Health

  • Report no:
    202307063
  • Date:
    July 2025
  • Body:
    Lothian NHS Board - Acute Services Division
  • Sector:
    Health

Summary 

The complainant (C) complained to my office about the nursing care and treatment given to their late parent (A) at home and in hospital (acute care) by Lothian NHS Board (the Board). A was an adult with multiple sclerosis (an autoimmune condition that affects the brain and/or spinal cord). Due to progression of the condition A was doubly incontinent, immobile, and unable to eat or drink independently. A required assistance daily from carers and weekly from district nurses. 

A developed pressure damage to their skin whilst in the community, and they were later admitted to hospital with sepsis (overwhelming infection). A was discharged home and readmitted within a short period of time. They died shortly after their readmission to hospital. 

C raised concerns that A did not receive appropriate treatment at home from the district nurses, and specifically that, pressure damage was not treated appropriately. C also raised concerns about the standard of acute nursing care specifically in relation to; pressure damage, nutrition, basic care, and record keeping. 

The Board said that the district nursing team considered that they had provided reasonable nursing care to A whilst they were at home. The Board also said, acute nursing staff were made aware of A’s needs and were concerned about the integrity of A’s skin. The Board highlighted that regular drinks were offered to A, however, A declined these on occasions. It was noted that some documentation was not present in the medical records. An action plan was agreed to make improvements in staff awareness, completion of documentation, and the importance of charts.

During my investigation I sought independent clinical advice from a registered nurse with experience in both community and acute care settings and with particular knowledge of the management and treatment of pressure damage. 

Having considered and accepted the advice I received I found that:

District nursing care

There was evidence of significant omissions in the care provided by the district nursing team including 

  • District nurses failed to update assessments accurately or in line with the minimum frequency.
  • District nurses failed to check A’s skin during joint visits.
  • There was a failure to plan visits with two staff members.
  • District nurses showed an over reliance on A to report the condition of their own skin.
  • The pressure ulcer risk assessment was not appropriately completed and updated.
  • There was a failure to have a person-centred care plan in place. 

Acute nursing care

There was evidence of significant omissions in the acute care provided by the Board including

  • The failure to provide reasonable basic nursing care and end-of-life care.
  • Nursing staff failed to create and follow a person-centred care plan.
  • Nursing staff failed to carry out and record reasonable care rounding.
  • Nursing staff failed to carry out relevant assessments and failed to reasonably complete appropriate charts.
  • There was a failure to provide continuity of wound care treatment and follow the appropriate national guidance.
  • There was a delay in referral for assessments for pressure damage and nutrition.

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

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 district nursing care and treatment was unreasonable. 

Under complaint point (b) I found that the nursing care and treatment given to A in hospital during two admissions was unreasonable.

Apologise to C for the failures identified in this report. 

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: 25 August 2025

We are asking Lothian NHS Board - Acute Services Division to improve the way they do things:

Rec number. What we found What the organisation should do What we need to see
2.

Under complaint point (a) I found that the district nursing team failed to

  • Complete assessments in an appropriate timescale;
  • Review assessments/reassess A within a reasonable timescale;
  • Complete the Waterlow assessment appropriately; and
  • Develop a person-centred care plan
 Patients receiving district nursing care in the community should be appropriately assessed and have appropriate care plans in place that are regularly reviewed and updated.

Evidence that the findings of my investigation have been fed back to the district nursing team involved in a supportive manner for reflection and learning. 

By: 25 August 2025

Evidence the Board have taken action to ensure all staff are proficient in completing risk assessments (including Waterlow) and developing person-centred care plans. 

By: 24 November 2025

Evidence an independent audit of patients within the district nursing care has been completed by an independent person external to the Board with the appropriate level of expertise and experience. 

The purpose of the audit should be to ensure that district nursing care has been appropriately undertaken. In particular that appropriate risk assessments (including Waterlow) are in place, along with a person-centred care plan and where appropriate a wound care chart. If gaps are identified, evidence that action has been taken to rectify the situation in each case. 

Progress update by: 24 November 2025

Completed audit by: 23 January 2026
3.

Under complaint point (a) I found that the district nursing team failed to plan two person visits to A after it was identified this was required to complete basic nursing care, particularly skin checks. 

Under complaint point (a) I found that the district nursing team relied on A to report on their own skin condition when unable to assess their own skin. 

