Scottish Public Services Ombudsman

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  • Case ref:
  • Date:
    May 2016
  • Body:
    Ayrshire and Arran NHS Board
  • Sector(s):
  • Subject:
    clinical treatment / diagnosis
  • Outcome:
    Some upheld, recommendations


Mrs C complained about the gastroenterology care she received from the board. Mrs C was attending an out-patient clinic at University Hospital Ayr and had previously undergone surgery to remove her gallbladder. She continued to experience various problems with her digestion along with skin problems, particularly on her hands. Mrs C complained that there had been too many consultants involved in her care and that there had been a lack of continuity in her care. Mrs C also complained that the board had not coordinated her care appropriately and that they unreasonably failed to reach a diagnosis of her condition.

During our investigation, we took independent advice from a consultant gastroenterologist. We found that the board had acknowledged there were a number of gastroenterologists involved in Mrs C's care due to retirement and sick leave and they had apologised for this. However, the advice we received was that for patients with chronic conditions like Mrs C, the use of short term locum consultants should be avoided. We found that this had affected the continuity of Mrs C's care and resulted in a potentially avoidable referral to another NHS board. We upheld Mrs C's complaints regarding the number of consultants involved and the lack of continuity in her gastroenterology care.

The adviser considered that there was evidence of good coordination of Mrs C's care with referrals to other specialties being followed up promptly by a single consultant and consequently we did not uphold that element of her complaint. We also did not uphold Mrs C's complaint about a lack of definitive diagnosis. The advice we received was that the board had carried out numerous investigations to try to determine the cause of Mrs C's continuing symptoms and that reasonable steps were taken in attempts to reach a definitive diagnosis. The adviser highlighted two blood tests that could be carried out for completeness but overall, the board's action on diagnosis was considered to be reasonable.


We recommended that the board:

  • ensure that all relevant staff are made aware of the adviser's comments on locum consultations for patients with chronic conditions; and
  • ensure that Mrs C's consultant is made aware of the adviser's comments on additional blood tests that could be carried out for completeness.

Download case 201405195 as a PDF (12.94 KB)

Updated: May 18, 2016