SPSO Individual Decisions

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

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

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

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

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

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

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

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

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

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

C complained on behalf of their partner (A) about the care and treatment provided to A by the board when they presented to the obstetric triage department 25 weeks’ gestation with pain and abdominal tightening. A was assessed as having Braxton Hicks (when the womb contracts and relaxes during pregnancy, also known as ‘false labour’) given advice on what to do if their condition worsened, and discharged. Four weeks’ later A suffered preterm prelabour rupture of the membranes (PPROM) and their child was delivered prematurely. C complained about the care and treatment provided to A as they considered the assessment at 25 weeks’ gestation was a missed opportunity for further investigation or follow-up. The board’s complaint investigation identified that according to local guidelines, A should have been reviewed by a more senior doctor. However, they were of the view that it was unlikely that this would have led to a different outcome. We took independent advice from a medical adviser. We found that while there were some areas for potential improvement, overall the care and treatment provided to A was reasonable. We therefore did not uphold C's complaint, though we did provide feedback to the board according to the adviser’s comments. Related reading View Decision Report 202400979 as a PDF (24.45 KB) Updated: June 18, 2025

C complained about the care and treatment given to their late sibling (A) by the board. A, who had a history of addiction issues and Chronic Obstructive Pulmonary Disease (COPD, a group of lung conditions that cause breathing difficulties), was admitted to A&E after overdosing on non-prescription drugs. A was treated for the overdose and was discharged to C’s care. A died the following day. C complained that the board inappropriately discharged A and that the treating doctor had failed to communicate adequately with them. The board did not identify any failings in A’s care, but did apologise that A was discharged with a cannula in place. The board also apologised for communication failures with C. C remained unhappy and brought their complaint to us. We took independent advice from a consultant in emergency medicine. We found that A was monitored for approximately 12 hours before discharge. This is the minimum period recommended by Toxbase (the primary clinical toxicology database of the National Poisons Information Service). However, we found that A would have required observation over and above this minimum period. This was because of A’s history of acute seizures, intoxication with opiate drugs and their complex medical history. In the circumstances, we found that it would have been reasonable for A to have remained as an in-patient to enable a greater period of medical observation. Therefore, we considered that the decision to discharge A was unreasonable. We upheld C's complaint.

C complained that the board failed to provide their parent (A) with reasonable care and treatment when they attended the A&E with symptoms including a loss of sight in one eye. C raised concerns about the delay in assessing A and failures by staff to reasonably diagnose and treat A. C also said that the board failed to reasonably communicate and provide A and C with sufficient information after A was taken to a cubicle, to provide A with appropriate personal care, to adequately record information about A’s care and treatment and to follow the relevant policies and procedures in providing care and treatment to A. We took independent advice from a consultant neurologist and a nurse. We found that there was an unreasonable delay in A being assessed by a doctor. We also found that there was poor record keeping in A’s medical and nursing records, which showed the level of care and observation A had received was unreasonable. We found that, had A’s observations been recorded as required, it was possible that a deterioration in A’s condition would have been picked up sooner. Consequently, we found that the care and treatment provided to A in the A&E was unreasonable. We, therefore, upheld this part of C’s complaint. C also complained that, after A was transferred to the high dependency unit, a consultant neurologist failed to sensitively explain to them about A’s diagnosis and prognosis. We found that adequate and appropriate information was conveyed to C by the consultant neurologist and the communication between them had been clinically appropriate and satisfactory. It was not possible to determine whether or not the consultant neurologist had failed to explain this sensitively. We did not, therefore, uphold this part of C’s complaint. C further complained that a senior research nurse failed to take reasonable steps to contact them regarding a stroke research study. We found that there was a failure to take reasonable steps to contact C regarding the stroke research stud

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

C complained on behalf of their spouse (A) about the standard of care and treatment received in the months before A died. The board partially upheld the complaint, including failings in communication and a lack of privacy and dignity shown to A. We took independent advice from a registered nurse. We found that while the board had acknowledged some failings, they had not identified other issues with person-centred care planning, care delivery and documentation. We therefore upheld this part of the complaint. C complained that the board had failed to communicate with A and their family to a reasonable standard. The board acknowledged that despite C being A’s carer, and it having been agreed to utilise email communication, information was not always shared with the wider team, which may have contributed to C’s perception that communication was lacking. We found that the board’s position that there was no record of any upset between A and individual staff members was factually incorrect. We thereby upheld this part of the complaint. C complained that there was no record of a care plan, and that the package of care was not adequate for A’s needs. The board acknowledged the lack of a suitable care package had an impact on discharge planning, and that they had failed to establish a more detailed person-centred care plan once A was discharged. We found that there was detailed planning and discussion around discharge involving C and A. We did not uphold this element of the complaint because, on balance, while the delivery of care did not match C and A’s expectations, this did not make the plan unreasonable in the circumstances. C also complained that the board’s response to their complaint was unreasonable and delayed. We found that C’s complaint was complex and multi-faceted accounting to some extent for the delay. However, the response had inaccuracies and failed to identify all the failings in care. For that reason, on balance, we upheld this aspect of the complaint.

