• Case ref:
  • Date:
    July 2018
  • Body:
    Ayrshire and Arran NHS Board
  • Sector(s):
  • Subject:
    clinical treatment / diagnosis
  • Outcome:
    Some upheld, recommendations


Mrs C, who works for an independent advocacy service, complained that there was unreasonable delay in providing the required care and treatment to her client  (Miss A) when Miss A was admitted to Crosshouse Hospital after her Percutaneous Endoscopic Jejunostomy tube (PEJ tube - a feeding tube that is put inside an outer tube which goes into the stomach. The inside tube goes into the small intestine) became blocked. Mrs C also complained that the board's handling of her complaint was unreasonable.

We took independent advice from a gastroenterologist (a doctor who specialises in the digestive system). We found that the board's staff referred Miss A for an initial review, specialist review, arranged investigations and arranged for a replacement PEJ tube in a reasonable time. In view of this, we did not uphold Mrs C's complaint regarding the time taken to treat Miss A. However, we identified that there was no nutrition team involvement in Miss A's care, and that a nutrition assessment was not carried out. We were critical of this and made a recommendation to the board to address this matter.

Regarding complaints handling, we found that there was a lack of clarity as to how the board were investigating the issues raised by Mrs C. In addition, we found that the board did not adhere to the timescale required, nor did they appropriately update Mrs C on their progress. We, therefore, upheld this aspect of the complaint.


What we asked the organisation to do in this case:

  • Apologise to Mrs C for the failure to clarify how the complaint would be handled and for not keeping her reasonably informed about the progress of the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

  • The involvement of a nutrition team should be considered where stopping of nutrition due to a blocked feeding tube is the reason for admission, and the patient cannot be easily assessed with regards to nutrition status. Nutritional assessment of such patients should be documented.

In relation to complaints handling, we recommended:

  • Complaints should be dealt with in accordance with the complaints procedure.

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.