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Case ref:202402698
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Date:December 2025
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Body:Lanarkshire NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:Clinical treatment / diagnosis
Summary
C complained about the care and treatment provided to their parent (A). A suffered a heart attack and was treated with increased levels of digoxin (heart medication) in hospital. Over a two-week period A became increasingly paranoid and agitated and needed to be medicated. A was then transferred to a nursing home.
A’s digoxin levels were found to be very high and this medication was reduced. C believed that A was suffering from digoxin toxicity. C felt that A’s digoxin levels were not properly monitored or controlled and that A's outcome might have been different with better monitoring.
We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). We found that A’s digoxin was not appropriately monitored. However, it is difficult to assess whether A was suffering from digoxin toxicity. The board acknowledged this failing and provided information on the action taken by individual staff members as well as the board as an organisation to reflect on A’s experience and improve the delivery of care and treatment in the future. We upheld C's complaint and made recommendations to ensure these changes were taken forward.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/meaningful-apologies.
In relation to complaints handling, we recommended:
- Complaints should be investigated fairly and fully and in line with the requirements of the NHS Scotland Complaints Handling Procedure. Complaint responses should be accurate, complete and address all the points raised in line with the NHS Scotland Complaints Handling Procedure. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.
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.