Summary
The complainant (C) complained to me about the standard of medical and nursing care and treatment provided to their late parent (A) by Lothian NHS Board (the Board). In particular, C was concerned about how medical and nursing staff cared for and treated A when they developed the infection, staphylococcus aureus bacterium (SAB, many SABs are a healthcare acquired infection (HAI), a type of serious infection which can lead to blood poisoning and needs significant and careful treatment).
A was unwell and admitted to hospital where clinicians determined A had a urine infection and kidney issues. A received intravenous fluids by way of a peripheral venous cannula (PVC, Peripheral Venous Cannula (PVC) or Peripherally Intravenous Cannula (PIVC) – a small tube that is put in the vein to allow medication such as antibiotics and fluids to be put into the blood) as part of their treatment. A few days later, the PVC showed signs of infection and tests confirmed that A had SAB, which was assumed to have arisen from the use of the PVC.
C complained to me that A’s SAB infection was not managed in a reasonable way and that nursing staff actions in relation to the PVC were unreasonable. C also complained about the way their complaint was handled, and in particular about the adverse event review (a national framework for reviewing and learning from adverse events in NHS Scotland (the Framework) sets out guidance to help health boards manage adverse events) undertaken by the Board.
During my investigation I sought independent advice from a Consultant in Care of the Elderly and a Registered Nurse. Having considered and accepted the advice I received, I found that:
- The medical care and treatment A received was reasonable because: medical staff took regular and detailed reviews of A’s care; the medical care of A’s SAB infection was in keeping with the relevant guidance; and there was frequent communication with A’s family about A’s condition by medical staff.
- A’s condition was serious and significant when they were admitted; it was likely A was suffering from organ failure in addition to an antibiotic resistant urinary tract infection, and it was possible they may not have survived these conditions. Even so, the additional burden of the SAB infection made it much more likely that A’s condition would worsen, and much less likely that A would survive.
- The nursing care and treatment A received was not reasonable both in relation to record keeping and PVC care. There was a lack of documents relating directly to PVC care and maintenance with sections left blank or incomplete and overall, there was a lack of information recorded to guide nursing care. Nursing care also failed to meet the relevant guidance for PVC care and there were failings in relation to skin assessment and assessing a wound on A’s arm.
Taking all of the above into account, I did not uphold C’s complaint about the standard of medical care and treatment provided to A. I did uphold C’s complaint about the standard of nursing care and treatment provided.
I also found that the Board’s handling of C’s complaint was unreasonable in relation to the adverse event review undertaken by the Board in that:
- the Board used the terms local adverse event review (LAER) and significant adverse event review (SAER) interchangeably even though there are key differences between the two types of review;
- a SAER should have been undertaken - the case met the criteria for an SAER, given that A died from a SAB infection, under both the national and the Board’s own criteria;
- the family were not involved in the review process as they should have been;
- the person carrying out the review would not have been in a position to judge the medical aspects of the care and treatment provided and it was not clear if the person who carried out the review was independent;
- the review missed pertinent facts, it did not refer to the national guidance for PVC care or identify key learning and improvements, and the recommendations were insufficient to ensure the event was not repeated.
I am concerned that my office is continuing to find substantive issues with the way in which health boards have conducted SAERs. A public report*, issued by my predecessor in February 2025, highlighted similar SAER findings and issues identified in this case. They also wrote to Healthcare Improvement Scotland (HIS) and the Scottish Government highlighting these concerns at this time. While I recognise and commend the revised Framework introduced by HIS in February 2025 and the work being undertaken by HIS in this regard, I consider more needs to be done by health boards to address the situation and to ensure SAERs are being carried out in line with the revised Framework.
*Case 202300512, which cited cases 202100979; 202209575; 202100560; 202101928; 202105840; 202200588
Recommendations
What we are asking Lothian NHS Board - Acute Services Division to do for the complainant:
| Rec. number | What we found | What the organisation should do | What we need to see |
|---|---|---|---|
| 1. |
Under complaint (b) we found that the standard of nursing care and treatment was unreasonable in relation to:
Under complaint (c) we found we found that the way the Board dealt with C’s complaint in relation to the SAER was unreasonable in that:
|
Apologise to C for the failings identified in this investigation in relation to the standard of nursing care and treatment and the review. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies |
A copy or record of the apology. By: 23 October 2026 |
We are asking Lothian NHS Board - Acute Services Division to improve the way they do things:
| Rec. number | What we found | Outcome needed | What we need to see |
|---|---|---|---|
| 2. |
Under complaint (b) we found that the standard of nursing care and treatment was unreasonable in relation to:
|
Patients who have PVCs should be cared for and treated in line with the relevant guidance. Patients who have SAB should receive nursing care and treatment in line with the relevant guidance. Patients’ records should be completed to a reasonable standard and in line with the relevant Code. Skin assessment and wound care should be appropriately carried out and recorded. Patients and families should be updated about a patient’s condition fully and within a reasonable time. |
Evidence that my findings have been shared with relevant staff (in all clinical areas subject to the complaint) in a supportive manner for learning and improvement By: 25 January 2027 Evidence that the Board have reviewed their systems and the training needs of relevant nursing staff (in all clinical areas subject to the complaint) to ensure patients with PVCs are treated appropriately and in line with the relevant guidance and skin assessment/wound care is appropriately undertaken. Details of the review and action to be taken to be provided to SPSO By: 25 January 2027 Evidence that the Board have reviewed their systems and the training needs of relevant nursing staff (in all clinical areas subject to the complaint) to ensure patients with SAB are treated appropriately and in line with the relevant guidance. Details of the review and action to be taken to be provided to SPSO. By: 25 January 2027 Evidence that relevant nursing staff (in all clinical areas subject to the complaint) are complying with the guidance on care of PVCs and patients with SAB by the carrying out of an audit. Details of the audit and action to be taken to be provided to SPSO. By: 25 January 2027 Evidence that nursing staff (in all clinical areas subject to the complaint) are complying with the recordkeeping requirements of the Code by the carrying out of an audit. Details of the audit and action to be taken to be provided to SPSO. By: 25 January 2027 |
We are asking Lothian NHS Board - Acute Services Division to improve their complaints handling:
| Rec. number | What we found | Outcome needed | What we need to see |
|---|---|---|---|
| 3. |
Under complaint (c) we found we found that the way the Board dealt with C’s complaint in relation to the SAER was unreasonable in that:
|
Local and Significant adverse event reviews should be reflective and learning processes that ensure failings are identified and any appropriate learning and improvement taken forward. Adverse event reviews should be held in line with relevant guidance. 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 |
Evidence that my findings have been shared with relevant staff in a supportive manner for learning and improvement. By: 23 October 2026 Evidence that the Board have reviewed their process for carrying out adverse event reviews to ensure these reviews properly investigate, identify learnings, and develop system improvements to prevent similar incidents occurring and follow up with an audit in all areas subject to the complaint to ensure compliance. This includes reviewing their procedures for undertaking adverse event reviews to ensure compliance with the Framework. Details of the review and action to be taken to be provided to SPSO. By: 25 January 2027 Evidence that the Board have ensured they have assessed and addressed any training needs for the carrying out of adverse event reviews in all clinical areas subject to the complaint. Details of the assessment and action to be taken to be provided to SPSO. Evidence that the Board have notified HIS of the findings of this investigation. By: 25 January 2027 |
Feedback
Points to note
I accept the medical advice I received that the care of the PVC was not well documented in A’s clinical notes, and that medical staff should have competed parts of the documentation relating to this care. The Board should reflect on this with relevant staff.