Patients receiving district nursing care should be given basic nursing care with regular checks, such as skin checks, as required.

Patients should receive safe and appropriate care from an adequate number of district nursing staff and in line with their assessed needs. 

Patients who are frail, immobile, experiencing deteriorating health, and who are unable to visually check, should not be expected to report on their own well-being or condition (i.e. skin health) in lieu of appropriate checks by a clinician. 

Evidence that the findings of my investigation have been fed back to the district nursing team involved in a supportive manner for reflection and learning. 

Evidence an independent audit has been completed as detailed in recommendation 2.

Progress update by: 24 November 2025

Completed audit by: 23 January 2026
4. 

Under complaint point (b) I found that the hospital nursing team failed to

  • Complete appropriate assessments on admission to hospital;
  • Develop a person-centred care plan;
  • Complete and maintain appropriate charts such as; wound chart, care rounding, and food intake chart. 

Patients who are admitted to hospital should be appropriately assessed and have a person-centred care plan in place.

These should be reviewed regularly. 
Patients in hospital should have their condition, well-being, and nutrition monitored and recorded appropriately. Appropriate monitoring and recording would include records added in their medical notes, care rounding, and charts. 

Evidence that the findings of my investigation have been fed back to the relevant involved in a supportive manner for reflection and learning. 

By: 25 August 2025

Evidence an independent audit of inpatient nursing care, particularly in relation to the carrying out of nursing assessments and completion of patient paperwork/documentation.

This should be carried out by a person independent to the Board with the appropriate level of expertise and experience. The purpose of the audit would be to ensure that appropriate nursing assessment and documentation is completed within the correct timescales, and that particular consideration has been given to ensure wound charts are completed as required by the Vale of Leven Enquiry recommendations 2014.

Progress update by: 24 November 2025

Completed audit by: 23 January 2026
5.

Under complaint point (b) I found that there was a delay in making appropriate referrals for specialist review of A. Specifically there was

  • An unreasonable delay in making a referral to the tissue viability nurse; and
  • An unreasonable delay in making a referral to a dietician. 
 Patients who require specialist review/input into their care should have referrals made without delay.

Evidence that the findings of my investigation have been fed back to the district nursing team involved in a supportive manner for reflection and learning. 

Evidence that the Board have robust referral pathways in place for: 

  • Tissue viability referrals; and
  • Dietician referrals

By: 23 September 2025
6.

Under complaint point (b) I found that care and treatment provided by nursing staff was unreasonable, particularly

  • A’s skin damage was not managed correctly, including the use of inappropriate products;
  • A was not repositioned regularly to avoid exacerbating pressure damage;
  • A was not assisted in eating and drinking regularly.
  • The basic nursing care offered to A was unreasonable, for example, mouth care was not carried out and led to oral thrush. 
     

Patients who are admitted to hospital should receive reasonable basic nursing care to meet their needs.

Patients with skin damage/pressure damage should receive care and treatment using appropriate and correct products that are safe for them and their condition. 

Patients with, or at risk of, pressure damage should receive reasonable nursing care and treatment including regular repositioning. When they are reluctant to be repositioned, they should be offered the use of turn assist equipment to help. 

Patients who have been admitted to hospital should have their basic nutritional and hydration needs met, particularly when, they are unable to meet their own needs independently due to their medical condition. Patients should receive appropriate support from nursing staff. 

Evidence that the findings of my investigation have been fed back to relevant staff in a supportive manner for reflection and learning. 

Evidence staff members are aware of formulary products for skin damage, their use and contraindications. 

Evidence the Board have in place a process for assessing whether pressure assist equipment is needed and that this equipment is available for use when required. 

By: 23 September 2025

If any gaps in care are identified by the audit (in recommendation 4), evidence that these have been addressed to avoid a similar situation happening again.

By: 23 January 2026
 

Feedback

Response to SPSO investigation

In providing information in response to enquiries made by my complaints reviewer, the Board were asked to provide both clinical notes from admissions to hospital and the district nursing notes prior to admission to hospital. The district nursing notes were not provided in response to this initial enquiry. 
When my complaints reviewer contacted the Board to notify them that the complaint would be investigated, they made a further specific request for district nursing notes to be provided. In response the Board provided a copy of the written ‘house’ notes from A’s home. There was no indication that any other notes were available. 

