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:
    Upheld, recommendations


Mr C complained about the care and treatment that his late wife (Mrs A) had received at University Hospital Crosshouse across a number of admissions. Mr C was concerned that staff were overly focussed on Mrs A's existing conditions and did not pay enough attention to new symptoms that were unconnected to these. Mrs A passed away after she became very unwell with a bleeding duodenal ulcer (an ulcer in part of the bowel, just after the stomach) following a number of admissions to the hospital across four months.

After taking independent advice on this case from a consultant geriatrician, we upheld Mr C's complaint. We found that while many aspects of Mrs A's care had been good, there was a failure to carry out appropriate investigations to determine the cause of her anaemia after this was revealed by blood tests during one of her admissions. We received advice that this meant a potential opportunity to diagnose the ulcer earlier was missed and that this could have led to specific treatment to reduce the risk of this bleeding. We made a number of recommendations to address the issues we identified.


We recommended that the board:

  • issue Mr C with a written apology for the failure to take further action to establish the cause of Mrs A's anaemia following a specific admission;
  • ensure that this case is included for discussion at the appraisals of the relevant clinicians; and
  • discuss this case at an appropriate clinical governance forum.

Download case 201500693 as a PDF (13.05 KB)

Updated: May 18, 2016