further suture was removed. More than a year later, A noted black suture material extruding from the scar line on their nose. They were commenced on antibiotics and further review arranged. C complained that the medical records did not support the board’s position that a suture was intentionally left in place and that the board had failed in their duty of candour. We took independent advice from a consultant otorhinolaryngologist (specialist in ear, nose, and throat medicine). We found the standard of care and treatment when A attended 12 days after surgery unreasonable. We also found that A was wrongly told that all remaining suture material had been removed at that time. With regard to the suture material which extruded from the scar line more than a year later, we found that the board’s explanation that this suture was intended to remain in place permanently was not supported by the records. Had it been intended to remain in place permanently, it should have been clearly recorded. We found the board had failed in their duty of candour and that it was unreasonable for the board not to have offered A a second opinion, even if that required referral outwith the board area. We therefore upheld the complaint.

C’s parent (A) suffered a number of falls during an admission to hospital where A sustained a head injury and subsequently died. C complained to the board that A’s falls risk was not effectively managed. The board identified some failings in relation to A’s falls care, including a lack of personalised falls prevention plan and a lack of falls risk signage over A’s bed. However, they noted that staff were fully aware of A’s falls risk and took measures to reduce this, and they did not find that A fell due to a lack of reasonable care. We took independent advice from an experienced mental health nurse. We found that there was a failure to effectively assess A’s significant falls risk and tailor interventions to their individual needs. We noted that the board did not consider it appropriate for A to have received one-to-one nursing or be moved to a more observable area, however, no evidence was provided of consideration having been given to the risks and benefits of such interventions. We upheld this complaint.

C complained about the care that their adult child (A) received from the prison healthcare team and particularly a failure to formulate a treatment plan for ongoing symptoms of stomach pain, nausea, diarrhoea and weight loss. The board noted that numerous tests had been carried out to investigate the cause of A’s symptoms, which had come back negative. They initially mistakenly stated that tests were negative for Irritable Bowel Syndrome (IBS), then later clarified that there is no definitive test for IBS and it is diagnosed by a process of elimination. They said that A had no formal diagnosis of IBS, but received treatment and dietary advice for this possibility. They noted that tests for Inflammatory Bowel Disease (IBD) were negative. As A did not have a diagnosed long-term or chronic condition, the board said a treatment plan was not required and they concluded that A received appropriate care. We took independent advice from a general practitioner. We found that reasonable and thorough tests were done regarding A’s symptoms but a reasonable care plan was not put in place to address possible IBS. Staff appeared to lack a clear understanding of the difference between IBS and IBD. A had an inflammatory eye condition which is associated with IBD, and there was a failure to note this potential link and consider a referral for a colonoscopy (examination of part of the intestines with a camera on a flexible tube). If a colonoscopy was negative for IBD, this would point towards a diagnosis of IBS and a dietician referral and care plan would be appropriate to support dietary changes. We upheld this complaint.

C complained that the board failed to communicate appropriately with their partner (A) regarding charges for treatment. A is a non-UK resident and was charged for non-urgent treatment at hospital following an accident. C complained that A was not informed of the financial liabilities they would incur prior to their treatment, despite having confirmed that they were a non-UK resident and having repeatedly tried to ascertain this information. According to the relevant guidance, any liability to charging should be explained from the outset and patients should be asked to sign an undertaking that they agree to this, ideally before treatment commences. In their response to the complaint, the board said that the correct process had been followed, and that the variation to the standard processing of A’s case was due to the local address information that was initially recorded. The board confirmed that further training and advice would be provided for clinical teams to ensure that they are fully aware of the guidance and how to advise potentially liable patients appropriately. We found no evidence that the guidance was followed in A’s case. We considered it a failing on the board’s part that A’s overseas address was not recorded at their initial presentation, noting that their overseas status was documented in the records at that time. We also found that there was a missed opportunity to follow up on matters when A’s relative contacted the Private and Overseas Financial Team with an enquiry a few days after A’s initial presentation at the hospital. Therefore, we upheld C's complaint. We acknowledged that the board had taken significant steps to improve their service following C’s complaint. A's insurer had also settled the outstanding sum. Therefore, we made no financial recommendation.

