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Health

  • Case ref:
    202404349
  • Date:
    August 2025
  • Body:
    Highland NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    Nurses / nursing care

Summary

C complained about the care and treatment provided to their late parent (A). A was admitted to hospital due to a nose bleed that would not stop. During admission, A used a hospital trolley to cross the ward to the toilet. A jug of water spilt from the trolley and A fell, sustaining a fractured shoulder and a fractured knee. C was concerned about A’s medical and nursing care and about the communication from the board.

We took independent advice from a nursing adviser and a consultant geriatrician.

We found that the falls screening questions were not completed on A’s admission, safe care pauses were not demonstrable from the daily care plan or nursing documentation, A’s walking aid was not within reach and a decision was made to mobilise A when the floor was wet, rather than call for help and ensure the environment was safe. We found that the board’s investigation into A’s fall did not make attempts to identify the second staff member who witnessed the fall and take a statement from them. There was also a failure to activate the Duty of Candour process in this case. We found that A’s B12 injection should have been administered in a more timely way and that medical staff did not promptly inform C and their family of the results of the X-rays and the implications of the fractures for A. Finally, we found that the board did not respond to all of the concerns that C raised. We upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C and their family 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:

  • Appropriate steps should be taken in the prevention and management of falls.
  • Where appropriate, patients and/or their families should be informed of the results of X-rays by medical staff.
  • When an incident occurs that falls within the Duty of Candour legislation, the board’s Duty of Candour processes should be activated without delay.
  • Where a patient has fallen and sustained harm, attempts should be made to identify and take statements from all the staff who witnessed the fall.
  • Where clinically appropriate, B12 injections should be administered in a timely way.

In relation to complaints handling, we recommended:

  • Complaints should be investigated and responded toin 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. 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.

Related reading

  • Case ref:
    202311619
  • Date:
    August 2025
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    Appointments / Admissions (delay / cancellation / waiting lists)

Summary

C complained about the lack of care and treatment that the board provided in relation to not being recalled for a colonoscopy. C had undergone regular colonoscopies to monitor disease progression. C was not recalled when the next colonoscopy was due. The COVID-19 pandemic led to suspension of services with a long backlog of patients. When C did subsequently undergo a colonoscopy, this led to a diagnosis of cancer.

We took independent advice from a consultant gastroenterologist and hepatologist. We found that the board failed to identify C as someone at significant increased risk that needed the procedure to be re-booked as a priority. We found that it was unreasonable that C’s colonoscopy was an overdue procedure that was not clinically reviewed. Therefore, we upheld this complaint. We also found that it was unreasonable that the board had not carried out a significant adverse event review into the matter.

C also complained that the board failed to provide a reasonable response to their complaint. We found that the board’s complaint handling of C’s complaint was unreasonable, as the failure to clinically review C’s overdue procedure and failure to identify C as someone at significant increased risk, were inadequately investigated as part of the complaints process. In light of that specific failing, we also upheld this 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.

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

  • The board should have a robust clinical prioritisation process for rescheduling endoscopy procedures that may have been delayed for whatever reason
  • When a relevant adverse event occurs, the board should promptly carry out an SAER to investigate the cause and identify any potential learning.

In relation to complaints handling, we recommended:

  • 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. 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.

Related reading

  • Case ref:
    202305315
  • Date:
    August 2025
  • Body:
    Grampian NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C, a Patient Advice and Support Service (PASS) adviser, complained on behalf of their client (B) about the care and treatment provided to B's late spouse (A). A was under the care of two health boards for treatment of a concurrent bladder and colorectal cancer. C complained about the care and treatment received for their colorectal cancer. They also complained about the adequacy and conclusions reached by a Level 2 Adverse Event Review and a Level 1 Significant Adverse Event Review carried out by board A, as well as a lack of transparency under the Duty of Candour and the way that they had handled the complaint. While the bladder cancer was timeously treated, A died without having received treatment for the colorectal cancer.

In responding to the complaint, the board outlined their management of A’s colorectal cancer through the regional multi disciplinary team process, having reviewed the care and treatment as a Level 2 adverse event review and a Level 1 significant adverse event review.

We took independent advice from a colorectal surgeon. We found that there was a failure to provide a reasonable standard of care and treatment to A, particularly in relation to delays in initiating treatment for their colorectal cancer. We upheld this complaint. We found that the Adverse Event Review and the Significant Adverse Event Review (SAER) conducted by the board were inadequate, with inaccuracies in the timeline and unsupported conclusions. We upheld this complaint. We found that there was a failure by the board to meet their Duty of Candour obligations, and we upheld this complaint. We also found that the board’s handling of the complaint was unreasonable, and we upheld this 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.

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

  • Patients should receive reasonable and timeous care.
  • When an unexpected or unintended incident occurs, processes should be followed to ensure reporting and learning and improvement takes place. This should be in line with both statutory duties and in keeping with any additional internal processes relevant to the incident type, including but not limited to adverse event reviews and Duty of Candour.