Very late in my investigation the Board disclosed that there were further electronic district nursing notes held within their TRAK system. Once aware that there were further electronic notes available, my complaints reviewer requested that these be shared with us. 
When we make enquiries to organisations for records relating to a complaint, and particularly in the case of medical records, we ask that all the relevant records relating to the complaint be provided. In this case, both the written and electronic district nursing notes should have been provided in response to our initial request for medical records. Not doing so extended the time taken for me to complete my investigation.

I expect all Boards to provide all the relevant information in response to my office’s initial request and I urge the Board to ensure this happens going forwards. 

Points to note

  1. I draw the Board’s attention to the Adviser’s view that there may have been potential breaches of the NMC’s The Code. The Adviser told us that they consider there may have been breaches in: delivering the fundamentals of care, preventing ill health, working with colleagues to preserve the safety of those receiving care, identifying risks, completing records, accuracy of records, putting situations right, and escalating concerns. I strongly encourage the Board to consider this carefully, discuss with staff involved with a view to taking action or sharing a copy of this report with the NMC.
  2. The written house district nursing records in this case do not always match the electronic TRAK records. On occasions some information is omitted from one or the other of the records. Records both written and electronic should be an accurate, complete record of what happened during a visit to a patient. I encourage the Board to reflect on the records in this case and consider whether there is any learning in relation to record keeping for the staff involved. 

Related reading

  • Report no:
    202307762
  • Date:
    July 2025
  • Body:
    Lanarkshire NHS Board
  • Sector:
    Health

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:

  • perform an MRI;
  • consult with the neurosurgical team; and
  • ensure a clear stroke review was carried out.

Under complaint point (b) I found that complaint handling was unreasonable in that there was a failure to: 

  • evaluate the evidence by checking the clinical records;
  • obtain input from another health board;
  • collate all the relevant information so that the facts were established before responding to the complainant;
  • acknowledge clear errors and significant clinical failings;
  • reflect and learn from the clinical and complaint handling failings. 

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:

  • perform an MRI;
  • consult with the neurosurgical team; and
  • ensure a clear stroke review was carried out.
     

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: 

  • evaluate the evidence by checking the clinical records;
  • obtain input from another health board;
  • collate all the relevant information so that the facts were established before responding to the complainant;
  • acknowledge clear errors and significant clinical failings;
  • reflect and learn from the clinical and complaint handling failings.

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.

Related reading

  • Case ref:
    202407136
  • Date:
    July 2025
  • Body:
    Tayside NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about care and treatment provided to them by the board in relation to diagnosis and treatment of prostate cancer. C had concerns about medical treatment both prior to and after surgery, and about nursing care when they were in hospital following surgery.

We took independent advice from a urologist and a nurse. We found that overall, medical care and treatment had been reasonable and did not uphold these aspects of C’s complaint. However, in relation to nursing care, we found that C’s needs and risks were not properly assessed, resulting in a lack of person-centred care planning and implementation. We upheld the complaint about nursing care.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for the failings in nursing care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

What we said should change to put things right in future:

  • Patients admitted to hospital should receive appropriate nursing care including complete assessments and development of person-centred care plans. These should be updated to reflect the patient’s presenting condition.

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.

Related reading

  • Case ref:
    202401449
  • Date:
    July 2025
  • Body:
    Tayside NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, no recommendations
  • Subject:
    Admission / discharge / transfer procedures

Summary

C, an advocate, complained on behalf of A. A had been detained by the board under mental health legislation. C complained as to whether the board had taken steps to address the acknowledged deficiencies in discharge planning experienced by A, and whether A's personal belongings were securely stored in a way which allowed patients to access them.

The board said that there was evidence of discharge planning, however they accepted that A’s need for district nursing care was omitted. The process had been reviewed, and the board were happy to provide a report to demonstrate progress had been made. The board said that patients’ rooms were lockable and while staff had the keys for rooms, patient access was not restricted, beyond the need for staff to open and close rooms for individuals. Restricted items were stored separately, and patients would be supported by staff in accessing these.

We took independent advice from a mental health clinical adviser. We found that the board’s response demonstrated that they were taking reasonable steps to review the discharge process. However, we found that A’s discharge planning did not include the district nursing team. We upheld this aspect of the complaint but made no recommendations. We found that the board’s approach to the storage of possessions was reasonable. We did not uphold this aspect of the complaint.

