SPSO Individual Decisions

C complained about the care and treatment of their adult child (A) following A’s admission to hospital. A had a long standing, complex medical history including two kidney transplants and kidney cancer, and A died during their admission. In particular, C complained about A being prescribed Dapsone for a skin infection without discussion with A’s Renal Consultant and also that the Respiratory Team did not review A in the days prior to A’s death. C also complained that the board had failed to communicate in a reasonable way, in that critical information relating to A’s care had not been passed on between clinical teams or shared with the family. The board said that A’s renal disease did not contraindicate Dapsone which was frequently used following renal transplantation. The progressive respiratory reaction which A suffered would be a very rare side effect. The board said that Dapsone was appropriately discussed with A and prescribed, with no known lung or kidney-related risks in standard guidance. The Renal Consultant was informed and raised no concerns. The board acknowledged that the communication between clinical teams as documented in the medical records was open to interpretation and that this aspect of the complaint could have been better addressed in the formal complaint response. We took independent advice from a Renal Consultant and a Respiratory Consultant. We found that the clinical care and treatment was reasonable, and in keeping with normal practice. There was no requirement to seek advice from A’s Renal Consultant about the prescription, but they were aware of it and had no concerns. The side effect that A experienced is extremely rare such that the effect and outcome could not have been foreseen. We found that the Respiratory Team were appropriately involved where required and that the care provided was reasonable. We did not uphold this complaint. However, we found that the board had failed to communicate in a reasonable way and that communication fe

C complained that they were inappropriately triaged at A&E because sepsis had not been considered, their symptoms and history were not accurately recorded and medication was not appropriately considered. C felt extremely unwell after taking medication for alopecia, attended the A&E and were triaged within one hour. An allergic reaction was considered, observations were taken and cocodamol was administered. C was categorised as a priority level 3 for urgent but stable conditions, which should be seen within one hour. C was advised that they may have to wait seven hours as the A&E was busy. C left the A&E as they felt too unwell to wait. They were returned to hospital the following evening, by ambulance, with sepsis and blood clots in their lungs. The board advised that C was correctly prioritised according to the observations and symptoms recorded at the time. They advised that a nurse in charge would check patients during their waiting time and re-categorise as necessary. They also advised that more detailed checks and tests would be done at the point of medical assessment. We found that the triage process was in line with guidance and that the categorisation was correct. However, we noted that the blood pressure reading was high and should have been rechecked. We also noted that the extended waiting time for triage and medical assessment was not in line with guidance. On careful balance, we found that the triage process was reasonable because C was correctly categorised. We acknowledged that if C had waited, further review and medical assessment would have taken place. We did not uphold the complaint. Related reading View Decision Report 202502009 as a PDF (24.6 KB) Updated: May 20, 2026

C complained about the care and treatment that their late partner (A) received from the board’s gynaecology and oncology services at Glasgow Royal Infirmary. A was admitted to hospital, diagnosed with liver cancer, given two months to live and died. C also complained about the board’s handling of their complaint. We took independent advice from a consultant gynaecologist and a consultant oncologist. We found that there appeared to be no evidence that A had any follow-up appointments with the board until 1 year and 11 months after completion of their cancer treatment, contrary to the west of Scotland cancer network guidelines. We noted that the board had acknowledged that A had a long wait for their gynaecology follow-up appointments, their cancelled appointments were not reappointed within a month, and they had to chase for appointments. We noted that the board had apologised for these failings and indicated that they were taking remedial action to address this. Given the board’s failure to follow the guidelines and their repeated cancellation of A’s gynaecology appointments, on balance, we upheld the complaint. C also said that the board’s response to their complaint did not give them any option to ask for clarification or to challenge the response. We found that the board failed to follow the NHS Model Complaints Handling Procedure and advise C that a named member of staff was available to clarify any aspect of the response. We, therefore, upheld the complaint.

C complained about the care and treatment provided to their parent (A). A had dementia and had suffered several falls. C complained that the board failed to reasonably investigate A’s fall and that they failed to reasonably consider carrying out a Significant Adverse Event Review (SAER). We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly) and a registered nurse. We found that the board should have identified ambiguous and confusing language was used to describe A’s fall in its investigation. It should also have established that the fall was unwitnessed. We upheld this complaint. In relation to a SAER, the board were able to demonstrate that they had followed the guidelines in place at the time for determining if an SAER was required. In the period following the incident, local guidelines governing the holding of an SAER were superseded by national ones. We did not uphold this complaint.

