Decision Report 201701848

  • Case ref:
  • Date:
    June 2018
  • Body:
    A Medical Practice in the Fife NHS Board area
  • Sector:
  • Outcome:
    Upheld, recommendations
  • Subject:
    admission / discharge / transfer procedures


Miss C complained on behalf of her late mother (Mrs A) that the practice unreasonably admitted Mrs A to hospital when it was her wish to remain at home. Mrs A had terminal cancer and was being cared for at home. A GP from the practice visited her at home and was concerned about the ability to meet her care needs there. Therefore, the GP arranged for Mrs A to be admitted to hospital where she died two days later. Miss C was concerned that this was against Mrs A's wishes as she had wanted to remain at home.

We took independent advice from a GP. The adviser considered that the initial decision to have Mrs A admitted to hospital was reasonable. However, by the time that the ambulance crew had arrived, she had lost consciousness. We found that, at that point, the GP should have consulted the family about having Mrs A admitted to hospital. We considered that Mrs A should have been allowed to remain at home if that was what her family wanted. Therefore, we upheld Miss C's complaint.


What we asked the organisation to do in this case:

  • Apologise to Mrs C for not clarifying and acting in line with her family's wishes about Mrs A's admission to hospital. The apology should meet the standards set out in the SPSO guidelines on apology available at:

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

  • When someone is in the final days of their life, there should be shared decision making with them and with their family, as appropriate, about their care.

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 2, 2018