SPSO Individual Decisions

C complained about the care and treatment provided to their adult sibling (A). A had treatment for breast cancer, was admitted to hospital a short time later and died approximately two weeks after being admitted. C complained about A’s medical and nursing care and treatment in hospital and about the communication with A’s family. The board said that when A was admitted to hospital, a CT scan (a test that takes detailed pictures of the inside of the body) revealed extensive metastatic disease (disease that has spread from its original location) in A’s liver and bones. Treatment options were discussed with A. A was initially independent after admission to hospital, but A’s condition deteriorated. A was reviewed by an oncologist (a doctor who is a specialist in cancer), and A was deemed too ill for further treatment. The board said that they respected A’s wishes regarding communication with A’s family. We took independent advice from a specialist doctor in palliative care and a registered nurse. We found that the medical and nursing care and treatment were reasonable, and the board’s communication with A’s family was reasonable. Therefore, we did not uphold C’s complaint. Related reading View Decision Report 202409961 as a PDF (24.35 KB) Updated: May 20, 2026

C complained about the standard of medical care provided by the board during two attendances at A&E with severe abdominal issues. C was discharged home on both occasions, and shortly after the second discharge, the results of a magnetic resonance scan (MRI) indicated that they had significant abnormalities of the bowel. C was then admitted to hospital for treatment of inflammatory bowel disease. We took independent advice from consultants in emergency medicine and general medicine. We found that the standard of medical care provided was not reasonable in that recordkeeping and communication was poor, C was misdiagnosed with constipation at the second visit, there was a failure to act on the results of the MRI scan and discuss C’s care with the relevant specialists at the second visit, and there was a delay in treating C and admitting them to hospital. We upheld the complaint.

C complained about the decision of the practice to remove them from their list and about the way that the practice handled their complaint. C had a consultation with a GP at the practice. A few days later C was removed from the practice list. Practices are entitled to remove patients from their lists in certain circumstances. That said, for a removal to be reasonable, the practice need to be able to demonstrate that they have acted in a way that is consistent with The National Health Service (General Medical Services Contracts) (Scotland) Regulations 2018 (the 2018 Regulations) and General Medical Council guidance to ending a professional relationship with a patient. Regarding C’s removal from the practice, we found that the practice did not act in accordance with the 2018 Regulations and the GMC’s guidance. The practice did not provide any contemporaneous written records setting out the reason why no warning was given in this case and the circumstances of the removal. They also did not provide records of the justification for removing C from the practice list for expressing dissatisfaction about the care and treatment provided and the grounds for it not being considered appropriate to provide C with a more specific reason for the removal. Regarding the handling of C’s complaint, we found that the practice failed to fully investigate and respond to the points of complaint being raised in accordance with the practice’s complaint handling procedure and the NHS Model Complaints Handling Procedure. They also failed to provide C with a copy of the practice’s Public Facing Complaints Handling Procedure. We upheld C's complaints.

C complained about the care and treatment provided following their referral for a transurethral resection of the prostate (TURP, an operation to reduce the size of the prostate gland). The surgery was cancelled on the day when C's prostate was measured and considered too large for TURP surgery. C was then referred for Holmium Laser Enucleation of the Prostate (HoLEP, a procedure that uses a laser to remove enlarged prostate tissue) at another board. C complained of unreasonable waiting times for surgery; contraindicated medication; lack of prostate measurement during pre-op checks; that the operation was unreasonably cancelled; poor communication and administration of the referral and errors in the board’s complaint response. The board acknowledged delays due to service pressures and apologised for errors in the complaint response. They outlined steps taken to improve waiting times; validate waiting lists; measure prostates during wait; and improve communication and administration. They confirmed that HoLEP is preferred for prostates over 80 cc and explained that C’s prostate was measured at 100 cc. 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 waiting time for surgery was unreasonable and that C should have been given the option of the TURP surgery, with the risk and benefits explained, given the long wait. We found that C was appropriately prescribed medication which was not contraindicated. We also noted that pre-op checks were anaesthetic checks and not usually used for prostate measurement. Overall, we found that C's care and treatment was unreasonable due to the excessive waiting time and lack of option for TURP. Therefore, we upheld C's complaint. However, as the board had taken several steps to address issues, it was not considered that this situation would happen again. No further recommendations were made. Related reading View Decis