C complained that Lothian NHS Board (Board 1) unreasonably failed to maintain records of specialist advice they provided to another board (Board 2). C attended A&E at Board 2 with symptoms of significant pain, problems passing urine and lack of sensation. On the specialist advice of neurosurgery at Board 1, C was admitted to the Orthopaedics department of Board 2’s hospital and an MRI was carried out the following day. The MRI scan results were discussed with the Board 1's neurosurgery team, following which C was discharged. C later required emergency surgery and considers the outcome would have been better if they had undergone surgery when they originally attended hospital. When C complained to Board 2, they confirmed that they had relied on the Board 1’s specialist advice but Board 1 had failed to keep a record of the referral. C complained that Board 1 unreasonably failed to maintain records of the specialist advice provided to Board 2. C also complained about the neurosurgery advice provided by Board 1 to Board 2. We took independent advice from a consultant orthopaedic surgeon in relation to the complaint about maintaining accurate records. We found that Board 1 unreasonably failed to maintain records of the specialist advice provided to Board 2. We upheld the complaint. We took independent advice from a consultant neurosurgeon in relation to the complaint about neurosurgery advice. We found that C had been appropriately assessed with a thorough examination. As such, we did not uphold this complaint.

C complained that the board failed to provide them with appropriate orthopaedic (specialists in the treatment of diseases and injuries of the musculoskeletal system) care and treatment following a fall. The board operated on C’s left wrist the day after the fall. Two days later, they performed revision surgery on C’s wrist and operated on their left elbow. C said that they had been advised by an orthopaedic surgeon at the board that their initial wrist surgery had not been done correctly. C said they had developed nerve compression pain issues and would require further surgery. We took independent advice from an orthopaedic consultant. We found that C’s initial wrist surgery was reasonable. However, the tilt of the radius was slightly beyond the normal range, which carried a minor increased risk of longer term functional impairment in the wrist. We considered that, if C had not required additional surgery for the elbow, the initial wrist fixation might have been left unchanged, as any potential long-term dysfunction could still have been treated later if necessary. However, given that C was already scheduled for elbow surgery, the decision to proceed with revision surgery on the wrist was considered reasonable. We also noted that key indicators related to pain were appropriately assessed in C’s case, and there was no indication that the surgery had been performed in a manner likely to cause excessive pain. Therefore, we did not uphold C’s complaint. Related reading View Decision Report 202301420 as a PDF (24.53 KB) Updated: November 20, 2024

C complained about the care and treatment that their late parent (A) received while in hospital. A suffered a fall and broke their hip. C complained that A was never provided with a falls monitor despite being assessed as a falls risk. C also said that there was a delay in reporting the fall and having A assessed. The board apologised to C for the fact that, due to a lack of falls alarms, A had not received one. They explained that additional alarms had been obtained to ensure a sufficient supply on the ward. They also accepted that a ‘top to toe’ examination should have been carried out following A’s fall and that there was a delay in identifying that A had a broken hip. They explained that a full review of A’s fall was underway, and if any learning points were identified, they would be acted upon. In addition, a teaching session had been carried out to ensure best practice was followed at all times. The board provided us with details of the learning points that had been identified as a result of the complaint. We took independent advice from a registered nurse. We found that there was no evidence that A received timely risk assessments or person-centred care. Although a fall with harm was apparent from A’s misaligned leg, this went unnoticed. Basic assessments, including pain assessment, were not conducted, resulting in a delay in recognising A’s pain. Additionally, wound charts were not completed, and there was a failure to follow policy regarding pressure ulcer prevention, malnutrition, and wound assessment and management. While the board had taken action in response to the complaint, we considered that there were still areas for learning and improvement. Therefore, we upheld C’s complaint. We also found that the board’s complaint response had not been open, transparent, and accurate. The board had failed to identify a number of failings in A’s care and treatment. Additionally, the board had not provided this office with all relevant information in response to o

