Summary
The complainant (C) complained to me about the standard of nursing care and treatment provided to their late spouse (A) by Borders NHS Board (the Board). In particular, C was concerned about how nursing staff cared for and treated A.
A was cognitively impaired and suffered from terminal prostate cancer with cancer in their bones. Following a period of delirium, A was admitted to hospital for pain management; they had complex pain needs including neuropathic pain. A also had a tendency to wander.
C complained to me that A’s pain, and their tendency to wander, was not managed in a reasonable way and that nursing staff actions, including communication towards C, was unreasonable.
The Board said in their response to C that, overall, they considered A’s care was appropriate; A had their pain assessed daily and only required additional pain relief on two occasions. A’s tendency to wander had also been managed by following specialist advice. However, there were a number of shortcomings in communication with C for which the Board apologised.
During my investigation I sought independent advice from a registered nurse. Having considered and accepted the advice I received, I found that:
- A was cognitively impaired and their pain was not adequately assessed or managed even though they were admitted for pain management arising from metastatic prostate cancer and had complex pain needs. This meant A was left in unnecessary pain.
- Documentation and record keeping was poor and fell below an acceptable standard including that there was no evidence the Board undertook enhanced observations of care as they should have.
- Nursing staff did not follow specialist advice and instruction in managing A and their pain. They also did not act on the information provided by C and look for non-verbal clues for A being in pain.
- There were a number of avoidable incidents that should not have happened including:
- the ward ran out of medication at one point;
- nursing staff could not access the drug cupboard because the keys were locked elsewhere;
- on two occasions, A managed to take medication they should not have had access to; and
- A was able to leave the ward and hospital grounds and managed to get on a bus on one occasion.
Taking all of the above into account, I upheld C’s complaint about the standard of nursing care and treatment provided to A.
Complaint handling
Having considered the Board’s complaint file and the evidence from the clinical records, I also found the Board’s complaint handling was unreasonable in that there was a failure to ensure the complaint response was accurate and substantiated by the clinical records. The Board also failed to provide a clear and full complaint response.
Recommendations
What we are asking Borders NHS Board to do for the complainant:
| Rec number. | What we found | What the organisation should do | What we need to see |
|---|---|---|---|
| 1. |
Under complaint (a) I found that the standard of nursing care and treatment was unreasonable in that the Board failed to:
Under complaint point (b) I found that complaint handling was unreasonable in that there was a failure to:
|
Apologise to C for the failings identified in this investigation in relation to the standard of nursing care and treatment and complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies. |
A copy or record of the apology. By: 22 September 2025 |
We are asking Borders NHS Board to improve the way they do things:
| Rec number. | What we found | Outcome needed | What we need to see |
|---|---|---|---|
| 2. |
Under complaint (a) I found that the standard of nursing care and treatment was unreasonable in that the Board failed to:
|
Patients who are cognitively impaired and in pain should be assessed by the appropriate tool, and receive adequate pain relief. Patients should receive person centred care and for those with cognitive impairment, information provided by carers and/or family members should be taken into account to ensure person centred care planning. Staff should take into account any specialised advice provided. If a decision is made not to act on it, the reason for this should be documented. Documentation and record keeping should meet the required standards and policy. |
Evidence that the findings of my investigation have been fed back to the staff involved, in a supportive manner, for reflection and learning. Evidence staff are competent in the use of the relevant pain assessment tools and take into account relevant guidance and specialist advice. For example, by the carrying out of a ward audit, and identifying and addressing training needs. Evidence that person centred care documentation meets the required standard. For example, by the carrying out of a ward audit, and identifying and addressing training needs. By: 20 November 2025 |
We are asking Borders NHS Board to improve their complaints handling:
| Rec number. | What we found | Outcome needed | What we need to see |
|---|---|---|---|
| 3. |
Under complaint point (b) I found that complaint handling was unreasonable in that there was a failure to:
|
Complaints should be investigated fairly and fully and in line with the requirements of the NHS model complaints procedures. Complaint responses should be accurate, complete and address all the points raised in line with the NHS model 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. |
Evidence that the findings of my investigation have been fed back to the staff involved, in a supportive manner, for reflection and learning. By: 22 September 2025 |
Evidence of action already taken
Borders NHS Board told us they had already taken action to fix the problem. We will ask them for evidence that this has happened:
| Complaint number | What we found | What the organisation say they have done | What we need to see |
|---|---|---|---|
| (a) |
Under complaint (a) I found that the standard of nursing care and treatment was unreasonable in that the Board failed to:
|
Training for nursing staff on detention orders under the relevant legislation. |
Evidence training occurred. By: 22 September 2025 |