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Decision Report 201605328

  • Case ref:
  • Date:
    December 2018
  • Body:
    Lothian NHS Board - Acute Division
  • Sector:
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis


Ms C complained about a number of aspects of the mental health care and treatment provided to her by the board over a number of years. In particular, Ms  C felt that the board failed to provide her with appropriate crisis support and appropriate psychiatric treatment. Ms C also complained that their communication around these matters was unreasonable and that their handling of her complaint was poor.

We took independent advice from a mental health nurse and a psychiatrist. We found that some of the crisis care provided to Ms C was reasonable, however, there were a number of areas where care could have been improved. We were not satisfied that the board had taken appropriate action, following an upheld complaint about staff attitude, to ensure that this issue did not impact on Ms C's access to the service in future. The mental health adviser noted that an out-of-hours care plan was not reviewed within the appropriate scheduled timescale and that the board held conflicting information in relation to Ms C's ability to access other services. Therefore, we upheld this aspect of Ms C's complaint.

In relation to Ms C's psychiatric treatment, we found that the care provided by a psychiatrist and a psychologist was reasonable. The psychiatric adviser noted that both the psychological treatment that Ms C received, and the administration of medication, was appropriate. Therefore, we did not uphold this aspect of Ms  C's complaint.

Additionally, Ms C felt that the board's communication around these matters had been poor as she had been unreasonably excluded from meetings where her care was being discussed. The psychiatric adviser considered that the board followed their usual and appropriate practice in relation to meetings held about a patient. We did not find evidence to suggest that Ms C had been unreasonably excluded from these meetings and that the boards communication with her was unreasonable. Therefore, we did not uphold this aspect of Ms C's complaint.

Finally, we found that the board had not consistently handled Ms C's complaints in line with their complaint handling guidance in place at the time. Therefore, we upheld this aspect of Ms C's complaint. However, we noted that since Ms C first made a complaint, a new complaints handling procedure has been introduced by the board and therefore, we made no recommendations for improvement on this point.


What we asked the organisation to do in this case:

  • Apologise to Ms C for failing to review her out-of-hours care plan as had been scheduled, failing to communicate with her consistently and accurately about her ability to access a crisis support service and failing to handle her complaints appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

  • Staff should treat patients with courtesy and respect at all times. Staff should have access to appropriate focused clinical support and supervision.
  • Care plans should be reviewed within the scheduled timescale. Where this is not possible, a reason for this should be documented. Care plans should accurately reflect a patient's ability or inability to access other support services, and communication about this matter should be consistent.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Updated: December 19, 2018