• Case ref:
  • Date:
    March 2019
  • Body:
    Highland NHS Board
  • Sector(s):
  • Subject:
    clinical treatment / diagnosis
  • Outcome:
    Some upheld, recommendations


Mrs C complained about the medical and nursing care and treatment her late mother (Mrs A) received when she was admitted to Lorn and Islands Hospital. She also complained about the communication with her family and that the board had failed to handle her complaint in a reasonable way.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nursing adviser. We found that it was difficult to provide an overall view about the medical care and treatment given to Mrs A due to the length and complexity of her admission. However, we found there had been a delay in diagnosing Mrs A's delirium and that she had a urine infection. We also found that the death certificate process was handled insensitively. Therefore, we upheld this aspect of Mrs C's complaint.

In relation to the nursing care given to Mrs A, we found no failings on the part of nursing staff regarding Mrs A's dehydration, dietary intake and her personal care. Therefore, we did not uphold this aspect of Mrs C's complaint.

In relation to communication, we found that the nursing communication was reasonable. However, we found that there was a delay in medical staff communicating the results of a CT scan and the overall assessment of Mrs A's health to Mrs C. Therefore, we upheld this aspect of Mrs C's complaint.

Finally, in relation to complaint handling, we found that the board had failed to comply with their complaints handling procedure and we upheld this aspect of Mrs C's complaint.


What we asked the organisation to do in this case:

  • Apologise to Mrs C for the failings in clinical care, communication and complaint handling. 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:

  • Staff should be aware of the potential for elderly patients to have delirium. Staff should be careful and sensitive with the death certification process and junior doctors should have senior supervision of this process as set out in national guidance.
  • Families or carers should be involved in identifying delirium. Results of CT scans and the overall assessment of a patient's health should be communicated timeously to families.

In relation to complaints handling, we recommended:

  • Complaints should be dealt with in accordance with the complaints handling process.