Scottish Public Services Ombudsman

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  • Case ref:
  • Date:
    February 2014
  • Body:
    Ayrshire and Arran NHS Board
  • Sector(s):
  • Subject:
    clinical treatment / diagnosis
  • Outcome:
    Some upheld, recommendations


Mrs C complained on behalf of her daughter (Ms A), who had been diagnosed in 2003 with bipolar disorder. Mrs C said that in 2011, despite her concerns, Ms A's diagnosis was changed, as was her medication. Ms A was not offered a second opinion and Mrs C said that her daughter’s condition went into 'free fall', reaching a crisis point in the summer of 2012. She complained that Ms A was offered little in the way of psychiatric support, and that appointments with a community psychiatric nurse were often cancelled without being rescheduled.

We gave all the relevant documentation, including the complaints correspondence and Ms A's medical records, careful consideration. We also obtained independent advice on the case from a consultant forensic psychiatrist and a mental health nurse. Our investigation found that despite Mrs C's concerns, it was entirely correct for Ms A's diagnosis and medication to be kept under review and that the board had acted appropriately and reasonably in doing so. Mrs C's disagreement with this was well recorded, and was not discounted. However, in the circumstances, our adviser said that it might have been prudent to offer Ms A a second opinion.

The investigation also established that there had been no delay in providing new appointments when some were cancelled. However, there was evidence that the frequency of appointments was inconsistent and not as planned.


We recommended that the board:

  • make a formal apology to Mrs C and Ms A for inconsistencies in the timing of appointments.

Download case 201301712 as a PDF (12.34 KB)

Updated: February 26, 2014