SPSO Launches New Interactive Complaints Map

The Scottish Public Services Ombudsman (SPSO) has launched the first phase of an interactive map. This shows the number of complaints closed in 2022—23 for each Local Authority area in Scotland across the sectors it oversees, mapped against measures of deprivation. 

The map highlights the percentage of cases coming from the most deprived parts of Scotland according to the Scottish Index of Multiple Deprivation (SIMD). The SIMD ranks areas across Scotland from most to least deprived. 

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  • Report no:
    202300512
  • Date:
    February 2025
  • Body:
    Lanarkshire NHS Board
  • Sector:
    Health

The complainant (C) complained to my office about the care and treatment provided to their late grandparent (A) by Lanarkshire NHS Board (the Board).

A arrived at the Emergency Department of University Hospital Monklands by ambulance in the afternoon of 11 June 2022 and was admitted to hospital in the early hours of 12 June 2022. 

While in hospital, A’s condition deteriorated. Over the course of the evening of 12 June 2022, A became seriously unwell. A vomited, developed abdominal pain, and had a distended abdomen. A received abdominal x-rays and input from the surgical team, and staff attempted to stabilise A.

A small bowel obstruction (narrowing or blockage in the bowel, which usually requires urgent treatment) was identified in the early hours of 13 June 2022. Sadly, A died a short time later.

C complained to me (having been though the Board’s complaint process) about the events preceding A’s death. In particular, C complained about events relating to the assessment of A on admission and that communication with A’s family prior to A’s death was unreasonable. 

The Board reviewed this case again after receiving notification of my investigation and identified some areas for improvement. They determined that further investigation through a Significant Adverse Event Review (SAER) was not required. 

During my investigation I took independent advice from a Consultant in Acute and General Medicine. Having considered and accepted the advice I received, I found that:

Care and treatment

  • An abdominal x-ray should have been carried out when A was admitted to hospital in the early hours of 12 June 2022 on the basis of A’s presentation and also as part of an assessment for Clostridium difficile (C. diff, an infectious disease) as set out under relevant national prescribing guidelines. 
  • It was unreasonable that there was no record of an abdominal examination by a consultant on the morning of 12 June 2022 given an abdominal examination should have been carried out and documented based on A’s presentation.
  • The Board’s failure to carry out an abdominal x-ray on admission and the lack of evidence that an abdominal examination was carried out by the consultant on the morning of 12 June 2022 means that the opportunity to detect signs of bowel obstruction was missed at an earlier stage when A was stable enough to undergo life-saving treatment. Therefore, there is a prospect that A might have survived.

Communication

  • On balance, I found that the Board’s communication with A’s family was reasonable.

Taking all of the above into account, I upheld C’s complaint about A’s care and treatment. I did not uphold C’s complaint about the Board’s communication. 

I was also critical that a SAER was not held in this case given it related to an unexpected death and given the Board’s review had identified three specific points where consideration should be given to escalating to a SAER.

Finally, I found the Board’s handling of C’s complaint was unreasonable.

Further comment

It is of concern to me that I have made similar findings regarding Health Boards not carrying out adverse event reviews in other recent public reports (case references 202100979; 202209575; 202100560; 202101928; 202105840; 202200588). I intend to write to the Scottish Government and Health Improvement Scotland to draw their attention to the findings and recommendations I have made in relation to adverse event reviews in recent cases, including this one.

Recommendations

The Ombudsman’s recommendations are set out below:

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 the Board’s care and treatment fell below a reasonable standard. In particular I found the Board should have:

  1. carried out an abdominal x-ray when A was admitted to hospital in relation to A’s presentation and as part of screening for C. diff.
  2. carried out an abdominal examination on the consultant ward round the morning after A’s hospital admission and appropriately documented the results of the examination. There is no evidence that this happened which is unreasonable.
  3. the Board’s own review, which was only carried out after I decided to investigate, did not identify all of the significant failings in care and areas for improvement including that this was a potentially preventable death. This was unreasonable.
  4. the Board did not appropriately consider carrying out a SAER.
  5. in relation to complaint handling, I found that the Board’s complaint investigation was unreasonable. In particular the Board failed to update about delays to the final response and to provide a full and informed response to the complaint about A’s care and treatment.

