Source · SPSO (Scottish Public Services Ombudsman)

Ayrshire and Arran NHS Board

SPSO (Scottish Public Services Ombudsman) Partly Upheld Reference 202100839 Sector Health Category Clinical treatment / diagnosis Decided 01 December 2023

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Full decision

Summary

C’s parent (A) was receiving palliative chemotherapy, following a diagnosis of terminal cancer, which was suspended as the COVID-19 pandemic worsened. A was admitted to hospital following a prolonged period of vomiting that had not responded to treatment. A remained in the hospital for several weeks before passing away. C raised complaints with the board detailing C’s family’s concerns about A’s cancer diagnosis, decisions about A’s chemotherapy, aspects of the care and treatment of A, and communication with C and their family during A’s hospital admission. The board’s responses indicated that they considered A’s care and treatment had been reasonable overall, but accepted that there had been some aspects that could have been improved. They accepted that there were aspects of their communication that could have been improved, particularly that they should have contacted A’s next of kin when A’s condition deteriorated over a particular night.

C was dissatisfied with the board’s responses and brought their complaint to us. We took independent advice from a specialist in palliative care. We found that A’s treatment had been reasonable overall and that while there were certain aspects of A’s care that could have been improved, overall the board provided reasonable care to A.

In relation to the aspects of the complaint about the board’s failure to contact A’s next of kin when A’s condition deteriorated over a particular night and about the board’s responses to C’s complaints, we upheld these aspects of the complaint. In relation to the board’s handling of C’s complaints, we found that there were delays in responding, failure to address various clearly raised issues in responses, unreasonable action around the arrangement of a promised meeting within a reasonable timescale and the inclusion of statements that were not supported by evidence. We upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case: Apologise to C that they did not respond reasonably to their complaints. The apology should include specific reference to the board’s failure to address various issues raised in the complaints, failure to maintain reasonable action around the arrangement of a promised meeting, and inclusion of statements in the complaint response that were not supported by evidence. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets. The board should consider C’s request that the apology be provided at an in-person meeting at which C has an opportunity to read a personal statement.

In relation to complaints handling, we recommended: Complaints are properly investigated and responded to in line with the board’s 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

View Decision Report 202100839 as a PDF (27.6 KB) Updated: December 20, 2023

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