In relation to complaints handling, we recommended:

  • Complaint investigations should be managed in accordance with HYPERLINK "https://www.spso.org.uk/the-model-complaints-handling-procedures" The Model Complaints Handling Procedures | SPSO. Complaint investigations should fully investigate the matters of complaint made and identify actions for learning and improvement.

Related reading

  • Case ref:
    202406679
  • Date:
    August 2025
  • Body:
    Forth Valley NHS Board
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about the care and treatment that they received from the board. In particular, C complained that the board had failed to recognise or timeously act on the significance of the severity of their pain and abdominal symptoms. C later received emergency surgery in treatment of a ruptured caecum including formation of a stoma.

We took independent advice from an obstetric adviser and a general surgery adviser.

We found that C’s care had been reasonably managed in relation to their discharge from obstetrics and their re-admission when symptoms continued. We considered that the plan made for surgery was reasonable, noting the rare and rapidly progressing nature of the complication C experienced. We also considered the board’s own review of the episode of care was reasonable.

We found that there were aspects of C’s care which were unreasonably managed, specifically, that there were incomplete medical records kept following a surgical review. On balance, we considered the standard of care provided to C was reasonable. We did not uphold this complaint.

Related reading

  • Case ref:
    202400331
  • Date:
    August 2025
  • Body:
    Forth Valley NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about the care and treatment provided to them in relation to their health in prison. C experienced difficulties in relation to their medical needs, including staff not attending when C requested, not receiving their medication, lack of communication and that the complaint response did not answer all of C’s concerns.

We took independent advice from a qualified GP. We found that the board seemed to lack appreciation that without medication for stomach acid, C would be left very symptomatic and sore and that they failed to supply the alternative medication to C when it was due. Once the medication had been obtained, they failed to locate C within the prison to give them the medication and failed to follow protocol to store the medication for reissue. We found that the board failed to communicate the problem with their medication to C and failed to reach a solution about C’s missing medication. We also found that the board failed to attempt to reach a solution about the poor communication between them and the Scottish Prison Service (SPS). Therefore, we upheld this complaint. We acknowledged that the board had taken learning and improvement action in relation to a number of these failings.

C also complained that the board unreasonably failed to respond to all of C’s concerns in their complaint response. We found that the board’s first complaint response was unreasonable, and while the second response was generally reasonable, the length of time it took for the board to issue this was unreasonable.

On balance, we upheld this complaint. We also acknowledged that the board had taken some learning and improvement action in relation to these matters going forward.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for the failing 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:

  • All staff should follow relevant processes and procedures in relation to prisoners medication and medical needs. There should be clear communication between staff and prisoners in relation to their medication and medical needs
  • When it is decided that a prisoner needs to be seen by medical / nursing staff, this should be adequately communicated.

In relation to complaints handling, we recommended:

  • Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. The board should investigate and respond fully to the key issues raised, identify and action appropriate learning, and signpost to other relevant organisations as soon as practical. 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.

Related reading

  • Case ref:
    202309879
  • Date:
    August 2025
  • Body:
    Forth Valley NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    Nurses / nursing care

Summary

C’s spouse (A) who had prostate cancer was admitted to the Clinical assessment unit (CAU) of the hospital following a few days of deteriorating health. During their admission, A remained in the CAU for three days before leaving the building without staff being aware of this. A contacted C in confusion and told C that they had not received food or hydration, had not been washed and had not been able to sleep. C returned A to the hospital on the condition that A was moved to a ward, which they were. The next day C was told that A had suffered an unwitnessed fall and was to be discharged to attend an oncology appointment. A also had lesions on their groin which had developed and not been cared for during their admission. A died within two weeks of being discharged.

C complained to the board. The board accepted that there were a number of areas for improvement in the care and treatment that A had received, apologised and advised of actions that they would take or had taken to address these matters. C was dissatisfied with the board’s responses and raised their complaints with SPSO.

The board identified further areas where the care they had provided to A had not been reasonable and advised of further actions that they would take to address these. Given this, we upheld C’s complaint that the board did not provide reasonable care to A, with specific reference to care of lesions on A’s groin and the discharge of A.

We took independent advice from a nursing adviser. We found that the board, in considering how best to reflect on A’s care and treatment, had focussed too narrowly on A’s fall, that they should have considered the experience of A and their family more broadly and that relevant guidance indicates a Significant Adverse Event Review should have been carried out. We also found that there was a delay in providing a response to C’s complaints and that C had not been updated regularly while the complaints were being considered. We also found that the actions proposed and taken by the board to address the issue of patients remaining in the CAU for prolonged periods would not fully address the areas for improvement identified. Therefore, we upheld the complaint that the board did not respond reasonably to C’s complaint.

Recommendations

What we asked the organisation to do in this case:

  • Provide a further apology to C which acknowledges that specific areas of unreasonable care provided to A were found as a result of both the board’s consideration of C’s complaint and the Board’s consideration of subsequent enquiries by the SPSO. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/meaningful-apologies" www.spso.org.uk/meaningful-apologies .
  • Provide a further apology to C which acknowledges that:
  • relevant guidance indicates an SAER should have been carried out regarding A’s experiences,
  • regular updates were not provided to C during the investigation of their complaint
  • the actions proposed and taken by the board did not fully address the areas for improvement identified by their investigation of the issue of patients remaining in the CAU for prolonged periods.
  • 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:

  • The Board develop policies on actions to be taken to escalate discharge for patients remaining in the CAU for prolonged periods, and to address the lack of access to shower facilities for patients in the CAU.
  • The board’s consideration of whether to undertake SAERs takes into account patient experiences reasonably widely and relevant guidance.