C complained about the care and treatment provided by nursing staff to their late sibling (A), who was admitted to hospital with a chest infection. A was discharged with injuries and delirium, which C believed was due to a fall they had shortly after admission. A was a wheelchair user and especially vulnerable to falls because of their bone condition (osteoporosis). C said that a full assessment of A’s risk of falling was not carried out and that the fall caused A to deteriorate, and led to their death three months later. We took independent advice from a registered nurse adviser. We found that the standard of nursing care provided was not reasonable in that a falls risk assessment was not carried out fully and accurately, documentation and record keeping did not meet the required standards, communication needs were not met and full learning and improvement was not achieved because a significant adverse event review was not carried out. We upheld the complaint.

C complained about the care and treatment that they received from the board.Towards the end of their pregnancy, C contacted the Maternity Assessment Unit due to reduced fetal movements. After phone advice and subsequent in-person assessment, they were discharged home. C again reported concerns at 39 weeks and 5 days gestation at a routine community midwife appointment. Fetal movements were discussed and further review was advised the following week. At the next appointment, tests were carried out,which sadly confirmed fetal loss. Labour was induced, and C delivered their baby. We took independent advice from a senior midwife. We found that the board provided a reasonable standard of maternity care and treatment to C. We found that fetal movements were appropriately discussed, measurements were consistent with earlier assessments,and it was reasonable not to arrange additional investigations. We did not uphold this complaint. Related reading View Decision Report 202400402 as a PDF (24.28 KB) Updated: March 18, 2026

C complained about the care and treatment provided by the board during a planned caesarean section. C said that complications occurred during the procedure which could have been avoided based on information available from antenatal scans. C also complained about the timing of the procedure, record keeping, delays in arranging a debrief meeting, postnatal care for high blood pressure and infection, and the board’s handling of the complaint. We took independent advice from a midwifery adviser. We found that the care C received during the caesarean section was of a reasonable standard. It was reasonable to schedule C last on the theatre list due to an active COVID-19 infection, and there were no clinical indicators requiring enhanced planning. While complications occurred, we found that these were reasonably managed. We found that offering C the option of vaginal birth reflected good practice. We did not uphold this complaint. In relation to C’s post-natal care, we found that the monitoring and management of blood pressure, infection treatment, and follow-up care were appropriate and in line with clinical guidance, and the medical records were accurate. We did not uphold this complaint. We considered C’s complaint about the board’s handling of their complaint. We found that the board acted unreasonably by refusing to investigate on the grounds of time limits, despite the delay being due to a postponed debrief meeting and reassurances given that a complaint could still be made. The board did not provide a clear explanation for refusing to extend the timescale, contrary to complaint handling guidance. We upheld this complaint.

C complained about the treatment that the board provided to their late spouse (A) during a lengthy hospital admission. A's agitation and delirium was treated with anti-psychotic medication and sedatives. A was later discharged to a care home. C was concerned about the amount and appropriateness of the anti-psychotic medication and sedatives administered to A. They also highlighted what they considered to be inaccuracies in the recording of the medication administered and felt A was unreasonably discharged. We took independent advice from a consultant in old age psychiatry. We found that the type and amount of medication administered was in keeping with prescription guidelines and accepted clinical practice. Medication was also reasonably prescribed and adjusted after appropriate consideration of A’s history and symptoms. Therefore, we did not uphold this part of C's complaint. In respect of record keeping, we found that there was no firm evidence to indicate staff unreasonably failed to record medication on the electronic recording system. We recognised that there may appear to be discrepancies between what was on the online system and what was documented in the written notes. However, factors such as non-contemporaneous recording and separate medical/nursing records can account for this. As such, we did not uphold this part of C's complaint. Finally, we found that A's discharge was based on an appropriate consideration of their overall health, including delirium. Therefore, it was reasonable to conclude that A’s ongoing health could be managed in a care home setting. We did not uphold this part of C's complaint. Related reading View Decision Report 202405542 as a PDF (24.6 KB) Updated: February 18, 2026

