Source · SPSO (Scottish Public Services Ombudsman)

Ayrshire and Arran NHS Board

SPSO (Scottish Public Services Ombudsman) Partly Upheld Reference 202309740 Sector Health Category Clinical treatment / diagnosis Decided 01 March 2026

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Full decision

A, who was diabetic, had been diagnosed with conditions including Myasthenia Gravis (an autoimmune disorder causing muscle weakness). A was admitted to University Hospital Crosshouse (UHC) as an in-patient four times, initially with a diabetic foot ulcer. This deteriorated over the course of time leading to infection, surgery and amputation. A died during their fourth admission.

The board partly upheld C's complaint and identified failures in A’s care, particularly around the administration of medication for the treatment of Myasthenia Gravis and around communication with A’s family. They identified learning and improvements.

C remained unhappy and asked us to investigate. C complained that A had been provided with inadequate care and treatment as a podiatry out-patient and as an in-patient at UHC. C also complained that the board had failed to adequately investigate their complaint.

We took independent advice from a consultant vascular surgeon. We found that the out-patient podiatry care provided to A was reasonable and did not uphold this complaint. However, while we found that, overall, A’s care and treatment was reasonable during their in-patient admissions, there were failings in relation to A’s Myasthenia Gravis medication and in communication with A’s family. We upheld this complaint and recommended that the board provide us with evidence of the implementation of the learning and improvements they had previously identified.

We found that the board’s investigation of C’s complaint was reasonable. However, we were critical of the time taken to respond to the complaint and of the board’s failure to keep C regularly updated on the progress of their investigation. We noted that the board had accepted this and identified learning and improvements. We made no further recommendation for action.

Related reading

View Decision Report 202309740 as a PDF (24.71 KB) Updated: March 18, 2026

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