C complained about the care and treatment that they received from the board. C underwent a left total hip replacement but returned to the consultant orthopaedic surgeon for follow-up three months later as they were continuing to experience pain and mobility problems. C complained that they were told there was nothing the surgeon could do for them. C sought a second opinion and learned that they had impingement (pinching or rubbing together inside a joint) which would require further surgery. C said that they had been significantly impacted by the initial surgery, both mentally and physically. In their original complaint response, the board acknowledged the poor outcome of the surgery. Following our formal enquiry the board acknowledged that a different choice of acetabular (socket) implant would have been appropriate. The surgeon acknowledged that this case was one where they would have benefited from advice from a more experienced surgeon. They accepted that they had failed to discuss with C that a poor outcome from surgery was a risk, and failed to document decision making and consent discussions in C’s clinical records. They apologised for failings in communication with C during their post-operative consultation. They also apologised for record-keeping failings. The board said they should have discussed this case at a departmental Morbidity and Mortality meeting once it became clear that there were ongoing problems requiring further surgery. They considered that not doing so represented a failure of process, prompting them to review their relevant structures and processes. The board confirmed comprehensive measures to address what had gone wrong in C's case. We took independent advice from a consultant orthopaedic surgeon (specialists in the musculoskeletal system). We concluded that the board had now appropriately acknowledged the multiple failings in this case, apologising and confirming extensive learning and improvement. Taking all of this into account, we up

C complained about the nursing care and treatment provided to their late parent (A). A had a fall during an admission to hospital. Their condition deteriorated and a large intracranial (brain) bleed was identified. A died shortly after. C complained that the nursing staff provided unreasonable care and treatment as they did not put the correct safety measures in place, given A's frailty and instability on their feet. The board said that A was reviewed by physiotherapy who assessed A as being safe and able to mobilise independently with a walking stick. The board said that nursing staff carried out care rounding and that A was checked 30 minutes prior to their fall. Following the fall, it was noted that A was able to get up with assistance and an assessment was completed by nursing staff. When checked later, it was found A had become unconscious. The board carried out a scan of A’s head and found a large intracranial bleed. We took independent advice from a registered nurse. We found that there was a lack of documentation and documented evidence of action taken by staff in response to cognition and mobility. Care rounding documentation was not completed to a reasonable standard or carried out to the prescribed frequency. When A’s needs changed, the care rounding was not increased. We found that the nursing staff failed to complete the mobility risk assessment, consider the use of bedrails and identify A required more help when their condition changed. We noted that the care provided by nursing staff when the fall happened and after the fall was reasonable. We also found that the Significant Adverse Event Review that was carried out after the fall was not carried out in line with national guidance. The Duty of Candour process should have been followed in this case and it was unclear from the documentation whether this had been activated or not. We upheld C's complaint.

C complained about the care and treatment that their spouse (A) received from the board whilst they were a patient of the cardiology ward. C complained that A collapsed on arriving home having been discharged after undergoing a coronary angiogram (a type of x-ray used to take pictures of the heart’s blood vessels, the coronary arteries) and stenting procedure. A was found to have experienced a vascular complication (a large haematoma, where blood leaks from a large blood vessel) in front of the femoral artery (the main blood vessel supplying oxygen rich blood to the lower body) and had surgery to remove the haematoma. Following the second surgery, A developed an infection in the wound site. The board said that due care was taken to weigh up the risks and benefits of various treatments in A’s case. Whilst there were signs of a haematoma at the puncture site after the procedure, this was not increasing in size when A was discharged, and A’s blood pressure was normal. C complained to SPSO highlighting concerns about the decision to carry out an angiogram, the decision to discharge A, infection control and failures to follow protocol and use an ultrasound to assess the puncture site. We took independent advice from an appropriately qualified consultant cardiologist. We found that carrying out an angiogram was appropriate in the circumstances. We considered the care and treatment following the procedure and on A’s readmission to be reasonable. However, there were a number of factors which should have triggered staff to consider delaying discharge and seeking an ultrasound scan. We found that the need for an ultrasound scan was clinically indicated and that the decision to discharge was unreasonable. As such, on balance, we upheld the complaint.

