Summary
The complainant (C, an advocate) complained to me on behalf of A’s family about the standard of medical care and treatment provided to A by Lanarkshire NHS Board (the Board) when A was diagnosed with a bleed in the brain.
A had undergone surgery for cancer and while recovering at home, they began to experience symptoms that were later found to be due to a subarachnoid haemorrhage (a type of bleed in the brain). A was admitted to hospital and medical staff sought advice from a neurosurgical team at another health board. That team advised that A should have a stroke review, a CT angiogram (a type of x-ray used to examine blood vessels) and an MRI (a type of scan used to see inside the body) to find out the cause of the bleeding.
A had the CT angiogram but did not have an MRI and was discharged home after two days with a severe headache. A was readmitted the following day when their condition deteriorated. After emergency surgery at another hospital, and a long hospital admission, A died.
The Board said in their response to C that, overall, they considered A’s care was appropriate; they had sought and followed specialist neurosurgical advice. On the day of discharge, A was clinically stable and medical staff contacted the neurosurgical team who advised that no follow-up was necessary and to discharge A home.
C complained to me that A should not have been discharged from hospital when medical staff knew A had a subarachnoid haemorrhage and a severe headache.
During my investigation I sought independent advice from a Consultant Physician in Acute Medicine. Having considered and accepted the advice I received, I found that:
- A’s initial management, including planned care and treatment, was reasonable and in line with the relevant guidelines
- the standard of medical care and treatment provided to A on the day of discharge was below that which A and their family were entitled to expect; there was an unreasonable failure to follow the advice of the neurosurgical team, and relevant guidelines, and perform an MRI. Nor was there clear evidence that a full stroke review occurred contrary to the neurosurgical team’s advice
- there was also an unreasonable failure to discuss A’s discharge with the neurosurgical team beforehand, and
- in the absence of further advice from the neurosurgical team, the responsibility for discharge lay with the Board, and the decision itself to discharge A was unreasonable.
Taking all of the above into account, I upheld C’s complaint about the standard of medical 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 that the Board’s complaint handling was unreasonable and made recommendations to address this, in doing so I drew attention to my concern that my office had made a number of similar findings about the Board’s complaint handling in previous investigation cases.
Recommendations
What we are asking the Board to do for C:
| Rec. number | What we found | What the organisation should do | What we need to see |
|---|---|---|---|
| 1. |
Under complaint point (a) I found that the standard of medical care and treatment was unreasonable in that before discharging A 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 medical 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: 23 August 2025 |
We are asking the Board to improve the way they do things:
| Rec. number | What we found | Outcome needed | What we need to see |
|---|---|---|---|
| 2. |
Under complaint point (a) I found that the standard of medical care and treatment was unreasonable in that before discharging A the Board failed to:
|
Patients who suffer from an SAH should receive care and treatment that is line with the relevant guidelines and advice from specialist teams. If departing from relevant guidelines and/or specialist advice, this should be clearly documented including the reasons for doing so. Reviews carried out (e.g. stroke review) should be fully documented. |
Evidence that the findings of my investigation have been fed back to the relevant clinical staff, in a supportive manner, for reflection and learning. By: 23 August 2025 Evidence that the Board have reviewed their systems to ensure the relevant guidelines for treating SAH are embedded in working practices and that reviews carried out are fully documented. Evidence that the Board have monitored awareness of and compliance with the relevant guidelines in relation to this. For example, by the carrying out of an audit, and identifying and addressing training needs. By: 23 October 2025 |
We are asking the Board to do 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 Handling Procedure. Complaint responses should be accurate, complete and address all the points raised in line with the NHS Model Complaints Handling Procedure. All relevant information in relation to an SPSO investigation should be provided at the outset of our enquiries. 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: 23 August 2025 Evidence that the Board have reviewed their procedures for complaints handling to ensure that all relevant evidence is obtained (including from other organisations) and evaluated during the investigation. Evidence that the training needs for complaint handling staff have been assessed and that relevant staff have access to online training and other tools to improve complaint handling and their approach to our investigations and findings. Evidence that the Board have monitored compliance with the Model Complaints Handling Procedure and SPSO legislation, for example, by the carrying out of an audit. By: 23 October 2025 |
Feedback
My investigation has found that the standard of communication between clinicians may have been a contributory factor to why the planned MRI was not undertaken. I encourage the Board to reflect on this with clinicians.