SPSO Individual Decisions

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

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

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

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

C complained about the 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 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 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 process followed by the board in commissioning and completing a Level 1 Significant Adverse Event Review (SAER) with respect to the care provided to their partner (A), after they had been diagnosed with Barrett’s oesophagus (a condition where some of the cells in the oesophagus grow abnormally). The SAER was commissioned following the death of A. C complained to the board about their lack of inclusion and involvement in the SAER process. In response to the complaint, the board concluded that whilst the SAER was carried out appropriately and C had been involved in the process, they failed to adhere to their own and published national guidelines in a number of ways. The lack of an appropriate Family Liaison contact had negatively impacted communication with C during the process. C was dissatisfied with the board’s complaints response and brought their complaint to our office. We took independent advice from a consultant hepatologist (medical doctor who specialises in diagnosing and treating liver disease) and gastroenterologist (a medical doctor who specialises in conditions affecting your digestive system) We found that in conducting the SAER, the board had acted in the spirt of national policy and guidance with respect to including C in the SAER process. However, the board’s own policy sets more concrete standards about how communication should be managed. We found that overall C’s level of involvement with the SAER process was reasonable, but that there was issues with respect to miscommunication and managing C’s expectations in this regard. Whilst the board responded to C’s requests to meet relevant members of the SAER team, again the communications were not always consistently responded to by the board. Issues with communication were impacted by the board’s failure to follow process and appoint an appropriate point of contact to assist C and provide them with support. Given the failure to follow process, and issues with respect to communica

C complained about the care and treatment that their child (A) received from a dentist. A injured their front tooth and attended their dental practice for an emergency appointment. The dentist noted there was a 1mm extrusion (tooth displacement) but decided that no treatment was needed. C complained that the tooth wasn’t treated with a splint. The dentist said that dentists are able to use their own clinical judgement to decide whether or not to follow the guidelines in each case. In this case, the dentist decided that the tooth would recover on its own and made the decision not to splint the tooth. We took independent advice from a dentist. We noted that there are standards a dentist should follow. This includes providing patients with treatment that is in their best interests and keeping up-to-date with current evidence and best practices. If a dentist chooses to deviate from established practice and guidance, the reason why should be recorded. We found that the dentist did not record the reasons why they decided not to follow the guidelines and they did not inform C that there were guidelines that applied in this case. We also considered that the decision not to follow the guidelines in this case was unreasonable. Therefore, we upheld C’s complaint.

C complained about the care and treatment provided to their late parent (A) during two admissions to hospital. C complained that during their first admission A was given insulin that was for another patient and C was not timeously informed. C complained that during the second admission, A was initially diagnosed and treated for sepsis but when a CT scan was later performed a major stroke was discovered. C considered that stroke should have been considered and a CT scan should have been carried out earlier. A was given an infusion of both insulin and glucose to manage diabetes. C complained that A was inappropriately given intravenous (IV) glucose for 38 hours after IV insulin had stopped, noting that A became hyperglycaemic (when the level of sugar in the blood is too high) and then developed seizures. C also complained that nursing records were incomplete and that the board’s incident management and review process did not go far enough to recognise or rectify failings. We took independent advice from a registered nurse and a consultant specialising in medicine of the elderly. We found that the insulin error should not have happened. In relation to sepsis treatment, it was reasonable to treat the infection in the first instance but when C informed medical staff of A slumping to one side a medical assessment for stroke should have been carried out and a CT scan should have been booked. We also found that it was unreasonable to continue IV glucose after insulin had been stopped, record keeping was inconsistent and incomplete such that it could not be said that nursing care was reasonable and that incident management and review was also unreasonable. Therefore, we upheld C's complaints.

C complained about the care and treatment provided to their parent (A) when A was admitted to hospital with ongoing pain and mobility issues following a fall. A suffered from significant leg ulcers and had received a package of care while at home. While in hospital, A developed sepsis and did not respond to treatment. A died a few months after admission. C complained of failings in how A’s leg ulcers had been managed, stating that A’s dressings were being changed less frequently than when A was in the community. C highlighted times when family members had raised the need for A’s wounds to be dressed with nursing staff who repeatedly failed to respond to these requests. C also complained of similar failures to provide catheter care and stated their belief that these were contributing factors in A’s deterioration. We took independent advice from a nurse. We found significant failings had occurred with regards to washing and dressing the wounds, and a failure to adhere to the standard of monitoring, risk assessment and record keeping as per the relevant professional Nursing and Midwifery Council (NMC) code. We considered that the nursing care provided was unreasonable and upheld this part of C's complaint. The adviser also highlighted concerns about the medical care and treatment provided and on this basis we took additional advice from a geriatrician (specialist in medicine of the elderly). We found that the wound care provided lacked a coherent and consistent approach, and in particular, that A’s legs were not examined until a number weeks after admission. We also found insufficient attention was given to wound swab results and blood tests, as well as A’s level of pain and overall condition. We found that the medical care and treatment provided to A was unreasonable and upheld this part of C's complaint.