C complained about the care and treatment given to their late sibling (A) who had a history of schizoaffective disorder. After a change in the consultant responsible for A’s care, A’s diagnosis was changed and their medication withdrawn over an extended period which led to A becoming unwell. They required admittance to hospital on a number of occasions before their death by suicide. The board carried out a significant adverse event review (SAER) into what happened which identified a number of failures and made a number of recommendations as a result. Later the board issued their complaint response to C’s complaint which detailed the consultant’s position that A’s symptoms were not in keeping with a continuing psychotic illness, and that, this view was shared by the wider clinical team. We took independent advice from a consultant psychiatrist and a mental health nurse. We found that the decision to change A’s diagnosis was not supported by their presentation, that the various diagnoses were referred to with no explanation and that the consultant involved in A’s care held an incorrect belief that schizoaffective disorder and schizophrenia were, in essence, the same condition and were interchangeable. We also found that NICE guidelines were not always followed appropriately, that there was an over-reliance on remote methods of assessment, that changes were made to medication without having seen or assessed A and that clinicians unreasonably maintained that A did not present with psychotic symptoms when the evidence demonstrates otherwise. Finally, we found that the nursing care was reactive and treatment was crisis led and failed to provide support and strategies for early interventions, that there was a failure to create a community care plan and that there was a lack of multi-disciplinary working, and therefore, a lack of challenging decisions on patient care. As such, we found the care and treatment both in hospital and from the community nursing team to have been

C complained about the standard of medical care and treatment provided to their late partner (A) by the board in relation to their risk and diagnosis of liver cirrhosis (permanent scarring of the liver which leads to dysfunction) and gastrointestinal haemorrhage. A was initially under the care of the board’s rheumatology service for psoriatic arthritis, which was treated with medication. The board’s gastroenterology service then began to care for A, and, after testing, found that A had liver cirrhosis with portal hypertension (elevated blood pressure in the portal vein). After several months, A’s condition began to deteriorate and they attended the medical ambulatory care unit and A&E within a few weeks. A was discharged home both times. A died two days after their contact with A&E. We took independent advice from four advisers who are consultants in rheumatology, gastroenterology, general medical and emergency medicine. We found that the standard of rheumatology, general medical and emergency medicine was reasonable. However, we found that the standard of gastroenterology was not reasonable in that A’s signs of deterioration were not taken seriously enough by the gastroenterology service including that the signs of abnormalities were not reasonably investigated, that A’s portal hypertension should have been identified following an endoscopy and that A should have been referred to a liver transplant unit. We found that the multidisciplinary team meetings unreasonably failed to pick up A’s clear deterioration and arrange appropriate investigations and treatment, and discussions were brief and decisions were deferred. We found that keeping A in the specialist nurse led clinic when they were diagnosed with liver cirrhosis and portal hypertension, and deemed suitable for a transplant, was unreasonable. Finally, we found that there were record keeping failings including clinic letters that failed to contain important information about A’s diagnosis and condition and we f

C complained about the care and treatment provided to their parent (A). A suffered a heart attack and was treated with increased levels of digoxin (heart medication) in hospital. Over a two-week period A became increasingly paranoid and agitated and needed to be medicated. A was then transferred to a nursing home. A’s digoxin levels were found to be very high and this medication was reduced. C believed that A was suffering from digoxin toxicity. C felt that A’s digoxin levels were not properly monitored or controlled and that A's outcome might have been different with better monitoring. We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). We found that A’s digoxin was not appropriately monitored. However, it is difficult to assess whether A was suffering from digoxin toxicity. The board acknowledged this failing and provided information on the action taken by individual staff members as well as the board as an organisation to reflect on A’s experience and improve the delivery of care and treatment in the future. We upheld C's complaint and made recommendations to ensure these changes were taken forward.

C complained that the practice unreasonably failed to take the appropriate action in response to C's elevated prostate-specific antigen (PSA, a protein in the blood) test result. C requested a PSA test due to having a family history of prostate cancer. C complained about the failure to refer them to urology (specialists in the male and female urinary tract, and the male reproductive organs) based on the test result. The practice had said it was appropriate to advise C to repeat the test in one month’s time. This did not happen and C was diagnosed with prostate cancer 13 months later. We took independent advice from a GP. We found that the practice failed to follow Scottish Referral Guidelines for Suspected Cancer. According to the guidelines, due to C’s age, their family history and the test result, the GP should have referred C to urology for further investigation. We upheld C’s complaint.

