Summary
C complained that the board failed to report an injury to their spouse (A)'s wrist. A was in hospice care and was having their wrist examined by a consultant neurologist (specialists in disorders of the nervous system). C reported hearing a crack and that A was in pain. A underwent an x-ray at Forth Valley Royal Hospital but no break or fracture was found. A died a few weeks later.
We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). We found that clinicians acted reasonably in relation to the wrist examination. We did not uphold this part of C's complaint but provided feedback to the board regarding the records that were made of the examination.
C complained that the board failed to reasonably handle their complaint. The board acknowledged that there were unnecessary delays in providing responses which unreasonably breached the response times in their complaints handling procedure. We found that the board provided C with unreasonable responses to complaints, did not progress investigation of C’s complaints within reasonable timescales and did not update C regarding the progress of their investigations. They also delayed agreeing to meet with C and did not reasonably progress the making of arrangements for their eventual meeting with C.
These issues meant there was a cumulative two year delay in the board providing a reasonably clear and comprehensive response to C’s complaints. Therefore, we upheld this part of C's complaint. In making recommendations, we have taken into account changes the board have made to their complaints handling practices in the time since C’s complaints were first raised.
Recommendations
What we asked the organisation to do in this case: Provide a comprehensive apology to A’s family for the cumulative delay in providing a reasonably clear and comprehensive response to the complaints that they had raised. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
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 202500014 as a PDF (25.82 KB) Updated: June 17, 2026