C complained that the board failed to provide them and their baby (A) with appropriate care and treatment both during and after A’s delivery at the hospital. This included failing to advise C that one of the doctors involved in the delivery of A was a first year speciality trainee doctor and that the use of forceps in A’s delivery resulted in them suffering permanent injuries, erb’s palsy (a condition often caused by birth trauma that can affect the movement and feeling in a baby's arm) and phrenic nerve palsy (respiratory distress which can be caused by nerve damage during birth). C also complained that there was a failure by the board to carry out further investigations of A’s erb’s palsy, a failure to deal with A’s respiratory distress and diagnose that they had phrenic nerve palsy and a failure to adequately monitor A’s weight. We took independent advice from two medical advisers, a consultant obstetrician and gynaecologist and a consultant neonatologist. We found that birth injuries could occur even though there were no obvious difficulties with the birth. Given this and the evidence available, it was not possible to establish the cause of A’s injuries. However, we found there was a lack of communication with C during the consent process, C was not consented for the involvement of junior trainee speciality doctors at the birth of A and it was not explained to C that teaching of staff would take place during the birth. We found that no consideration was given to the use of ultrasound to determine the position of A prior to delivery, in accordance with Royal College of Obstetricians and Gynaecologists guidance, and medical documentation around the events of A’s birth was not of the expected standard in terms of the level of detail recorded. We, therefore, upheld this part of C’s complaint. In terms of the care and treatment of A following delivery, we found that, overall, this was reasonable. We found that there were no concerns about the diagnosis and treatment

C complained about the care and treatment provided to their late spouse (A) who had chronic obstructive pulmonary disease (COPD, a group of lung conditions that cause breathing difficulties). A was admitted to hospital as an emergency with kidney failure, and high blood acid and potassium levels. A died the following day. The cause of death appeared to be a cardiac arrest resulting from high potassium, in the context of coronary artery disease. C complained that A should not have been stepped down from the critical care unit to a medical ward resulting in a lack of monitoring and timely treatment for A and that A had inappropriately been deemed DNACPR (do not attempt cardiopulmonary resuscitation). C also said that the board’s review into A’s death failed to identify or acknowledge clinically significant evidence and that communication and provision for bereaved families was poor. We took independent advice from a consultant in acute and general medicine. We found that while it was reasonable for the board to have considered moving A to a general medical ward, an arterial blood gas test conducted prior to the transfer had indicated that A’s condition was deteriorating. This test was not acted upon. We were also critical that the board had missed the significance of these test results during their complaints investigation. Furthermore, while the process for declaring a DNACPR was reasonable, we found that the way in which this had been explained to C had been lacking. We also noted that while the board had confirmed that facilities for bereaved families were available, they were not utilised for A’s relatives on this occasion. Therefore, we upheld all of C’s complaints.

C complained that the board failed to provide their spouse (A) with reasonable care and treatment during an in-patient admission to hospital for a fractured hip. C who is A’s Power of Attorney also complained that the board failed to communicate adequately with them and A’s family. We took independent advice from an orthopaedic surgeon (specialist in the treatment of diseases and injuries of the musculoskeletal system) and a registered nurse. We found that the board had failed to provide A with adequate care and treatment, particularly in relation to pressure care management. We found that the board had failed to maintain a reasonable standard of care records. We also found that the board failed to communicate adequately with C and A’s family. Therefore, we upheld C’s complaints. Additionally we found that the board failed to adequately investigate C’s complaint and made a recommendation to address this. In response to our enquiries during our investigation, the board sent us a detailed list of actions that they have taken to address and learn from the failings we identified. We considered that these were reasonable, but that further learning could be identified.

C complained that the medical practice failed to provide their late parent (A) with reasonable care and treatment after A fell and hit their head. A had sustained a subdural haematoma (where blood collects between the skull and the brain). A was cared for in their home and later admitted to hospital. A died a few months after their fall. We took independent advice on this complaint from a GP. We found that the head injury assessment was unreasonable and not in line with NICE guidance. We were critical that the practice did not acknowledge this failing in their complaint response, the significant adverse event review (SAER) or in response to our enquiries. We found that it was unreasonable that concerns raised by C, after A’s fall, did not prompt further action by the practice. We also noted that the clinical notes did not adequately describe the head injury and there was no evidence that the practice understood the significance of the head injury and communicated that to the medical service they referred A onto. Therefore, we upheld this part of C’s complaint. C also complained that the practice unreasonably failed to carry out a SAER in line with the relevant Healthcare Improvement Scotland Guidance. We found that the initial SAER was of poor quality. The enhanced SAER was in line with the guidance, but we were again critical of the quality. Therefore, we upheld this part of C’s complaint. We also found that the practice’s complaint handling did not mirror the current Model Complaints Handling Procedure. Therefore, we made a recommendation to address this.