Apologise to C for the failings identified in this investigation.

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: 19 March 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 the Board’s care and treatment fell below a reasonable standard. In particular I found the Board should have:

  1. carried out an abdominal x-ray when A was admitted to hospital in relation to A’s presentation and as part of screening for C. diff.
  2. carried out an abdominal examination the morning after A’s hospital admission and appropriately documented the results of the examination. There is no evidence that this happened which is unreasonable.

Patients presenting with diarrhoea and vomiting should have their symptoms fully assessed and be appropriately examined in a timely manner in line with relevant guidance.

Evidence the findings of my investigation has been shared with relevant staff in a supportive manner for reflection and learning.

By: 16 April 2025

Evidence that the Board have reviewed their guidance for the screening of C. diff to ensure it is in line with national guidance in relation to the carrying out of an x-ray with details provided of any changes and how this will be disseminated to staff. 

Evidence that the Board have reviewed their guidance for clinical staff in the medical assessment unit in relation to the carrying out of abdominal examinations and x-rays and the recording of findings with details provided of any changes and how this will be disseminated to staff.

By: 16 May 2025

 

3.

The Board’s review into A’s case following notification of my investigation did not identify all of the significant failings in care and areas for improvement, including that this was a potentially preventable death.

The Board did not appropriately consider carrying out a SAER.

Reviews into patient care should be undertaken at the right time, identify failings and good practice, and findings and recommendations are followed up, to demonstrate learning. 

Where adverse event(s) occur a significant adverse event review should be held in line with the Board’s protocols and national guidance to ensure there is appropriate learning and service improvements that enhance patient safety.

Evidence the findings of my investigation has been shared with relevant staff in a supportive manner for reflection and learning.

By: 16 April 2025

Evidence that the Board’s systems for carrying out significant adverse event reviews have been reviewed to ensure they are carried out in line with the Board’s protocols and national guidance.

By: 16 May 2025


 

We are asking the Board to improve their complaints handling:

Rec number

What we found

Outcome needed

What we need to see

4.

The Board’s complaint handling was unreasonable. In particular I found the Board should have:

  1. updated about delays to the final complaint response.
  2. identified the failings that occurred and areas for improvement during the complaint investigation, prior to contact from my office.
  3. provided a full and informed response to their complaint about A’s care and treatment.

Complaints should be investigated and responded to in accordance with the Board’s complaint handling procedure and the NHS Model Complaints Handling Procedure.

Complaints investigators should fully investigate and address the key issues raised, identify and action appropriate learning.

Evidence that these findings have been fed back to relevant staff in a supportive manner that encourages learning, including reference to what that learning is (for example, a record of a meeting with staff; or feedback given at one-to-one sessions).

By: 16 April 2025

 

Evidence of action already taken

The Board told me they had already taken action to address the issues and provided me with an action log which I am satisfied are reasonable. I will ask them to confirm that all actions are now complete and for an explanation about how they will assess their effectiveness going forward. (By 16 April 2025)

Feedback 

Points to note

In the advice I took (and accepted), the Adviser said that:

  1. the Emergency Department Nursing Record (which recorded a history of diarrhoea and vomiting) provided very useful additional information that - had it been used - may have guided the team towards earlier investigation and management; 
  2. the record made by a junior doctor who admitted A to the MAU included a picture of a hexagon to signify the abdomen, with an arrow through it, to indicate everything was fine. The Adviser said this record is not detailed, does not address bowel sounds and does not record what the doctor found, only showing that nothing was abnormal. The Adviser said that, while not unreasonable, this is a concern; and
  3. A should have been nursed in a side room until potentially infective diarrhoea or vomiting was excluded.

I am drawing these points to the Board’s attention and encourage them to consider and reflect on them, and whether there is scope for further learning from them.

Related reading

  • Report no:
    202207986
  • Date:
    February 2025
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health

The complainant (C) complained to my office about the treatment provided to their late parent (A) by Greater Glasgow and Clyde NHS Board - Acute Services Division (the Board).

