In this month’s edition of the Ombudsman’s findings, we highlight our recent investigation reports.
This month we published decision reports from five complaints investigated by the Ombudsman. All five were about health services. The outcome of these five complaints were
- Fully upheld: 3
- Some upheld: 2
We made 26 recommendations for learning and improvement.
Our published decision reports can be read on our website.
Investigation reports
This month we published two investigation reports about the health sector. In these cases, we have made significant findings and laid a detailed report before Parliament. We publish these so that others can learn from the findings to prevent similar outcomes in the future.
202207986
We found that the board failed to provide reasonable care and treatment to a patient who died from cardiac arrest.
The patient was admitted to hospital after a fall at home. They received laryngectomy care when they reported their ‘larytube’ felt blocked, but a nurse was unable to replace the tube. They went into respiratory arrest which led to cardiac arrest.
We made eight recommendations to the board. We asked them to apologise to the patient’s family and ensure learning from the complaint is reflected in policy and staff training.
202300512 
We found that the board failed to provide reasonable care and treatment to a patient who died from a small bowel obstruction.
There was a missed opportunity for clinicians to detect signs of bowel obstruction earlier when A was still stable enough to undergo life-saving treatment.
We were also concerned that a Significant Adverse Event Review (SAER) was not held in this case, despite this being an unexpected death.
We made four recommendations to the board. We asked them to apologise to the patient’s family and review their systems to ensure SAERs are carried out in line with national guidance.
Commenting on this case, the Ombudsman, Rosemary Agnew, said:
“It is of concern to me that I have made similar findings regarding Health Boards not carrying out adverse event reviews in other recent public reports. I intend to write to the Scottish Government and Health Improvement Scotland to draw their attention to the findings and recommendations I have made in relation to adverse event reviews in recent cases, including this one.”
Our published investigation reports can be read on our website.