Related reading

  • Case ref:
    202404774
  • Date:
    July 2025
  • Body:
    Lanarkshire NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C gave birth involving a forceps delivery (where a medical instrument is used to assist birth) and suffered a fourth-degree perineal tear (significant injury to the area between the vaginal opening and anus). C had surgery to repair the perineal tear and again to have treatment for retained placenta (where some placenta remains in the womb after birth). C complained about the maternity care and treatment in hospital, the board’s communication with C in hospital and the board’s handling of C’s complaint.

The board apologised for poor communication during the birth and said that they were carrying out actions to improve management of obstetric and anal sphincter injury and obtaining consent for instrumental birth.

We took independent advice from a consultant obstetrician. We found that the maternity care and treatment provided to C during the time of the birth was reasonable. We did not uphold this aspect of the complaint.

We found that the board’s communication with C when C was in hospital was unreasonable. Though the birth situation was urgent, it was not an emergency, and a fuller discussion should have taken place with C regarding the forceps delivery. We upheld this aspect of C’s complaint.

We found the actions that the board said they were carrying out were reasonable in response to the failing in communication.

We found the board’s complaints handling was unreasonable, because C’s initial complaint was not reasonably progressed, the scope of the complaint investigation was not agreed with C, the board’s response to the complaint was not reasonably clear, and there were regular and significant delays in the board’s communication with C regarding the complaint. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

In relation to complaints handling, we recommended:

  • All staff should be aware of how to identify and progress complaints about the board. The board should provide full, clear and timely complaint responses in line with the NHS Scotland Complaints Handling Procedure.

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.

Related reading

  • Case ref:
    202308797
  • Date:
    July 2025
  • Body:
    Lanarkshire NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about the care and treatment of their late parent (A) following an admission to hospital with a hip fracture, and about the communication surrounding this. C raised concerns about A’s fitness for discharge, including a lack of rehabilitation in hospital and length of wait for community rehabilitation, as well as a lack of support with food and fluid intake, and a lack of adequate skin care. C also raised concerns about a lack of engagement with them as A’s next of kin and power of attorney.

We took independent advice from a consultant orthopaedic surgeon and a registered nurse. We found that A’s discharge was medically reasonable, and that the level of input from therapists was reasonable. The board acknowledged shortcomings in communication with C around their discharge, and a failure to document the nursing handover with the care home. The board also apologised that the target timescale for community rehabilitation was not met.

We found that there were unreasonable failings in the nursing documentation, person centred care, and pressure care that A received. A’s person centred care plan was not completed, and a documented instruction that A required full assistance with nutrition and hydration was not adhered to.

We identified frequent gaps in skin inspections and repositioning, and inconsistent completion of a pressure ulcer risk assessment. The relevant foot care did not take place in light of A’s diabetes, and there was no referral to podiatry when pressure damage to A’s heel was discovered. We were concerned to note that A’s nutritional needs were not met, and that there was a failure to protect A from pressure damage. We upheld this complaint.

We also identified inconsistencies in the board’s complaint responses and noted that important failings were overlooked. We made recommendations to the board to address these.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

What we said should change to put things right in future:

  • Food, fluid and nutrition standards should be met. Instructions set out in care plans to be adhered to, and patients to receive the appropriate level of assistance.
  • Patients’ person centred needs should be fully considered. Documentation should meet the professional standards required by the NMC – The Code.
  • Pressure ulcer prevention standards should be met, and patients protected from healthcare acquired pressure damage.

In relation to complaints handling, we recommended:

  • Stage 2 complaint responses should meet the aims of the NHS Scotland Model Complaints Handling Procedure. They should aim to establish all the facts relevant to the points made in the complaint and to give the person making the complaint a full, objective and proportionate response that represents the organisation’s final position. 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.

Related reading

  • Case ref:
    202205337
  • Date:
    July 2025
  • Body:
    Lanarkshire NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about the care and treatment that the board provided to A, who had long-term mental health conditions. A was subject to a Community Compulsory Treatment order (CTO, a legal order that allows a person who has been detained in hospital for treatment to be discharged and receive supervised mental health care in the community). C was A’s Named Person in respect of the CTO. A experienced a deterioration in their mental health over a short period of time, which concluded with them attending A&E and requesting hospital admission. A was not admitted to hospital and died later that night. The post-mortem believed that A may have completed suicide.

The board carried out a Significant Adverse Event Review (SAER) and concluded that the outcome could not have been predicted. The SAER identified areas of good practice but also some learning points. These centred on missed opportunities to refer A to addiction services and paper notes from the Forensic Community Mental Health Team (FCMHT) not being accessible by other services.