C complained that the board's communication around their spouse (A)'s care and treatment was unreasonable. C complained about a lack of face-to-face appointments, delays and the board not following their diagnostic pathway. C said that they were informed of A's prostate cancer over the phone, with no support provided to help them come to terms with the diagnosis or deciding on treatment which, due to A’s co-morbidities, was more complex. The board apologised that not all of the appointments were face-to-face but explained that this was due to demands on the service. They acknowledged that this was not ideal but it was necessary to reduce delays. The board said that the MRI result clinic was omitted from the diagnostic pathway in order to expedite A's biopsy. The MRI results were shared at the biopsy appointment. An MDT discussion took place a week after the biopsy results were reported and the diagnosis was shared with A by telephone rather than waiting a further four weeks for a face-to-face appointment. We took independent advice from a consultant urologist (a doctor who specialises in the male and female urinary tract, and the male reproductive organs). We found that the board’s communication was unreasonable. There was a lack of explanation about why the MRI results clinic was omitted from the pathway, as well as an inadequate explanation of the MRI result itself. It is clear that A did not understand the likelihood of cancer that prompted the biopsy and their understanding was not checked until the point of diagnosis. Therefore, we upheld C's complaint.

C complained about the care and treatment provided to their adult child (A). A has hereditary haemorrhagic telangiectasia (HHT, a rare genetic disorder characterised by abnormal blood vessel formation, leading to frequent bleeding, with potentially severe complications). A attended A&E as they had previously been bleeding from the left eye. A was triaged within 30 minutes and seen by a senior nurse within 90 minutes. The senior nurse discussed A’s presentation with a senior doctor. A was advised that they could await clinical review by a doctor, with a likely wait of up to two hours. A decided to leave and see an optician the next day. A was subsequently referred to the ophthalmology department (eye specialists) for further review and then to the oculoplastic clinic (specialists in surgical procedures around the eye) to consider cauterisation of a lesion inside the left, lower lid. C complained that triage and initial review were unreasonable, as no-one examined A’s eyes or nose, staff had little understanding of the condition, on-call ophthalmology were not consulted and A felt pressured to leave. Overall, C was concerned that A could have lost their sight without timeous, specialist intervention. The board considered that A had been appropriately managed in A&E. They noted that the discharge letter advised A had no active bleeding and no visual disturbance. A was offered to wait for medical review but decided to make their own optician appointment. We took independent advice from a consultant in emergency medicine. We found that triage and staff understanding of A's condition was reasonable. We found that it was reasonable to give A the opportunity to await clinical review and not to have ophthalmology input prior to clinical review. No harm came to A and no adverse event review was required. We did not uphold C's complaint. Related reading View Decision Report 202410876 as a PDF (24.78 KB) Updated: December 17, 2025

C complained that the board failed to provide them with reasonable care and treatment. C had a cancer diagnosis and was concerned about the length of time taken to arrange their surgery. We took independent advice from a consultant clinical oncologist (specialist in the diagnosis and treatment of cancer). We found that it was reasonable for C's treatment plan to change and the delays in arranging a date for surgery were unavoidable due to capacity issues. Therefore, we did not uphold this part of C's complaint. C also complained that the board's communication was unreasonable. We found that the board’s complaint response contained inaccurate information. In particular, it indicated that a provisional date for surgery was offered to C when this was not the case. Therefore, we upheld this part of C's complaint. However, we made no recommendations based on appropriate action already taken by the board. Related reading View Decision Report 202407399 as a PDF (24.26 KB) Updated: November 17, 2025

C complained that they had received substandard care across a series of surgeries to their nose. They said that the board inaccurately stated that C was suffering from a recognised complication and that the board failed to provide C with sufficient information about the possible complications of surgery. The surgery had left C with a deformed nose, significant impairment to their breathing, constant pain and affected their ability to work. C was seen for a second opinion by another Health Board in Scotland and had received surgery in England from a surgeon with expertise in this area. C believed that their medical records had been deliberately falsified or altered to conceal mistakes in their care. The board had responded to a series of complaints from C, but their position was that C was suffering from recognised complications, which treatment had been unable to resolve. They did not accept C had been misled about their treatment, or that C’s records had been altered or falsified. We took advice from a consultant surgeon, with expertise in the type of surgery C underwent. We found that C's complications were ones associated with the type of surgery that they had undergone. Therefore,we did not uphold this aspect of the complaint. Parts of C's records were not well maintained, although there was no evidence of falsification or alteration. Consequently, it could not be demonstrated that C had given informed consent to some of the procedures, and board staff failed to have full and frank discussions with C about their surgeries and the condition of their nose. We upheld this aspect of the complaint around providing sufficient information on the complications of surgery. We found that C was suffering from a recognised complication of surgery, but that the consent process had fallen below a reasonable standard. There were errors in C's medical records, particularly around the first surgery C underwent, but overall, we found that C's care and treatment was reasonably doc