C complained that the board failed to reasonably investigate and/or diagnose the cause of their symptoms of significant weight loss, intense abdominal pain, vomiting, altered bowel habit and nausea. C also complained that they were discharged from the board’s gastroenterology service (specialists in the diagnosis and treatment of disorders of the stomach and intestines) despite these ongoing symptoms. C said that they were left with no option but to obtain private care and treatment in England where they were diagnosed as suffering from mesenteric ischaemia (restricted blood flow to the intestines). C underwent surgery to correct this privately. While this resulted in significant improvements in C’s health, C complained that this course of action should not have been necessary and that there were cost implications. In their complaints response, the board acknowledged and apologised for issues with delays in providing investigations, and failings with respect to communication. However, they considered the clinical decisions made in relation to the investigation and management of C’s case were appropriate. We took independent advice from a consultant gastroenterologist and a consultant radiologist (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that the board should have considered a diagnosis of mesenteric ischaemia as a strong possibility based on C’s presenting symptoms. Furthermore, when a CT scan was undertaken there was a failure to report the narrowing of the blood vessels supplying the gut. We found that the decision to discharge C from the gastroenterology service was unreasonable given their ongoing persistent symptoms and, of particular concern, their ongoing weight loss. Therefore, we upheld C’s complaints.

C complained about the dental care and treatment that they received. C underwent root canal treatment (RCT) on their lower right tooth. C said that this was not performed appropriately and that they should have been referred earlier to an endodontist (a dentist with special training to treat problems affecting the inside of the tooth). C was also concerned that the dentist had caused injury to the inferior alveolar nerve (a nerve that runs through the lower jaw, providing sensation to the lower teeth, gum, lip and chin), left a gap in their tooth and caused a dent to another tooth. We took independent advice from a dentist. We did not find conclusive evidence that the dentist caused injury to the inferior alveolar nerve or a dent to C's tooth. We noted that the dentist did refer C to the endodontist but we did not find conclusive evidence that this should have happened sooner. However, we concluded that the dentist did not follow current guidance on endodontic practice. There was no evidence of the use of special tests or periapical radiographs (an x-ray that shows the entire tooth, from the crown to the root tip and surrounding bone) taken before the RCT was performed. As such, it was not possible to determine the case complexity. The dentist also used incorrect solution to irrigate the tooth canal and used an old method for assessing the quality of the radiograph imaging taken. Therefore, we upheld C's complaint.

C complained about the nursing care provided to their late parent (A) during their admission to hospital. A arrived at the emergency department before being admitted to a ward. While in hospital, A lost weight and had difficulty eating. Due to delirium, A’s mobility was poor and they experienced a number of falls whilst in hospital. This resulted in a broken hip requiring surgery. In response to the complaint, the board agreed that there had been multiple failings in relation to the management of A’s diet and reduction in weight. When mobilising A, it was explained that staff did so in accordance with physiotherapy assessments and a number of measures were put in place to prevent A from falls. However, the board acknowledged that due to staffing levels, A did not receive the level of care that they should have. We took independent advice from a nursing adviser. We found that basic nursing care could not be evidenced in A’s case due to a lack of individualised care planning and delivery. We found that the care provided to A was inadequate and inconsistent and was not provided to the standard required. Therefore, we upheld C's complaint.

C complained about the care and treatment that the board provided to their elderly parent (A). A was an active and independent adult who tripped in the community and was admitted to hospital. In hospital, A developed a grade 4 (most severe) sacral (lower back) pressure sore. The board treated A’s pressure sore using Negative Pressure Wound Therapy (NPWT). A deteriorated while in hospital and died approximately twenty weeks after they were admitted. C raised concerns about the medical and nursing care that the board provided to A. In particular, C was concerned about how the board handled A’s deterioration in hospital, that there were missed opportunities to discharge A from hospital and A’s end of life care. The board said that A’s mobility was limited due to pain after admission and that there were no missed opportunities to discharge A. The board apologised for delays in obtaining pressure-relieving equipment for A and that discussions with A regarding the commencement of NPWT were not fully recorded. The board shared an improvement plan regarding the care of pressure sores. We took independent advice from a consultant geriatrician (medicine of the elderly) and a registered nurse. We found that the medical care provided to A was reasonable. We did not uphold this point of C’s complaint. We found that A’s pressure sore was avoidable. We also found that the board failed to provide reasonable nursing care and treatment to A, failed to reasonably assess and treat A’s wounds, failed to reasonably use NPWT in A’s case and failed to complete a significant adverse event review and follow duty of candour procedures in response to A’s avoidable pressure sore. Therefore, we upheld this point of C’s complaint.

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

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

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

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

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

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

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

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

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