Scottish Public Services Ombudsman

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  • Case ref:
  • Date:
    January 2017
  • Body:
    Ayrshire and Arran NHS Board
  • Sector(s):
  • Subject:
    clinical treatment / diagnosis
  • Outcome:
    Some upheld, recommendations


Mrs C complained about the care and treatment given to her mother (Mrs A) at University Hospital Crosshouse prior to Mrs A's death. At the time of her admission, Mrs A had been very unwell with pneumonia and sepsis. Mrs C said that she and her family were not alerted to the seriousness of Mrs A's condition and were not prepared for her death. Mrs C said that Mrs A was not cared for appropriately, specifically that she was left in soiled clothes and bedding, not given medication in a timely manner, that there was a delay in moving Mrs A to the high dependency unit and that fluid was removed from Mrs A's lung in an incorrect way. Mrs C said that it was only after Mrs A's death that it was disclosed that she may have been suffering from leukaemia. Mrs C also complained that the board's response to her complaint was inadequate.

We took independent advice from a nursing adviser and a consultant physician and geriatrician. We found that overall, Mrs A's care had been reasonable. Mrs A had wanted to be independent regarding personal hygiene, with help from family members rather than from staff. Mrs A's medication was administered appropriately and in a timely manner. The procedure to remove fluid from Mrs A's lung was reasonable, as was the timing of moving her to a high dependency unit. We found evidence that Mrs C and her family had been kept updated about Mrs A's condition. We also found that it was only after Mrs A's death that it was determined that she had leukaemia. We did not uphold these aspects of Mrs C's complaint. However, our investigation did raise concerns about the facilities on the ward and we made a recommendation to address this.

We found that the board's response to Mrs C's complaint had been poor in that it failed to provide sufficient detail in a timely manner. We therefore upheld this aspect of Mrs C's complaint.


We recommended that the board:

  • confirm that action has been taken to improve the facilities concerned. If nothing has been done, they should provide details of the action they intend to take to remedy the situation;
  • apologise to Mrs C for the shortcomings identified in their correspondence to her; and
  • emphasise to relevant staff the importance of supplying information to allow a timely response to complaints.

Download case 201507617 as a PDF (13.41 KB)

Updated: January 25, 2017