C, a support and advocacy worker, complained on behalf of their client (B) about the care and treatment provided to B's late family member (A) during their admission to hospital. In particular, in relation to pain management, standard of care and communication. In response to the complaint, the board apologised for the failings identified in nursing care and communication. As a result of the failings the board had taken action. This included reiterating the importance of following the National Early Warning Score (NEWS) policy, reminding nursing staff of their obligations to comply with their code of professional conduct in the workplace, and reflecting on A’s care for the purpose of improving person centred care. B was dissatisfied with the board’s response and brought their complaint to the SPSO. During our investigation, the board accepted that aspects of A’s care and treatment should/could have been better and explained that reflection had taken place, and learning had been taken forward for the purpose of improving the level and standard of person-centred care provided to other patients. In addition, relevant staff had been given the opportunity to reflect on their communication with A’s family. We took independent advice from a consultant general and colorectal surgeon (specialist in in conditions in the colon, rectum or anus). We found that there had been a number of failings in the care and treatment A received. In particular, we found that there had been a delay in carrying out a CT scan and in diagnosing that A had a bowel obstruction. We found that this may have impacted on their management, including giving consideration to conservative/non-surgical intervention. We also found that A’s pain management had been unreasonable and that an adverse event review should have been conducted, particularly around a diagnosis of bowel obstruction and its management. In view of the failings identified, we upheld C's complaint.

C complained about the lack of care and treatment that the board provided in relation to not being recalled for a colonoscopy. C had undergone regular colonoscopies to monitor disease progression. C was not recalled when the next colonoscopy was due. The COVID-19 pandemic led to suspension of services with a long backlog of patients. When C did subsequently undergo a colonoscopy, this led to a diagnosis of cancer. We took independent advice from a consultant gastroenterologist and hepatologist. We found that the board failed to identify C as someone at significant increased risk that needed the procedure to be re-booked as a priority. We found that it was unreasonable that C’s colonoscopy was an overdue procedure that was not clinically reviewed. Therefore, we upheld this complaint. We also found that it was unreasonable that the board had not carried out a significant adverse event review into the matter. C also complained that the board failed to provide a reasonable response to their complaint. We found that the board’s complaint handling of C’s complaint was unreasonable, as the failure to clinically review C’s overdue procedure and failure to identify C as someone at significant increased risk, were inadequately investigated as part of the complaints process. In light of that specific failing, we also upheld this complaint.

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

C complained about the board’s decision not to provide thyroid chondroplasty (a surgery to reduce the size of the Adam’s apple) as part of their gender affirming treatment. The board explained that though they used to have surgeons who could carry out this surgery, they no longer do. They said that the Scottish Government does not fund thyroid chondroplasty and therefore they cannot recruit surgeons for the purpose of performing the surgery and are prevented from using public finances to fund it. We found that there is no obligation for the board to provide thyroid chondroplasty on the basis of Scottish Government protocols. However, protocols state that health boards should ensure they have clear documentation on what is available to their patients and have local policies in place regarding access to them. We gave feedback to the board on this point, but ultimately did not uphold C’s complaint. C also complained that when they were in the process of having hair removal prior to gender reassignment surgery, the board stopped providing this service. Because hair removal at the site of surgery is a requirement, C had to pay for the hair removal to be completed privately. During the course of our investigation, the board accepted that they had not been clear to them at the point of C’s complaint that it is the responsibility of the health board where the patient lives to arrange hair removal prior to gender reassignment surgery. The board apologised for the failure and financial inconvenience caused and offered to reimburse C for the laser hair removal. We upheld the complaint and made no further recommendations. Related reading View Decision Report 202311694 as a PDF (24.62 KB) Updated: May 21, 2025

