• Case ref:
  • Date:
    May 2018
  • Body:
    Forth Valley NHS Board
  • Sector(s):
  • Subject:
    admission / discharge / transfer procedures
  • Outcome:
    Some upheld, recommendations


Mr C's child, (child A), was born with a cleft palate (an opening or split in the roof of the mouth that occurs when the tissue doesn't fuse together during development in the womb) which led to difficulties in breathing and feeding. After treatment at one hospital, child A was transferred to Forth Valley Royal Hospital. They were discharged 11 days later, however, Mr C had to return child A to Forth Valley Royal Hospital that night because they had been struggling to breathe since their discharge. Child A was admitted and within a few days they were referred to another hospital. Mr C complained that child A should not have been discharged from Forth Valley Royal Hospital given their medical condition at the time. Mr C also complained that the board failed to address his complaint in a reasonable way.

We took independent advice from a paediatrician. We found that the decision to discharge child A was reasonable given his medical condition at the time. There were no medical concerns noted in the days prior to their discharge and we considered that the board's actions were appropriate. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to complaints handling, we found that the board fully addressed Mr C's concerns. However, we found that there was an unreasonable delay in arranging a meeting and that there had been a lack of communication with Mr C regarding this. Therefore, we upheld this aspect of Mr C's complaint.


What we asked the organisation to do in this case:

  • Apologise to Mr C for failing to deal with his complaint in a reasonable way. 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:

  • Meetings with complainants should be arranged within a reasonable time; complaint files should record any delays; and complainants should be told within a reasonable time of any alterations to the arrangements.

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.