C, a support and advocacy worker, complained on behalf of their client (A) about the care and treatment that A received from the board in relation to a planned gynaecology (relating to the female reproductive system) surgical procedure. Following a discussion with the operating consultant on the day of the surgery, A said that the planned procedure was changed from a keyhole subtotal hysterectomy (removing the main body of the womb and leaving the cervix in place) to a keyhole total hysterectomy (removing the womb and the cervix). A said that they felt they had been put under pressure to accept the operation, and did not understand the consequences of losing their ovaries. A’s surgery was carried out at a private sector hospital by the board’s surgical team due to the board experiencing issues with theatre capacity at that time. During the operation, a complication occurred which caused A to bleed and the procedure was converted to an open procedure to manage the bleeding. Having complained about the matter, the board explained to A that an issue with equipment during the surgery meant that the correct equipment had not been available during the procedure. A complained to the board on two further occasions in order to gain more understanding about the complication and the issue with the equipment which had occurred during the operation. A felt that the board’s responses were contradictory and asked C to complain to this office on their behalf. We took independent advice from a consultant gynaecologist. We found that there were failings in relation to the process of consent at both the pre-operative clinic and on the day of surgery. We also found failings in relation to the documentation of the operation, including the complication and the way this had been managed during the procedure, and in the equipment log of the surgical instruments used during the procedure. To manage the bleeding, we found that the choice of equipment used had been unreasonable, noting it was

C, a support and advocacy worker, complained on behalf of their client (A) who suffered from thyroid eye disease (an autoimmune disease in which the eye muscles and fatty tissue behind the eye become inflamed). A complained that the treatment provided by the board had been ineffective and requested a second opinion and a review of the treatment that they had received to date. We took independent initial advice from a consultant ophthalmologist (a specialist in the study and treatment of disorders and diseases of the eye). We found that while the board had obtained a second opinion on A’s condition and plan of care moving forward, they had promised to review A’s past care and treatment which had not been done. The board have now confirmed that a consultant has been found to review the relevant treatment and this has been agreed by all parties as a resolution to this complaint. Related reading View Decision Report 202109730 as a PDF (24.21 KB) Updated: April 17, 2024

C complained that the board failed to provide reasonable care and treatment to their sibling (A) after they were admitted to hospital. A had a cardiorespiratory arrest (the cessation of effective ventilation and circulation) in the hospital and suffered a brain injury as a result of this. We took independent advice from a consultant in critical care. We found that the board had provided reasonable care and treatment to A and we did not uphold this aspect of the complaint. C also complained that the adverse event review that the board subsequently carried out was unreasonable. In relation to this complaint, we found that the board had carried out a level 2 review when a level 1 review should have been carried out. The level 2 review had also been allocated to an inexperienced review team, it reviewed only part of A’s care journey, and it was short and poorly detailed. We also found that the record-keeping on the ward immediately before and after A’s cardiorespiratory arrest was limited and not of the standard expected. Detailed retrospective entries should have been completed shortly after these events occurred, by both medical and nursing staff. We therefore upheld this aspect of the complaint. We also found that the board’s complaint handling of C’s complaint was unreasonable.

C complained about the nursing care that their parent (A) received. A had dementia and was admitted following a fall in their care home, remaining in hospital until their death some weeks later. C complained that during A’s admission, A was not treated with dignity, that they were left without food or water, and that they were allowed to aspirate on pureed food because they were not safely positioned in bed. The board maintained that overall the nursing care was of a reasonable standard, but they accepted that documentation had been poor. They provided us with a detailed action plan which they were implementing in response to the failings that they had identified. We took independent nursing advice. We found gaps in record-keeping in relation to food and fluid intake. We found that the board had failed to evidence that A was cared for in a dignified and respectful manner. Comfort rounding was not provided as frequently as it should have been, taking into account A’s frailty and general condition. A had pressure ulcers and we found that the board had failed to demonstrate sufficiently frequent skin checks and repositioning. The board also failed to maintain wound charts, recording wound sizes and grade. There was no evidence of oral care having been provided. We did not find evidence to support the account that A was left to choke on pureed food on the day before they died. The records indicated that A was being checked on regularly that morning, and that A was asleep much of the time and noted to be ‘too drowsy for oral intake’. A was being treated for secretions, which we considered may have accounted for the gurgling sound reported. Although it was not possible to establish precisely what had happened on this date, it was regrettable that this incident caused so much distress to the family, and we noted that the board had apologised for the distress caused. Taking all of the above into account, we upheld the complaint. We found that the board’s action

C complained that the partnership had not provided the correct care and treatment for their ear infection in their right ear. C did not consider that the ongoing ear infection had been correctly diagnosed or treated, noting that the antibiotics which were prescribed had not been effective. C was concerned that although a referral to ENT had been made, the referral was not correctly prioritised, which had caused a significant delay. It was only when C saw a doctor, who phoned ENT, did C receive specialist input. We took independent advice from a GP adviser. We found that C had not been seen face to face for a six month period, the first was a routine referral and the second expedited referral did not reflect the clinical situation because C had not been examined. We also found that the overuse of antibiotics had likely aggravated the situation. Overall we considered that more could have been done to clinically assess and seek specialist input for C’s ear infection. We therefore upheld the complaint.