C complained to the SPSO as they felt that there were failings in the care and treatment provided to A that contributed to their death. In addition to this, C complained that the board did not communicate with them reasonably, given that they were A’s Named Person.

We took independent advice from an adviser with a background in forensic psychiatric nursing. We found that the overall care and treatment provided to A in respect of their mental health was reasonable. We considered it clear that access to the FCMHT records across services would have been preferable. This would have assisted the clinical decision-making when A presented to A&E. However, we found that there are no standard guidelines or requirements for the sharing of records across NHS services in Scotland. Based on A's presentation and what was known to clinicians at the time, we found that the care and treatment provided by the board was reasonable. Therefore, we did not uphold this part of C's complaint.

In respect of C’s role as A’s Named Person, we found that it was unreasonable not to involve C in discussions regarding A’s circumstances. Relevant Scottish Government guidance indicates that it is necessary for the board to ensure that Named Persons are given information regarding compulsory measures. We found that the board’s actions and responses did not fully reflect the Scottish Government guidance regarding Named Persons. Particularly as there were discussions at the time about ending A’s CTO. Under the circumstances, we found that the board did not involve or communicate with C to a reasonable level. Therefore, we upheld this part of C's complaint.

During our investigation, we found failures in the board's handling of C's complaint and made recommendations to address these.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for not involving or communicated with C to a reasonable level. 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:

  • Relevant staff and services should have a firm understanding of what the Named Person role involves. Services should engage and communicate with Named Persons in line with the relevant guidance issued by the Scottish Government: Mental Health Law in Scotland: A Guide to Named Persons

In relation to complaints handling, we recommended:

  • Causation/conclusion codes on adverse event review reports should accurately reflect the findings of the review.
  • Documentation that is relevant to the SAER should be available to and considered by the team carrying out the review.
  • In response to SPSO enquiries, every effort should be made to provide any requested information at the earliest opportunity.

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.

Related reading

  • Case ref:
    202204428
  • Date:
    July 2025
  • Body:
    Lanarkshire NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about the care and treatment of their late spouse (A). The day before A’s first admission to hospital, the GP submitted an urgent suspicion of cancer (USOC) referral. A was experiencing abdominal pain with vomiting and diarrhoea. The initial diagnosis had been a suspected blocked bowel. After symptoms settled, A was discharged before returning to hospital a few days later with ongoing symptoms. A was discharged home with a plan to return for an outpatient colonoscopy. However, A returned to hospital with a diabetic foot infection resulting in surgery. During this final admission, A was diagnosed with bowel cancer. C considered A was inappropriately discharged from hospital following the first two admissions with no clear diagnosis or plan in place. C said that communication throughout A’s hospital admissions was poor and also complained about the nursing care provided to A, particularly in relation to the care given to their feet as a known diabetic.

We took independent advice from a clinical adviser and senior nurse adviser. We found that given A’s symptoms, and the USOC referral, the board unreasonably failed to consider A for an inpatient colonoscopy during their second admission to hospital and unreasonably failed to schedule an outpatient colonoscopy for A one to two weeks after discharge. We also found A’s second discharge from hospital was inappropriate because their presentation, along with other relevant information, should have alerted clinical staff to the possibility of cancer.

We found that basic nursing care could not be evidenced due to poor documentation and that appropriate assessments were not carried out. We found that the foot care provided to A was unreasonable with no evidence to show wound assessment or monitoring was done to a reasonable standard. We upheld all aspects of the complaint relating to the care and treatment of A.

C also complained that the boards handling of the complaint was poor. We found that steps were taken to agree the complaints issues that would be investigated, regular updates were provided and steps were taken to manage contact with C, Therefore, we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for the failings identified. 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 should receive appropriate nursing care. In particular in relation to Food Fluid and Nutrition, Wound Assessment and Management and Pressure Ulcer Prevention, including CPR for feet.
  • Nursing documentation should be completed to the required standard.
  • Patients should receive appropriate investigations in relation to their presenting symptoms either during admission or as soon as possible on discharge.

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.

Related reading

  • Case ref:
    202300524
  • Date:
    July 2025
  • Body:
    Highland NHS Board
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about the care and treatment that the board provided to their parent (A). The complaint relates to several different primary and secondary care services, including A’s medical practice, which was managed directly by the board. A had a long history of peripheral arterial disease (a condition where a build-up of fatty deposits in the arteries restricts blood supply to leg muscles).

