Summary
C complained about the care and treatment provided to them by the board when they were admitted to hospitalwith chest pain and respiratory issues. C also complained that the board’s complaint response failed to respond reasonably to C’s concerns.
We took independent advice from a respiratory adviser. We found that it was unreasonable that the board had not performed a pleural aspiration (a procedure to remove fluidfrom the space around the lungs) and had not inserted a chest drain on the day that C’s condition deteriorated in hospital. We upheld this complaint.
We also found that the board’s response to the complaint was unreasonable given that they failed to identify failings in C’s care and treatment in their complaint investigation and failed to carry out a significant adverse event review (SAER). We upheld this complaint, however, we recognised that the board had accepted and apologised for failings.
Recommendations
What we asked the organisation to do in this case: Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
What we said should change to put things right in future: Patients should receive the necessary care to detect and address the progression in pleural infection, during the normal weekend respiratory cover period. All staff should follow relevant policies and a chest x-ray should be performed after a chest drain insertion.
Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. The board should fully investigate and address the key issues raised, identify and action appropriate learning and apologise where issues have been identified. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.
The board should undertake SAERs in line with relevant guidance.
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 202401680 as a PDF (27.99 KB) Updated: May 20, 2026