Summary
C complained about the care and treatment provided to their late parent (A). Following a fall, A was admitted to hospital, where they remained for almost a year due to their dementia and heart failure. As the hospital was in a rural area, GPs from the local practice were responsible for much of the clinical decision making during A’s admission. We therefore took independent advice from a GP as part of our investigation of the complaint.
C complained that the partnership failed to carry out microbiology urinary tests for a period of eight months following A’s admission to hospital. We found that there were missed opportunities to carry out urine tests, especially given the significant length of time A was in hospital. The partnership also accepted there was a lack of robust recording in this respect. Therefore, we upheld this aspect of C's complaint.
C made seven additional complaints about A's care. These related to clinical investigations, treatment for infection, the use of end-of-life medication, the use of medication to manage dementia-related symptoms, discharge procedures, an out-of-area placement for A, and the use of Datix (the internal incident reporting system). We found that the partnership's actions in these areas were reasonable and did not uphold any of these aspects of C's complaint.
C also complained that the partnership's handling of their complaint was unreasonable. The partnership acknowledged that it had taken an unreasonable length of time to respond to C’s complaint. We found that it had also failed to respond to C's concerns about antibiotic treatment. This appeared to be due to the partnership's understanding that the medical practice would address this aspect of the complaint. We were also concerned by comments in the investigation report indicating that GPs had been reluctant to assist with the partnership's investigation. Therefore, we upheld this aspect of C's complaint.
Recommendations
What we asked the organisation to do in this case: Apologise to C and A’s family for unreasonably failing to carry out microbiology urine tests for prolonged periods of time. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
Apologise to C for failing to handle C’s complaint reasonably and failing to address some of C’s key concerns. 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: Microbiology urine testing should be carried when required in order to optimise treatment.
In relation to complaints handling, we recommended: Complaints should be responded to in full, regardless of who provides a service on behalf of the partnership. Given the arrangements in place, there should be a clear understanding between the partnership and the GP practice concerned in respect of responding to complaints or complaint investigations. 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.
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 202402663 as a PDF (29.54 KB) Updated: August 19, 2026