A experienced gradually worsening pain in both their legs and had contacts with the Out of Hours (OOH) service, their GP and the board’s vascular team. Ultimately, A was admitted to hospital due to worsening critical limb ischaemia (severely blocked flow to one or multiple hands, legs or feet). It was decided to amputate A’s leg but, following the surgery, A’s condition deteriorated. They were diagnosed with myocardial infraction (a heart attack) and died in hospital.

C complained about several aspects of A’s care and treatment which covers both the period up to, and the time during, A’s admission to hospital. Firstly, they complained that the OOH Advanced Nurse Practitioner (ANP) failed to provide reasonable care and treatment. The board’s position was that the care and treatment provided by the ANP was reasonable but they apologised that C and A had been given the expectation that an OOH GP would attend.

We took advice from an independent GP adviser. We found that the care and treatment provided was reasonable, and that the ANP had appropriately reviewed A’s medical history before attending. Therefore, we did not uphold this complaint.

C’s second complaint related to A's medical practice. C stated that a GP in the practice had unreasonably failed to diagnose A’s condition correctly and provide appropriate treatment. The board concluded there were missed opportunities to see A face to face. However, they considered the practice’s clinical decision-making to be reasonable.

We took advice from an independent GP adviser. We found that different GPs may have taken different courses of action based on the same set of circumstances. However, this did not mean that the course of action taken here was unreasonable. Overall, we found that the care and treatment the practice provided to A was reasonable. Therefore, we did not uphold this complaint.

C’s third complaint related to the outpatient vascular care and treatment that the board provided to A prior to their admission to hospital. In C’s view, the Vascular Consultant involved in A’s care unreasonably refused to admit A to hospital in conjunction with A’s GP. The board concluded that A’s care and treatment plan under the care of the vascular team was managed appropriately. While they regretted not admitting A earlier, this would have been unlikely to change the outcome.

We took independent advice from a vascular consultant. We found that the vascular input provided by the board prior to A’s admission to hospital was reasonable. We also found that given A’s circumstances, the decision not to insist that admission to hospital was urgent represented established good practice. Therefore, we did not uphold this complaint.

C’s fourth complaint related to the clinical treatment provided to A following their admission to hospital. We took independent vascular advice on this complaint. We found that the clinical decision-making of the vascular team was reasonable. This included the decision to proceed with amputation in the absence of any alternative treatment options. In respect of A’s myocardial infraction, we found that the care and treatment from a vascular perspective was reasonable. We also concluded that there was a record of appropriate discussions regarding DNACPR and the risks of amputation. Given this, we did not uphold this complaint.

C’s fifth complaint related to the nursing care provided to A during their admission to hospital. The board had acknowledged some failings in this respect, particularly around communication. We did not uphold this complaint.

C’s final complaint related to the end of life care provided to A. We took independent nursing advice. We found that the end of life care, as documented in the records, was reasonable. We did not doubt C’s account of how traumatic A’s death was. However, in the absence of additional evidence that indicated staff failed to carry out the kind of actions that they should have, we did not conclude that the care provided was unreasonable. Given this, we did not uphold this complaint.

Related reading

  • Case ref:
    202310591
  • Date:
    July 2025
  • Body:
    Grampian NHS Board
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about the care and treatment of A, who had a background of complex medical conditions, including a history of diabetes, heart disease, chronic kidney disease and cardiorenal syndrome (a chronic disorder and imbalance of the heart and kidney function).

A was admitted to hospital three times over the course of approximately eight weeks. A had surgery for a fractured hip. After surgery, A developed bilateral non-arteritic anterior ischaemic optic neuropathy (NAION, a rare condition that causes sight loss). C complained about the medical and nursing care that A received.

We took independent advice from a consultant renal physician (a specialist in kidney conditions), a consultant ophthalmologist (a specialist in eye conditions) and a cardiac nurse (a nurse who specialises in heart conditions). We found that the board provided reasonable medical care to A over the course of their three admissions. Therefore, we did not uphold this part of the complaint.

We found that on one occasion, A was unreasonably recorded as being able to attend the toilet independently overnight, when A had an accident. In all other aspects, the board provided reasonable nursing care to A. Therefore, on balance, we did not uphold this part of the complaint.

Related reading

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