Summary
C complained on behalf of their spouse (A). The first of C’s complaints was that the board had failed to reasonably and accurately record and report an alleged incident between A and a member of staff. They also complained about the board’s investigation, and future references in records to the incident. We identified a number of failings including that the incident referred to was not reliably recorded on the board’s incident reporting system, that the board did not properly investigate C’s concerns, and that medical record correction notices issued were inaccurate and inconsistent. We upheld the complaint.
C also complained about the care and treatment that A had received. We took independent advice from a psychiatrist. We found that the care and treatment was of a reasonable standard. We did not uphold this aspect of C’s complaint.
Finally, C complained about the board’s handling of their complaints. While acknowledging that the complaints were numerous and complicated, we were of the view that the board could have taken action at an earlier point to define the complaints. They also could have investigated to a higher standard and responded more promptly. We therefore upheld this aspect of C’s complaint.
Recommendations
What we asked the organisation to do in this case: Apologise to C and A for their failings in relation to recording and reporting of, future references to, and investigation into, the alleged incident; and for failings in relation to complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
Place a new medical record correction notice in A’s records that accurately identifies the incorrect entries and corrects these.
What we said should change to put things right in future: Where a patient raises concerns about accuracy of medical records, this should be properly investigated and responded to.
In relation to complaints handling, we recommended: Complaints should be responded to timeously and investigations should accurately identity failings.
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 202402736 as a PDF (27.87 KB) Updated: December 17, 2025