Summary
C complained about the care and treatment the board provided to their late parent (A). A was admitted to hospital following a cardiac arrest. Several days later, A was found on the floor of their ensuite bathroom unresponsive and without telemetry (an observation tool that allows the monitoring of cardiac patients). A survived but did not fully recover and died around two months later.
C complained that the board did not adequately monitor A.We took independent advice from a cardiologist (specialist in diseases and abnormalities of the heart). We found that the care and treatment that A received was unreasonable because A was disconnected from their cardiac monitor when mobilising without being supervised by a member of staff. Therefore, we upheld C's complaint.
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: Documentation and record keeping should meet the required standards and relevant policies.
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 202406685 as a PDF (26.15 KB) Updated: June 17, 2026