A had a number of pre-existing health conditions and had previously had a laryngectomy (the surgical removal of the larynx (voice box) which disconnects the upper airway (nose and mouth) from the lungs).  A had a laryngectomy ‘larytube’ stoma and cannula in situ (where the trachea (windpipe) is cut and then the open end is stitched onto the front of the neck).

On 20 April 2021, A had a fall at home and was taken to the Emergency Department (ED) at Glasgow Royal Infirmary (the hospital) via ambulance. A was admitted to the Acute Medical Receiving Unit (AMRU).  A Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Order was put in place (meaning a patient does not receive resuscitation where their heart stops beating or their breathing stops). 

On 21 April 2021, A indicated that they felt that their larytube was blocked.  A student nurse provided laryngectomy care to A and was unable to replace the larytube. A experienced respiratory arrest (where breathing stops) followed by a cardiac arrest (where the heart stops beating) and sadly died. 

The Board carried out a Significant Adverse Event Review (SAER).  In their SAER, and their written response to C’s complaint, the Board’s overall conclusion was that the care provided to A was both appropriate and competent despite some failings having been identified.

C complained to my office about aspects of A’s laryngectomy care, including the decision to put a DNACPR Order in place and the conclusions reached by the SAER investigation.

During my investigation I sought independent advice from Consultant Physician in Acute Medicine and a Consultant Ear, Nose and Throat (ENT) Surgeon.  Having considered and accepted the advice I received, I found that:

  • Appropriate equipment was not available at A’s bedside for laryngectomy care.
  • It was unreasonable that A did not receive humidified oxygen in the Emergency Department and did not receive humidification in accordance with National Tracheostomy Safety Programme (NTSP) guidelines.  This may have prevented the blockage in A’s larytube from happening.
  • A student nurse acted without supervision in providing laryngectomy care to A.
  • In the circumstances, given A’s complex co-morbidities, it was reasonable for the medical team to put a DNACPR in place without discussion with the family.  Notwithstanding this, it was unreasonable (both in placing the DNACPR order and in following it through) that no distinction was made between the context of an expected death/sudden cardiorespiratory arrest and an unforeseen event/ readily reversible cause. As a result, it was unreasonable that ventilation/ resuscitation was not attempted.
  • Airway help was not sought immediately when the larytube could not be reinserted.
  • There was a failure to activate the duty of candour process in this case.
  • There was a failure to undertake a reasonable SAER that identified key learning and improvements.  This included recording conclusion Code 2 (Issues identified but they did not contribute to the event) when conclusion Code 3 (Issues identified which may have caused or contributed to the event) would have been more appropriate.

Taking all of the above into account, I upheld C’s complaints.
 

Redress and Recommendations

The Ombudsman’s recommendations are set out below:

What we are asking Greater Glasgow and Clyde NHS Board - Acute Services Division to do for the complainant:

Rec. number

What we found

What the organisation should do

What we need to see

1.

Under complaint point (a) I found:

  • it was unreasonable that appropriate equipment was not at A’s bedside.
  • it was unreasonable that A did not receive adequate humidification.
  • it was unreasonable that the student nurse acted without supervision in providing laryngectomy care to A.
  • unreasonable that airway help was not sought immediately when the laryngectomy cannula could not be reinserted.
  • it was unreasonable that ventilation/ resuscitation was not attempted.

Under complaint point (b) I found:

  • there was a failure to activate the duty of candour process in this case.
  • there was a failure to undertake a reasonable Significant Adverse Event Review that identified key learning and improvements.  This included recording conclusion Code 2 (Issues identified but they did not contribute to the event) when conclusion Code 3 (Issues identified which may have caused or contributed to the event) would have been more appropriate.

Apologise to C and her family for:

  • The failure to ensure appropriate equipment was at A’s beside.

  • The failure to administer adequate humidification to A.

  • The student nurse acting without supervision in providing laryngectomy care to A.

  • The failure to attempt ventilation/   resuscitation of A.

  • The failure to activate the duty of candour process.