C complained on behalf of their late partner (A) who died from a stroke caused by a blood clot. A was admitted to hospital with seizures after collapsing at home and sustaining a head injury. A couple of days later A was identified to have had a stroke, and they died the next day. C complained that an MRI scan was not carried out in order to verify the cause of A’s seizures (a blood clot), in a timely manner to enable acute stroke interventions. We took independent advice from a consultant in intensive care medicine and a consultant stroke physician. We found that receiving a CT head scan when A first presented was appropriate. A working diagnosis of seizure was reasonable at that time. We found that it was reasonable that time critical acute stroke interventions were not indicated, and therefore an MRI was not indicated. A repeat CT scan did not show any significant changes from the initial scan. We noted that an MRI scan at this point would have been unlikely to have altered A’s immediate management. C was concerned that placing A in a medically induced coma masked the progression of the stroke, however, we found that this action was in keeping with guidelines. We considered that the clinical management of A was reasonable. Therefore, we did not uphold C’s complaint. Related reading View Decision Report 202302038 as a PDF (24.47 KB) Updated: May 21, 2025

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

C’s adult child (A) was awaiting surgery for germ cell cancer when they became unwell and were taken to A&E. A was transferred to a ward where C raised concerns about the treatment that A was receiving. C felt that A was deteriorating and requested on a number of occasions that A be transferred to the High Dependency Unit (HDU) or another hospital. A number of reviews were undertaken and a transfer to HDU was agreed and actioned. Acute deterioration of A was noted and they were intubated and invasive mechanical ventilation began. It was also decided that A should be transferred to a different hospital. The transfer took place following the surgical removal of the catheter. A sustained a subdural haematoma (when blood escapes from a blood vessel, leading to the formation of a blood clot that places pressure on the brain and damages it), and developed multi organ failure and right and left ventricle failure. A died just over two weeks later. C raised complaints with the board regarding A’s care and treatment, including concerns that information C had sought to provide staff, and requests that they had made about A’s treatment, had been ignored. The board’s response concluded that generally A’s care and treatment had been reasonable. C was dissatisfied with this and raised their complaints with us. We took independent advice from a consultant emergency physician adviser. We found that a significant adverse event review (SAER) would have been justified in the circumstances. We advised the board of this and they indicated that they intended to undertake an SAER regarding A’s care and treatment. In the circumstances, we suspended our investigation whilst the SAER was undertaken. We became concerned about the time that was being taken to progress and finalise the SAER and when we began to progress the investigation again, the finalised SAER report was provided to C shortly afterwards. A later meeting led to a revised SAER report being provided. We found that the conclusion

C complained about the standard of care and treatment provided by the board to their late parent (A) during two hospital admissions and the communication around this. C also complained about the way that A was discharged and when they felt that they were unfit to be discharged. A was hard of hearing and a non-English speaker. C said that the failings led to a great deal of mental and physical stress and A’s premature death shortly after the second discharge. We took independent advice from a consultant physician specialising in medicine for older adults. We found that while aspects of the care and treatment were reasonable, there were failings. The board failed to communicate adequately in relation to A’s care and treatment. In particular, in relation to the seriousness of A’s illness and ensuring that A’s family understood that A was at the end of their life, and the lack of an in-person professional translator for A. Finally, we found that A was not discharged in a reasonable way on the second discharge home, that they should have been reviewed by a senior clinician and had all the relevant tests and investigations carried out and reviewed, and that on discharged, should have had all the required support from the community in place to meet their needs. We upheld the complaint.

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

C complained about the care and treatment provided to their 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 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 is a kidney transplant patient who was suffering from COVID-19 when they were admitted to hospital. C’s COVID-19 worsened and C developed blood clots in their lungs. C was treated with anti-coagulant medication. However, over time C developed a haematoma (a collection of blood) in their right arm and a large haematoma which caused permanent damage to nerves in C’s left thigh. C complained that staff had not been proactive enough in monitoring the effects of the anti-coagulant medication or in managing the blood clots and haematomas. C also complained that a referral to a neurologist should have taken place at the time and would have improved their long term prognosis. The board explained that the effect of the anti-coagulant was not usually measured, but could be useful in patients with kidney disease. They had therefore monitored as required. Medication was changed due to concerns that the blood clots were getting worse and then stopped in light of the bleed into C’s thigh. A neurology referral was not made, as following discussion with surgical and radiological experts it was determined that supportive therapy was the most suitable management strategy for C’s case. We took advice from a consultant haematologist and consultant neurologist. We found that C had both blood clots and significant bleeding. Both can be life-threatening, and treating one may make the other worse. We found that the monitoring and management of the anti-coagulant medication and the management of the haematomas and blood clots was reasonable and that it was reasonable not to refer to neurology and not to have considered femoral neuropathy. Therefore, we did not uphold the complaint. Related reading View Decision Report 202305722 as a PDF (24.66 KB) Updated: March 19, 2025