SPSO Individual Decisions

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

C complained about the care and treatment 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 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 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