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Case ref:202405136
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Date:December 2025
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Body:Tayside 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 that they received during an admission to hospital. C attended A&E and the Acute Medical Unit for symptoms that were later diagnosed as an acute ischaemic stroke.
We took independent advice from a consultant physician. We found that some aspects of C’s care were reasonable, particularly the communication between the board and C and their partner.However, we found that C’s assessment in A&E was unreasonably delayed in relation to their triage category. In addition, no structured stroke assessment was carried out.
We also found that there was a delay in senior medical review and a lack of specialist stroke input. Furthermore, a prescription for aspirin was not made timeously after a CT scan excluded bleeding. Therefore, we upheld C's complaint.
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 www.spso.org.uk/information-leaflets.
What we said should change to put things right in future:
- Patients presenting to hospital with symptoms potentially indicative of stroke should receive timeous assessment, investigation and treatment.
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.