C complained about the care and treatment provided to their parent (A). A was admitted to hospital with a suspected stroke, confusion and poor mobility. A CT scan was performed but the results were not reviewed until a few days later. The result was discussed with other specialists and a further scan was requested. A’s warfarin treatment (blood thinning) was reversed because A’s condition had deteriorated. C was concerned that A’s condition was not properly recognised as a stroke and that imaging of A’s head was not reviewed. Consequently A’s blood thinning medication was not stopped promptly. The board carried out a Significant Adverse Event Review (SAER) which identified delays in reviewing A’s scan, and a lack of clarity between medical staff over who was responsible for organising tests for A, as well as poor communication. C felt the SAER lacked rigour and failed to address all the issues in A’s care. We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). We found that the SAER lacked detail and did not contain sufficiently clear recommendations to ensure the failures in A’s care did not reoccur. It also did not adequately address the decision making around A’s scan or the level of awareness amongst clinicians of the scan being performed. During our investigation the board provided further evidence of the feedback provided to staff, and the actions taken in response to the incident involving A. We found that these were reasonable and proportionate. The board accepted that the SAER had not adequately explored all the issues in the case. Therefore, we upheld C's complaint but did not make any further recommendations. Related reading View Decision Report 202402634 as a PDF (24.68 KB) Updated: December 17, 2025

C complained about the care and treatment of their late spouse (A). A had a history of multiple myeloma (a type of blood cancer). C raised concerns about the board’s response to A’s symptoms, including a delay in carrying out a CT scan (a type of medical imaging) and a potential misdiagnosis of pancreatic cancer. The board said that A received prompt and appropriate management. We took independent advice from a consultant haematologist (specialist in blood disorders). We found that the board’s use of CT scanning to explore A’s symptoms was reasonable, and the investigation of a mass near A’s pancreas was reasonable and consistent with National Institute for Health and Care Excellence (NICE) guidelines. Therefore, we did not uphold this aspect of the complaint. We also investigated the board’s communication regarding A. We found no significant failings in communications in this case, and we did not uphold this aspect of the complaint. Additionally, C complained about the handling of their complaint. We found that the board reasonably investigated A’s complaint. Therefore, we did not uphold this aspect of the complaint. Related reading View Decision Report 202401075 as a PDF (24.32 KB) Updated: December 17, 2025

C complained on behalf of their sibling (A) about the cancer care and treatment that A received and the handling of C’s subsequent complaint about this. We took independent advice from a consultant urological surgeon (specialist in the male and female urinary tract, and the male reproductive organs) and a consultant oncologist (specialist in cancer). We found that there was a delay in arranging an MRI scan and a ureteroscopy (a procedure that uses a thin telescope with a camera on the end to look inside the ureters and kidneys) for A. We also found that it was unreasonable that A had to involve their GP to prompt urology treatment and that there was no evidence that A’s scan results were revealed or discussed with them. We found that the board’s investigation of the failings were inadequate. The board should have carried out a local significant adverse event review and there appeared to have been no process changes to prevent similar failings in future. The board also failed to keep C updated on the reason for the delay in issuing their complaint response. We upheld C's complaints. However, we considered that it is unlikely that earlier treatment would have changed A's prognosis.

C complained on behalf of their client (B) about the care provided to B's late parent (A) during their admissions to hospital. A was admitted and discharged from the hospital. A was readmitted a few days later following a fall at their home. A suffered significant injury including spinal and sacral fractures. A remained in hospital for treatment but died a few weeks later. C's concerns related to the clinical and nursing care provided to A during their admissions, particularly in relation to the assessment of A’s cognitive function and capacity, their falls risk, and overall assessments carried out with respect to their condition and deterioration. In response to the complaint, the board acknowledged that protocols on completion of falls and bed rail risk assessments were not followed and that in the day prior to A’s death, guidance on the timeliness and extent of observations which should have been carried out were not followed, and that the care fell below the expected standard. The board confirmed that appropriate documentation with respect to the assessment of A’s capacity was completed during their admission. C was dissatisfied with the board’s response. We took independent advice from a consultant geriatrician and a registered nurse. With respect to A’s clinical care, we found that documentation used to assess A’s capacity was not completed to a reasonable standard and we upheld this complaint. We found that the clinical treatment of A during the two days immediately prior to their death was reasonable and we did not uphold this aspect of the complaint. We considered the nursing care provided to A during the two admissions. We found that the care regarding falls management was unreasonable as appropriate documentation and assessments were not completed correctly or in a timely manner. We also found that there was a lack of evidence of the monitoring of A’s condition which would have made clinical assessment of A’s condition and deterioration more difficult. We