  • The failure to undertake a reasonable Significant Adverse Event Review that identified key learning and improvements.   This included recording conclusion Code 2 rather than conclusion Code 3.

     

The apology should be specific and meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

A copy or record of the apology.

By: 19 March 2025

We are asking Greater Glasgow and Clyde NHS Board - Acute Services Division 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 it was unreasonable that A did not receive adequate humidification.

Patients with laryngectomies should receive appropriate humidification as set out in The National Tracheostomy Safety Programme (NTSP) guidelines.

Evidence that:

  • these findings have been fed back to relevant staff in a supportive manner that encourages learning, including reference to what that learning is (for example, a record of a meeting with staff; or feedback given at one-to-one sessions).

  • the learning from these events is reflected in policy/  guidance and staff training with details of how this will be disseminated to relevant staff.

By: 19 August 2025

3.

Under complaint point (a) I found it was unreasonable that airway help was not sought immediately when the laryngectomy cannula could not be reinserted.

Where there is a difficulty reinserting laryngectomy cannulas, airway help should be sought without delay. 

4.

Under complaint point (a) I found it was unreasonable that ventilation/ resuscitation was not attempted in the circumstances of A’s case.

Decisions in relation to ventilation/ resuscitation when a DNACPR is in place should be taken in line with relevant national guidance.  Where a decision is taken not to follow relevant national guidance this decision, and the reasons for it, should be clearly recorded.

5.

Under complaint point (b) I found that there was a failure to activate the duty of candour process in this case.

When an incident occurs that falls within the duty of candour legislation, the Board’s Duty of Candour processes should be activated without delay.

Evidence that the Board have reviewed their Duty of Candour processes, including their process for identifying and activating the process.

By:  19 May 2025

6.

Under complaint point (b) I found that there was a failure to undertake a reasonable Significant Adverse Event Review that identified key learning and improvements. 

Local and Significant adverse event reviews should be reflective and learning processes that ensure failings are identified and any appropriate learning and improvement taken forward.  Adverse event reviews should be held in line with relevant guidance.

Evidence that the Board have reviewed their process for carrying out adverse event reviews to ensure these reviews properly investigate, identify learnings, and develop system improvements to prevent similar incidents occurring.

By: 19 May 2025

7.

Under complaint point (b) I found that the Board unreasonably recorded a conclusion of Code 2 (Issues identified but they did not contribute to the event) on the SAER when a conclusion of Code 3 (Issues identified which may have caused or contributed to the event) would have been more appropriate.

Conclusion codes on adverse event reviews should reflect the findings.

Evidence that the Board have noted the incorrect conclusion code on the SAER report and have ensured this is a matter of record either by reissuing a revised SAER report, or by issuing an addendum, in line with any relevant Healthcare Improvement Scotland guidance and advice.

By: 19 May 2025

 

We are asking Greater Glasgow and Clyde NHS Board - Acute Services Division to improve their complaints handling:

Rec. number

What we found

Outcome needed

What we need to see

8.

There was a failure to fully investigate and identify the significant failings in this case in accordance with the Board’s complaint handling procedure and the NHS Model Complaints Handling Procedure.  There was also a failure to apologise to C as part of the complaint response.

Complaints should be investigated and responded to in accordance with the Board’s complaint handling procedure and the NHS Model Complaints Handling Procedure.  Complaints investigators should fully investigate and address the key issues raised, identify and action appropriate learning and apologise where issues have been identified.

Evidence that:

  • the Board have carried out a review of the management of this case from a complaint handling perspective 
  • these findings have been fed back to relevant staff in a supportive manner that encourages learning, including reference to what that learning is (for example, a record of a meeting with staff; or feedback given at one-to-one sessions).

By: 19 May 2025

Feedback 

Response to SPSO investigation

The Board’s response to our enquiries initially provided us with the accounts of different specialists employed by the Board which differed in opinion on some significant points, without providing the Board’s overall view.  This resulted in delays to our investigation while we established what the Board’s overall view was.  When responding to SPSO enquiries, the Board should ensure that their response reflects the Board’s overall position.  I am including this as feedback for the Board to reflect on.

Related reading

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