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Decision Report 201807363

  • Case ref:
  • Date:
    July 2020
  • Body:
    Lothian NHS Board - Acute Division
  • Sector:
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis


Mr C complained that the board had not made reasonable decisions around whether to provide plasma exchanges (a procedure which separates your blood into its different parts: red cells, white cells, platelets and plasma. The plasma is removed from the blood and replaced by a plasma substitute) to his wife (Mrs A) and whether to further explore the possibility of thrombectomy (procedure of removing a blood clot from a blood vessel), or reasonably monitor her levels of consciousness during an admission to hospital following a stroke. We found that the board's decisions around plasma exchanges and the possibility of thrombectomy had been reasonable, but that the board had not reasonably monitored Mrs A's levels of consciousness for a period. This meant that there was a delay to the board providing her with specific treatment. Although this treatment had only a small chance of success, we decided that the board's actions had been unreasonable. Therefore, we upheld this aspect of Mr C's complaint.

Mr C also complained about how the board had responded to his complaint. We found that the board's responses had been reasonable and did not uphold this aspect of the complaint.


What we asked the organisation to do in this case:

  • Apologise to Mrs A's family for their unreasonable failure to monitor Mrs A's consciousness levels hourly, which caused a delay in providing reasonable treatment to her. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

  • The board should reasonably monitor patients' consciousness levels.

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: July 22, 2020