C complained about the care and treatment provided to their late parent (A) by a GP Practice when A was a resident in a care home. Care home staff had reported that A was agitated and unsettled, possibly in pain and with poor sleep at night. The practice requested that care home staff take a set of observations (temperature, oxygen saturation, pulse, blood pressure) and obtain a urine sample. When observations were later taken by care home staff, the practice advised that they were all normal, thereby giving a NEWS Score (a tool used to quickly determine the degree of illness of a patient and identify acute deterioration) of 0. They said that no visit was indicated at that time and queries about medication for agitation would be discussed on the next GP round to the care home. C was of the view that the report of agitation and confusion should have led to GP review. We took independent advice from a GP. We found that the care and treatment provided to A was unreasonable, as A had delirium until proven otherwise and should have been seen and assessed for this. We also noted that the practice appear to have relied on a NEWS score to decide no visit was needed, but NEWS is not validated for use in primary care. We therefore upheld the complaint. During the course of our investigation the practice carried out a Significant Event Review. As a result, they had developed a protocol, to be used alongside physiological measurements, for assessing delirium in the care home setting and had shared and discussed this with the care home. We considered these actions to reasonably address the failings in this case, so aside from apologising to C, we made no further learning and improvement recommendations.

C complained about the care and treatment provided to their late parent (A) by a GP Practice. Following a road traffic accident, A was found to be in atrial fibrillation (a type of heart rhythm where the heartbeat is not steady). The hospital asked the GP to review A for anticoagulation (medication to prevent blood clots from forming or growing) once their injuries had resolved. Several weeks later A had an appointment at the practice and was referred for a 24-hour ECG (a medical test that records the heart’s activity over a 24-hour period). Before the results could be assessed by the practice, A suffered a stroke. C complained that the practice unreasonably delayed in initiating anticoagulant therapy. We took independent advice from a GP. Following our initial enquiries, the practice provided additional explanation regarding the complexity of the decision making as to whether to prescribe anticoagulation to A, and the reasoning behind their decision to wait for the results of the 24-hour ECG. Following this additional explanation, we considered that the practice’s position and treatment plan was reasonable. We therefore did not uphold the complaint. However, we noted that not everything the practice had said in their further explanation was documented in the medical records and we provided feedback to the practice on this point. Related reading View Decision Report 202408315 as a PDF (24.47 KB) Updated: August 20, 2025

C complained about the board’s assessment of their parent (A) and the decision not to admit A to hospital for further assessment and treatment. C felt that the board inappropriately relied on information provided on behalf of A, rather than speaking with A directly, and that decisions were based on unreliable information. A tested positive for COVID-19 in their care home and the following day, care home staff contacted NHS24 about A’s condition and the call was passed to NHS Lanarkshire Out of Hours service. The call was triaged for a clinician to call back, and an out of hours GP contacted the care home shortly afterwards. During the call with the out of hours GP, the decision was taken not to admit A to hospital, but for care home staff to contact A’s GP the following day. A died later that day. In their response, the board explained that the out of hours GP spoke with A’s carers and concluded that an appropriate assessment was undertaken. We took independent advice from a specialist in general and geriatric medicine. We found that the assessment of A conducted over the telephone was reasonable. The record of the assessment was of the level and standard expected. We concluded that the assessment of A’s condition and the decision not to admit A to hospital at that time was reasonable. We therefore did not uphold the complaint. Related reading View Decision Report 202202757 as a PDF (24.4 KB) Updated: August 20, 2025

