Source · SPSO (Scottish Public Services Ombudsman)

Forth Valley NHS Board

SPSO (Scottish Public Services Ombudsman) Not Upheld Reference 202303760 Sector Health Category Clinical treatment / diagnosis Decided 01 October 2024

View NHS Forth Valley scorecard

Full decision

Summary

C complained on behalf of their spouse (A). A was taken into hospital with COVID-19 and low blood sugar and was discharged after two days. That night C was concerned that A’s condition had deteriorated. A was taken to ICU and died 4 days later. The cause of death was recorded as COVID-19, ketoacidosis (where a lack of insulin causes harmful substances called ketones to build up in the blood) and renal failure. C considered that A had been discharged inappropriately in the first instance.

The board explained that A was frail. They came into hospital with chest pains from COVID-19 and were checked for pulmonary embolism. A was discharged appropriately but unfortunately deteriorated rapidly at home. Every effort was made to treat A on readmission.

We took independent advice from a consultant physician, specialising in acute medicine. We found that A had a poor state of health prior to admission, that their discharge on the first occasion was reasonable and that there was no way the discharging team could have predicted A’s subsequent deterioration. Upon A’s second admission, medical teams and intensive care teams provided a reasonable standard of management and care. Overall, we considered that the care and treatment had been reasonable and that there was no requirement for a Severe Adverse Event Review or Duty of Candour to be initiated. Therefore, we did not uphold the complaints.

Related reading

View Decision Report 202303760 as a PDF (24.52 KB) Updated: October 23, 2024

View original on SPSO (Scottish Publ… website

Other decisions involving Forth Valley NHS Board

Reference Date Summary Outcome
202500014 01 Jun 2026 C complained that the board failed to report an injury to their spouse (A)'s wrist. A was in hospice care … Partly Upheld
202401232 01 May 2026 C, an independent advocate, complained on behalf of B, about the standard of medical and nursing care provided to B’s … Partly Upheld
202405861 01 Feb 2026 C complained about the care and treatment provided to their infant child (A) who was born with a terminal genetic … Not Upheld
202402894 01 Jan 2026 C complained on behalf of their partner (A) about the care and treatment that A received from the board during … Partly Upheld
202403721 01 Jan 2026 C complained on behalf of their sibling (A) in relation to the care and treatment that the board provided to … Upheld
View all decisions for this organisation