Source · SPSO (Scottish Public Services Ombudsman)

Western Isles NHS Board

SPSO (Scottish Public Services Ombudsman) Upheld Reference 202209846 Sector Health Category Clinical treatment / Diagnosis Decided 01 April 2024

View NHS Western Isles scorecard

Full decision

Summary

C complained about the care and treatment that they received from the community mental health team, after C was referred due to suicidal ideation. C said that they did not have a reasonable level of contact with the team and had difficulty changing the frequency of a prescription. C also said that the board unreasonably made reference to a historical referral to a befriending service in their complaint response.

We took independent advice from a specialist in adult mental health nursing. We found that the board’s position that prescribing is a matter for C’s GP to be reasonable. However, we found that C did not receive reasonable or adequate contact from the community mental health team and the board failed to follow through on a plan for C to have a face-to-face appointment with a consultant psychiatrist.

We also found that the board failed to follow through with a plan to discuss a referral to a befriending service with the clinical team. The board’s complaint response made reference to a referral submitted several years previously, which we found unreasonable with respect to complaints handling. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case: Apologise to C for the failings identified by this investigation. 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 community mental health team should have robust administrative systems in place to ensure that planned appointments are arranged as intended and that patients are effectively notified of their personal appointment arrangements in a timely manner.

In relation to complaints handling, we recommended: Complaint responses should include information relevant to the events complained about.

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 202209846 as a PDF (27.11 KB) Updated: April 17, 2024

View original on SPSO (Scottish Publ… website

Other decisions involving Western Isles NHS Board

Reference Date Summary Outcome
202300806 01 Apr 2025 C complained about the standard of surgery and post-operative care that they received when they had an elective operation for … Partly Upheld
202106315 01 Jul 2024 C, an advocacy worker, complained on behalf of the family of A, about a failure to appropriately investigate A’s symptoms, … Upheld
202103246 01 Nov 2023 C complained about the board's decision not to fund the travel and accommodation costs they and their spouse had incurred … Upheld
202104143 01 Jul 2023 C engaged with the board’s mental health services and believed that they had received a diagnosis of Borderline Personality Disorder … Not Upheld
201904226 01 Jul 2021 C's child (A) was born with a rare congenital condition where the urethra does not develop properly and underwent reconstructive … Upheld
View all decisions for this organisation