C complained about the care and treatment of their late spouse (A). The day before A’s first admission to hospital, the GP submitted an urgent suspicion of cancer (USOC) referral. A was experiencing abdominal pain with vomiting and diarrhoea. The initial diagnosis had been a suspected blocked bowel. After symptoms settled, A was discharged before returning to hospital a few days later with ongoing symptoms. A was discharged home with a plan to return for an outpatient colonoscopy. However, A returned to hospital with a diabetic foot infection resulting in surgery. During this final admission, A was diagnosed with bowel cancer. C considered A was inappropriately discharged from hospital following the first two admissions with no clear diagnosis or plan in place. C said that communication throughout A’s hospital admissions was poor and also complained about the nursing care provided to A, particularly in relation to the care given to their feet as a known diabetic. We took independent advice from a clinical adviser and senior nurse adviser. We found that given A’s symptoms, and the USOC referral, the board unreasonably failed to consider A for an inpatient colonoscopy during their second admission to hospital and unreasonably failed to schedule an outpatient colonoscopy for A one to two weeks after discharge. We also found A’s second discharge from hospital was inappropriate because their presentation, along with other relevant information, should have alerted clinical staff to the possibility of cancer. We found that basic nursing care could not be evidenced due to poor documentation and that appropriate assessments were not carried out. We found that the foot care provided to A was unreasonable with no evidence to show wound assessment or monitoring was done to a reasonable standard. We upheld all aspects of the complaint relating to the care and treatment of A. C also complained that the boards handling of the complaint was poor. We found that steps were taken to a

C complained about the care and treatment that the board provided to A, who had long-term mental health conditions. A was subject to a Community Compulsory Treatment order (CTO, a legal order that allows a person who has been detained in hospital for treatment to be discharged and receive supervised mental health care in the community). C was A’s Named Person in respect of the CTO. A experienced a deterioration in their mental health over a short period of time, which concluded with them attending A&E and requesting hospital admission. A was not admitted to hospital and died later that night. The post-mortem believed that A may have completed suicide. The board carried out a Significant Adverse Event Review (SAER) and concluded that the outcome could not have been predicted. The SAER identified areas of good practice but also some learning points. These centred on missed opportunities to refer A to addiction services and paper notes from the Forensic Community Mental Health Team (FCMHT) not being accessible by other services. C complained to the SPSO as they felt that there were failings in the care and treatment provided to A that contributed to their death. In addition to this, C complained that the board did not communicate with them reasonably, given that they were A’s Named Person. We took independent advice from an adviser with a background in forensic psychiatric nursing. We found that the overall care and treatment provided to A in respect of their mental health was reasonable. We considered it clear that access to the FCMHT records across services would have been preferable. This would have assisted the clinical decision-making when A presented to A&E. However, we found that there are no standard guidelines or requirements for the sharing of records across NHS services in Scotland. Based on A's presentation and what was known to clinicians at the time, we found that the care and treatment provided by the board was reasonable. Therefore, we did not uphold th

C gave birth involving a forceps delivery (where a medical instrument is used to assist birth) and suffered a fourth-degree perineal tear (significant injury to the area between the vaginal opening and anus). C had surgery to repair the perineal tear and again to have treatment for retained placenta (where some placenta remains in the womb after birth). C complained about the maternity care and treatment in hospital, the board’s communication with C in hospital and the board’s handling of C’s complaint. The board apologised for poor communication during the birth and said that they were carrying out actions to improve management of obstetric and anal sphincter injury and obtaining consent for instrumental birth. We took independent advice from a consultant obstetrician. We found that the maternity care and treatment provided to C during the time of the birth was reasonable. We did not uphold this aspect of the complaint. We found that the board’s communication with C when C was in hospital was unreasonable. Though the birth situation was urgent, it was not an emergency, and a fuller discussion should have taken place with C regarding the forceps delivery. We upheld this aspect of C’s complaint. We found the actions that the board said they were carrying out were reasonable in response to the failing in communication. We found the board’s complaints handling was unreasonable, because C’s initial complaint was not reasonably progressed, the scope of the complaint investigation was not agreed with C, the board’s response to the complaint was not reasonably clear, and there were regular and significant delays in the board’s communication with C regarding the complaint. We upheld this aspect of the complaint.

