Case: 202405059
NHS organisation: Lothian NHS Board
Subject: Concerns culture
Outcome: Fully upheld
Date: March 2026
Summary
C is employed at the Board and was concerned about a number of patient safety issues within the maternity triage department at the Royal Infirmary of Edinburgh. C was also concerned that management did not listen to staff when issues were being raised and staff lacked confidence that their concerns would be taken seriously, and appropriate action taken.
The Board investigated C’s concerns under the National Whistleblowing Standards (the Standards) and issued a stage 2 response, with a number of recommendations made in relation to patient safety issues within the triage department and staff feeling unable to raise concerns.
C was unhappy with the stage 2 response and brought the complaint to INWO. C stated that while they had seen improvements with triage processes as a result of the recommendations, there had been no improvement in the speak up culture within the department.
We reviewed the evidence provided by C and the Board. We recognised that the Board have undertaken a larger piece of work to address culture across the whole of women’s services and welcome the commitment of the Board to improve speak up culture within the maternity triage department. However, we found that the recommendations made by the Board in the stage 2 response had not sufficiently addressed the specific concerns raised by C in relation to speak up culture or the associated risks.
Therefore, we upheld C’s complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C for the shortcomings in handling and investigating their whistleblowing concerns. The apology should meet the standards set out in the SPSO guidelines on apology. Offer to meet with C to discuss the progress of the planned improvements and how this programme of work will lead to an improved speak up culture within the maternity department.
In relation to compliance with the Standards, we recommended:
- Staff investigating whistleblowing concerns need to be aware of the requirements under the Standards and of robust investigative processes.