Related reading

  • Case ref:
    202402836
  • Date:
    August 2025
  • Body:
    Borders NHS Board
  • Sector:
    Health
  • Outcome:
    Resolved, no recommendations
  • Subject:
    Nurses / nursing care

Summary

C complained about the lack of care and understanding for their parent (A) who died in hospital. C referred to incorrect information being passed to the family and the lack of notes and records of events which occurred during A's admission. C said that while the board replied with some apologies and acknowledgement that errors were made, they did not fully explain the actual events that happened in the lead up to A's death.

Having sought initial advice, we agreed to investigate the care and treatment provided to A and the board's communication with the family.

Related reading

  • Case ref:
    202308943
  • Date:
    August 2025
  • Body:
    Ayrshire and Arran NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained that nursing staff had failed to properly supervise their parent (A) resulting in a fall and that there was a lack of documented information about A's plan of care in the medical records. A was admitted to hospital for hip surgery following a fall at their home. A few weeks later, A fell and hit their head. This led to A sustaining a subdural haematoma (SDH, a brain injury) and A died as a result.

C complained that following A’s fall there was a failure to treat A as a priority, and raised concerns that A was transferred from a trauma ward to an orthopaedic ward. C believed that A should have been transferred to another hospital, outwith the board, for surgery.

In response, the board said that A’s care pre-fall had been in line with the relevant supervisory assessment. They apologised for a delay in A receiving a medical review following the fall, however, they said that nursing staff had carried out appropriate neurological observations. The board added that A was not considered suitable for surgery by surgeons and that the case had been considered at a local management team review (LMTR).

We took independent advice from a consultant specialising in the care of the elderly, and an experienced nurse. We found that the documentation in A’s nursing records did not evidence that the care and interventions A received to keep them safe from harm and to support their mobility were to the standard required to prevent A falling. Additionally, we found that there were failings in relation to A’s neurological observations with a lack of proper assessment, implementation and evaluation and gaps in recording. We considered that while these measures may not have ultimately prevented A’s fall, there was unreasonable care and as such we upheld C’s complaint.

We found that A’s post-fall care fell well below a reasonable level and did not meet the standards described in the board’s head injury protocol and the relevant NICE guidance for the management of head injuries. Issues identified included a lack of consultant oversight and a failure to carry out timely neurological interventions and tests when A’s condition deteriorated. Additionally, as A had suffered harm and death as a result of a fall, the board should have completed a significant adverse event review (SAER). We upheld C’s complaint on that the care and treatment provided to A was unreasonable.

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:

  • Care and treatment should be provided in line with the relevant guidance on head injuries.
  • Patients presenting with a decline in their cognitive and/or neurological functions should have their symptoms fully assessed, evaluated and monitored in a timely manner in line with relevant guidance. All nursing documentation should comply with the standards set out in the board’s guidance and the NMC The Code.
  • Patients presenting with a decline in their cognitive and/or neurological functions should have their symptoms fully assessed, evaluated and monitored in a timely manner in line with relevant guidance. Where a GCS assessment has shown deteriorations in a patient who has sustained a head trauma, prompt action should be taken in respect of carrying out scanning and seeking specialist advice.
  • Where adverse event(s) occur a significant adverse event review should be held in line with the board's protocols and national guidance.

In relation to complaints handling, we recommended:

  • Complaint investigations and responses should be accurate in their findings and conclusions, clear, and supported by relevant evidence, such as medical records and where possible include responses from staff involved in the events complained about. 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.

Related reading

  • Report no:
    202308705
  • Date:
    August 2025
  • Body:
    Borders NHS Board
  • Sector:
    Health

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:

  • assess and manage A’s pain in a reasonable way;
  • ensure documentation and record keeping met the required standards;
  • ensure specialist advice and instruction was taken into account; and
  • listen to C and involve them in person centred care planning.

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

  • ensure the complaint response was accurate and substantiated by the clinical records; and
  • provide a clear and full complaint response. 
 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:

  • assess and manage A’s pain in a reasonable way;
  • ensure documentation and record keeping met the required standards;
  • ensure specialist advice and instruction was taken into account; and
  • listen to C and involve them in person centred care planning.
     

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:

  • ensure the complaint response was accurate and substantiated by the clinical records; and
  • provide a clear and full complaint response.

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:

  • assess and manage A’s pain in a reasonable way;
  • ensure documentation and record keeping met the required standards;
  • ensure specialist advice and instruction was followed; and
  • listen to C and involve them in person centred care planning.
 Training for nursing staff on detention orders under the relevant legislation. 

Evidence training occurred.

By: 22 September 2025

Related reading

  • 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. 

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