C complained about the care and treatment of their late parent (A) following an admission to hospital with a hip fracture, and about the communication surrounding this. C raised concerns about A’s fitness for discharge, including a lack of rehabilitation in hospital and length of wait for community rehabilitation, as well as a lack of support with food and fluid intake, and a lack of adequate skin care. C also raised concerns about a lack of engagement with them as A’s next of kin and power of attorney. We took independent advice from a consultant orthopaedic surgeon and a registered nurse. We found that A’s discharge was medically reasonable, and that the level of input from therapists was reasonable. The board acknowledged shortcomings in communication with C around their discharge, and a failure to document the nursing handover with the care home. The board also apologised that the target timescale for community rehabilitation was not met. We found that there were unreasonable failings in the nursing documentation, person centred care, and pressure care that A received. A’s person centred care plan was not completed, and a documented instruction that A required full assistance with nutrition and hydration was not adhered to. We identified frequent gaps in skin inspections and repositioning, and inconsistent completion of a pressure ulcer risk assessment. The relevant foot care did not take place in light of A’s diabetes, and there was no referral to podiatry when pressure damage to A’s heel was discovered. We were concerned to note that A’s nutritional needs were not met, and that there was a failure to protect A from pressure damage. We upheld this complaint. We also identified inconsistencies in the board’s complaint responses and noted that important failings were overlooked. We made recommendations to the board to address these.

C complained about the obstetrics (specialists in pregnancy and childbirth) care and treatment that they received from the board during and after the delivery of their baby by planned caesarean section. C said that there was a delay in diagnosing retained products of conception (tissue that remains in the uterus after a pregnancy) which led to infection. C also said that they were kept nil by mouth (not allowed to consume food or drink by mouth) for over 30 hours as their surgery for evacuation of the retained products kept being delayed. We took independent advice from a consultant obstetrician and gynaecologist. We found that some aspects of C’s care and treatment were reasonable. However, a doctor should have attended when C passed a large clot. There was also a misunderstanding between C and a doctor regarding how long they would be kept nil by mouth for before their evacuation procedure. We also found that the board failed to address C’s concerns about the conduct of a sonographer (specialist in the use of ultrasonic imaging devices) in their response to the complaint. Therefore, we upheld C's complaint

C complained about the care and treatment provided to their parent (A) in relation to a number of hospital admissions. C complained that A was discharged without clear advice as to whether they had sepsis, and how to manage A’s condition. C also said that the board did not provide a discharge letter. C complained that when A attended hospital four days later, they should have been admitted rather than being sent home with oral antibiotics. Lastly, C said that when A was readmitted to hospital the following month, a day passed before they were seen by a consultant. We took independent advice from a consultant urological surgeon (specialist in the male and female urinary tract, and the male reproductive organs). We found that, while A received appropriate care during their initial admission, the board's communication around A's sepsis was unreasonable. They also did not provide an interim discharge summary. In relation to A's second discharge, we found that A's symptoms raised the possibility of a complicated kidney infection. Therefore, we considered that discharging A with oral antibiotics was unreasonable. A should have received treatment with IV antibiotics and consideration should have been given to admission, which may potentially have prevented the need for A to be admitted the following month. We upheld these parts of C's complaint. Finally, we found that A's condition when they were readmitted did not meet the criteria for an urgent consultant review. Therefore, we did not uphold this part of C's complaint.

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

C complained about the care and treatment they received from the board when they attended the hospital with pain and a tight feeling in their leg. C raised concerns that the board failed to: reasonably assess them on admission to hospital, and undertake the correct scans; provide them with timely information about their test results; reasonably identify an arterial clot and diagnose their condition; and provide them with reasonable treatment following admission to hospital. We took independent advice from a consultant in acute medicine. We found that a detailed clinical assessment of C’s right leg and foot was carried out on their admission to hospital, and that it was reasonable that the clinicians did not identify an arterial clot at that time. We found that the possible diagnoses that were considered at the time were correct, and the diagnosis of plantar fasciitis was a reasonable conclusion to have reached. We also found that the correct scan had been carried out to exclude deep vein thrombosis (DVT, a blood clot in a vein) as a cause of C’s symptoms, and that the care and attention C received from medical staff was reasonable. Therefore, we did not uphold C’s complaint. Related reading View Decision Report 202304888 as a PDF (24.33 KB) Updated: May 21, 2025

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

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