C was concerned about a number of issues regarding their care and treatment, and that of their child (A), during their pregnancy, A’s birth and afterwards. C raised complaints with the board and were dissatisfied by their response. The board’s response accepted that there had been issues with aspects of the boards complaint handling and a number of issues with their communication, but did not indicate that the board considered that there had been any issues with C or A’s care or treatment. We took independent advice from qualified advisers with experience of obstetrics, neonatology and midwifery (the medical specialisms for pregnancy, childbirth etc.). We found that, overall, C and A had received reasonable care and treatment from the board and that, where areas for improvement around communication had been identified, reasonable actions had been taken to address these. We did not uphold these part's of C's complaint. We noted that the board had accepted that C had been assigned to an incorrect consultant’s waiting list for a post-birth debrief and upheld this complaint. We also noted that the board had appropriately apologised to C for this. However, we considered that the board should have taken steps to minimise the possibility of a similar situation recurring in the future. In considering the board’s response to C’s complaints, we found that there were specific areas where the board’s response and actions could have been improved. However, taking into account those areas for improvement in complaints handling the board had identified, the apologies provided to C and the specific circumstances of the time C raised their complaints, overall the board responded reasonably to C’s complaint. We did not uphold this part of C's complaint.

C complained to the board about various aspects of the board’s care and treatment of their partner (A) and their communication with C and A during an inpatient admission covering the end of A’s pregnancy and the birth of their child (B) by caesarean section. The board accepted that a number of areas of communication had not been reasonable and apologised for this. The board explained what action would be taken to address these areas for improvement. The board also accepted that in a few specific cases, A had not received reasonable care but indicated that they considered A’s care and treatment had been reasonable overall. In response to a specific complaint from C, the board stated that A had not had sepsis (blood infection) or been treated for it during their admission. A few months later, however, the board wrote to C and stated that their labour had been complicated by sepsis. We took independent advice from an appropriately qualified midwife. We found that, overall, A and B received good care and appropriate standards of treatment that were in line with relevant professional standards. Given this, and that reasonable actions to minimise recurrence were taken in relation to areas where the board had accepted care was not of an acceptable standard, and where communication could have been improved, we did not uphold the complaint that the board had not provided reasonable care and treatment to A. We found that A had had sepsis during their admission and receive prompt and appropriate care. However, we considered that the board’s repeated altering of their position on whether A had sepsis, both minimised A’s experience and, potentially risked inadequate care and treatment responses being provided to patients with suspected sepsis in the future. We upheld the complaint that the board’s response inaccurately stated that A did not have sepsis and was not treated for sepsis during their admission.

C complained about the ear, nose and throat surgery (ENT) that they received from the board. C was referred for surgery for biopsy of a nasal ulcer that would not heal, and for treatment of a nasal drip. C complained that the biopsy had not been taken as expected, which they were not aware of until making a complaint. C also complained that they had been left worse off due to a perforation being caused during the procedure. This has caused them to have an audible whistling sound when they breathe. C said that, while the risk of perforation had been mentioned at the outpatient appointment, they were led to believe it was not something they had to worry about. Furthermore, they were not told that if it happened, it wouldn’t heal naturally, and surgery to fix it often fails. The board explained that the biopsy had not been taken as the ulcer had healed by the time C attended for surgery. The board apologised for the perforation. They noted that the surgeon was not aware of one occurring before in their career but had since changed their practice to ensure it was discussed when obtaining consent. We took independent advice from an ENT adviser. We found that C had not been reasonably consented for surgery at the outpatient clinic or on the day of surgery. We noted that the documentation did not support the reported discussions which took place about the surgery or the associated risks, or the implications should C have decided not to proceed with the procedure. We also found that the written information provided to C was unreasonable. The patient information leaflet did not provide information about the short and/or long-term implications of a perforation or that it may occur after the surgery has taken place. It did not note that it was unlikely to heal on its own, that surgery to correct it may not be an option or, if attempted, successful. We considered that C had received reasonable post-operative care and follow-up from the board. It was reasonable to plan to see th

C complained about the care and treatment provided to their parent (A) on two separate admissions to hospital. A was detained on both occasions under the Mental Health (Care and treatment) (Scotland) Act 2003. C had concerns about A being sedated and that staff had restrained A in an inappropriate manner. In their response to the complaint, the board explained the care provided to A, the reasons for the administration of medication, how this was overseen and adjusted to address A’s levels of sedation, and the process and performance of restraints when they were required. C was dissatisfied with the board’s response and brought their complaint to us. We took independent advice from a consultant psychiatrist and a mental health nurse. We found that on both admissions, there was appropriate oversight of A’s medication and care was taken to consider sedative effects and find a balanced approach. We found that medications were administered appropriately to manage A’s distress and aggression. Therefore, we did not uphold this part of C’s complaint. In relation to the use of restraints, we found that these had been performed reasonably and that A’s concerns about pain to their ribs was appropriately assessed. Therefore, we did not uphold this part of C’s complaint. However, we did provide the board with some feedback on the requirements for accurate record keeping. Related reading View Decision Report 202204112 as a PDF (24.47 KB) Updated: May 22, 2024