Summary
C complained on behalf of their partner (A) about the care and treatment that A received from the board during their two admissions to hospital for suspected pulmonary embolus (when a blood clot blocks a blood vessel in the lungs). A had a stroke during their second admission.
We took independent advice from a consultant in general medicine. For A’s first admission, we found that the triage nurse who took A’s bloods, clearly documented that a D-Dimer (a test to detect blood clots) had been done and the results were available on the board’s system before A was discharged but it was not noted or considered. We found that A’s D-Dimer result should have been considered and doing so could have led to an earlier diagnosis of A’s pulmonary embolus. We found this aspect of A’s care unreasonable and we upheld this aspect of the complaint.
For A’s second admission, we found that the treatment of A’s blood clots with medication appeared to be in accordance with relevant guidance which was reasonable. We did not uphold this aspect of the complaint.
We noted that the board advised C in their complaint response that they would take A’s case forward to their adverse events review group for further consideration and that 16 months later, there had been no indication that a significant adverse events review had taken place, which appeared unreasonable. In addition, we found that in their complaint response, the board should have provided C with an explanation of what happened when A was readmitted to hospital, and the nature of A’s stroke, as well as more detailed description of when the adverse events review group’s decision would be made and if this would be communicated to C.
Recommendations
What we asked the organisation to do in this case: For the board’s staff in the CAU to read notes made by triage staff when patients are passed on to them.
The board should carry out SAERs in a timely manner.
In relation to complaints handling, we recommended: For the board to provide C with a written explanation of what happened when A was readmitted and the nature of A’s stroke. For staff to address all aspects of a complaint in the complaint response. For the board to obtain statements from key staff during their 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 202402894 as a PDF (27.21 KB) Updated: January 21, 2026