Scottish Public Services Ombudsman

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  • Case ref:
  • Date:
    December 2015
  • Body:
    Ayrshire and Arran NHS Board
  • Sector(s):
  • Subject:
    clinical treatment / diagnosis
  • Outcome:
    Some upheld, recommendations


Mr C received treatment from the board's mental health team over a number of years. He complained to the board about the accuracy of his diagnosis and about frequent changes to his medication. He also questioned whether he should have been prescribed anti-psychotic medication as he felt this had an adverse effect on his condition.

The board met with Mr C to discuss his concerns, but they did not respond to him in writing due to concerns about the impact this may have had on his mental health. Mr C complained about the lack of a formal response to his complaint. He also asked us to investigate his concerns about his medication regime.

We sought independent advice from a medical adviser who is a mental health specialist. We found that the board appropriately assessed Mr C's symptoms and took into account information provided by him when prescribing medication. His medication was altered on a number of occasions as a result of this, but in each case we were satisfied that the board worked in line with national guidance.

We were critical of the board's handling of Mr C's complaint. We acknowledged their concerns about the impact of a written response on his mental health, but we found their approach to be inconsistent because Mr C's consultant had written to him with a detailed report on his condition. We felt that a formal response from the board would have been appropriate and that their communication generally could have been better.


We recommended that the board:

  • review their practices for monitoring side effects for patients being treated for schizophrenia and ensure that they are working in line with national standards;
  • apologise to Mr C for their poor handling of his complaint; and
  • review their handling of Mr C's complaint with a view to improving the quality and consistency of their communication with patients with mental health issues.

Download case 201404886 as a PDF (13.27 KB)

Updated: February 1, 2016