Decision Report 202200046

Summary

C complained about the actions of the board when carrying out a post-mortem examination of their adult child (A). C said that the board had failed to secure A’s admission blood samples, resulting in them being lost. C also believed that the board had failed to carry out the post-mortem properly, as no further blood samples had been taken.

We found that A’s admission blood samples had been collected by Police Scotland and taken to another board for tests. There was no audit trail of paperwork other than the police statement of their actions. Once Police Scotland had collected the samples they ceased to be the responsibility of the board. While the board are not responsible for the misplacement of A’s admission blood samples, they should have ensured the samples were signed for and copies of the paperwork retained. Therefore, we upheld this part of C's complaint. The board had already apologised for this failing and taken appropriate action so we did not make any further recommendations

In relation to the post-mortem, we found that the pathologist had followed the appropriate guidance. This recognised that admission samples were always preferable to post-mortem samples and at the time the post-mortem was carried out, there was no reason to suppose the admission samples were lost. Therefore, we did not uphold this part of C's complaint.

C also complained about the board's communication. We found that the board's communication with C was reasonable. Therefore, we did not uphold this part of C's complaint.