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Decision Report 201803891

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


Mr C complained about the clinical care and treatment provided to his late mother (Mrs A). Mr C complained that Mrs A had been incorrectly diagnosed with dementia and that the care and treatment Mrs A received during her admission to the Western General Hospital (WGH) and by the community mental health team (CMHT) prior to her death was unreasonable.

We took independent advice from a consultant psychiatrist and a consultant geriatrician (a specialist in medicine of the elderly). We were concerned that the board had failed to follow their retention and destruction policy and that some of Mrs A's medical records had not been retained in line with that policy and were therefore not available during the investigation of the complaint. However, from the available evidence, we found that the diagnosis of dementia was questionable and that there had been a failure to review this diagnosis as new information emerged. Therefore, we upheld this complaint.

In relation to the clinical care and treatment given to Mrs A during her admissions to the WGH, while we found that aspects of the care and treatment given to Mrs A was reasonable, there had been a number of failings and we upheld the complaint. However, we noted that the board had carried out a significant adverse review event and had made a number of recommendations.

In relation to the community mental health care given to Mrs A, we were unable to address all the issues raised by Mr C due to the absence of relevant medical records. However, based on the available evidence we found that there had been a lack of coordination and communication between the various mental health teams and as a result, we upheld the complaint.


What we asked the organisation to do in this case:

  • Apologise to Mr C and the family for the failings identified in this case. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets.

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

  • Medical records should be retained in line with the retention and destruction policy.
  • The board should ensure that in psychiatry of old age the diagnosis of dementia is reviewed as new information emerges.

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: June 17, 2020