This month, we published five investigations, we made nearly 700 decisions on complaints and our Assessment and Guidance team responded to 1,331 enquiries.
In one particular case, we upheld several complaints about the care provided to a patient (A) by NHS Greater Glasgow and Clyde and the Board's subsequent review following their death from complications related to a bowel perforation.
A had bowel cancer and a confirmed bowel blockage. We found that delays in transferring them to the Glasgow Royal Infirmary and aspects of their clinical care were not reasonable. We also found that the Board's Significant Adverse Event Review (SAER) was too narrow in scope, limiting opportunities to learn from the case.
We made recommendations to address the issues identified.
Concerns about the quality and consistency of SAERs are a longstanding feature of our casework and have been highlighted by Healthcare Improvement Scotland (HIS) who have issued guidance to all health boards.
We will continue monitoring cases involving SAERs, while guidance from HIS is embedded across health boards.