Source · SPSO (Scottish Public Services Ombudsman)

Ayrshire and Arran NHS Board

SPSO (Scottish Public Services Ombudsman) Partly Upheld Reference 201906391 Sector Health Category Clinical treatment / diagnosis Decided 01 August 2021

View NHS Ayrshire & Arran scorecard

Full decision

Summary

C complained that their adult child (A)'s dyslexia was not taken into account when the board provided them with care and treatment, and that the care and treatment was not of a reasonable standard. C believed that if A's treatment had been better, then they would have had a better chance of surviving their cancer diagnosis. C felt that A's condition had been misdiagnosed because of A's age, as they were much younger than most people who suffered from this type of cancer.

We took independent advice from an appropriately qualified adviser. We found that the board accepted that they had not been aware of A's dyslexia. We also found that there was no evidence that A lacked the capacity to make decisions about their care and treatment and that at the majority of their appointments, they had been accompanied by their other parent. Therefore, we did not uphold this aspect of C's complaint.

In terms of their care and treatment, we found that A had been difficult to diagnose because the options were limited for medical staff, due to A's unwillingness to agree to treatment. However, it would have been appropriate for A's case to have been discussed earlier at a multidisciplinary team meeting. This might have resulted in A's cancer being identified sooner. We upheld this aspect of C's complaint. However, this did not mean that the outcome for A would have been different, as the cancer was very aggressive, and it was unlikely that its progression could have been slowed or halted.

Recommendations

What we asked the organisation to do in this case: Apologise to C for not having held a multidisciplinary team meeting to discuss A's case at the earliest opportunity. 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: The board should ensure clinicians have time to access multidisciplinary team meetings including all appropriate specialties to discuss unusual cases.

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

View Decision Report 201906391 as a PDF (26.5 KB) Updated: August 18, 2021

View original on SPSO (Scottish Publ… website

Other decisions involving Ayrshire and Arran NHS Board

Reference Date Summary Outcome
202408417 01 Mar 2026 C complained on behalf of their adult child (A), who underwent septorhinoplasty surgery (to improve the function and appearance of … Upheld
202309740 01 Mar 2026 C complained about the care and treatment provided to their late parent (A) by the board. A, who was diabetic, … Partly Upheld
202308080 01 Nov 2025 C complained that the board failed to reasonably investigate and/or diagnose the cause of their symptoms of significant weight loss, … Upheld
202308943 01 Aug 2025 C complained that nursing staff had failed to properly supervise their parent (A) resulting in a fall and that there … Upheld
202407708 01 Jul 2025 C was Power of Attorney (POA) for the patient (A). C complained about the care and treatment that A received … Upheld
View all decisions for this organisation