Decision Report 201803544

  • Case ref:
  • Date:
    September 2019
  • Body:
    Scottish Ambulance Service
  • Sector:
  • Outcome:
    Not upheld, recommendations
  • Subject:
    clinical treatment / diagnosis


Ms C complained about the care provided to her by the Scottish Ambulance Service (SAS) when she experienced an episode of cellulitis (a potentially serious skin infection). She said that SAS failed to identify that she was suffering from sepsis (a serious complication of infection) and take the appropriate action.

We took independent advice from an adviser who is experienced in pre-hospital, emergency and unscheduled care. We found that the care and treatment provided by SAS to Ms C was reasonable and in line with relevant guidance. We did not uphold Ms C's complaint.

However, during our investigation we identified that SAS had failed to respond to Ms C's complaint within the appropriate timescales and had not kept her updated on the delay. We therefore made a recommendation under section 16G of the SPSO Act 2002, which requires the Ombudsman to monitor and promote best practice in relation to complaints handling.


What we asked the organisation to do in this case:

  • Apologise to Ms C that her complaint was responded to outwith 20 working days and she was not provided with an explanation for the delay or a revised timetable for sending the response. The apology should meet the standards set out in the SPSO guidelines on apology available at

In relation to complaints handling, we recommended:

  • Complaints should be responded to within 20 working days, and if the investigation will take longer, SAS should discuss this with the complainant and agree revised time limits.

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: September 18, 2019