Summary
C complained about the care and treatment that they received in A&E, and the subsequent handling of their complaint by the board. C initially attended the A&E with vomiting, diarrhoea and abdominal pain. Although C and their partner raised the possibility of appendicitis, this was dismissed. C was diagnosed with gastroenteritis and discharged without a full abdominal examination or review by a senior clinician. The following day C’s condition deteriorated, and C was found to have a ruptured appendix and septic shock, requiring emergency surgery, ventilation, and a prolonged hospital stay.
We took independent advice from an Advanced Nurse Practitioner. We found that the care and treatment that C received was unreasonable because a thorough abdominal examination was not carried out by a senior decision maker and documented to exclude appendicitis as a differential diagnosis, prior to discharging C. It was also unreasonable that the board did not initiate an Adverse Event Review at an earlier stage. We upheld C’s complaint.
Regarding complaint handling, we found that the board failed to provide a response addressing all issues raised and did not give C a revised timescale for their delayed response, contrary to the NHS Model Complaints Handling Procedure. We upheld C’s complaint about the board’s complaint handling.
Recommendations
What we asked the organisation to do in this case: Apologise to C for the failures 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: When a relevant adverse event occurs, the board should promptly carry out an Adverse Event Review to investigate the cause and identify any potential learning.
In relation to complaints handling, we recommended: Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised. 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 202504517 as a PDF (28.26 KB) Updated: May 20, 2026