Case: 202307236
NHS organisation: Scottish Ambulance Service
Subject: Record keeping
Date: May 2025
Summary
C raised concerns with the Scottish Ambulance Service (SAS) about several issues including delays by managers in providing information to support the Significant Adverse Event Review (SAER) process. SAS investigated and partially upheld C’s concern.
C was dissatisfied with the response and complained to the Independent National Whistleblowing Officer (INWO). We agreed to investigate whether SAS unreasonably failed to address delays in completing the SAER process and whether SAS failed to handle the whistleblowing concerns in accordance with the National Whistleblowing Standards (the Standards).
We considered the findings of an audit of governance and management of Adverse Events, which supported C’s concerns. We also considered the outputs of a subsequent SAER recovery plan including changes in the Adverse Event policy and governance arrangements. We took independent advice and found that the actions SAS has taken should address C’s complaint, provided there is sufficient time, training and organisational commitment given to the changes.
We recognised that C had raised concerns about the SAER process over an extended period of time, and insufficient action had been taken to address delays in the process prior to C’s concern. Therefore, we upheld this part of C’s complaint.
In relation to the handling of C’s whistleblowing concern, we found that the findings of the local investigation were not clear, and SAS did not follow its own whistleblowing process. We also found that SAS was not open with C, and did not initially co-operate with an information request from the INWO. In addition, we found that SAS did not respond appropriately to an earlier whistleblowing concern C raised. We upheld this part of C’s complaint and made recommendations regarding SAS’s compliance with the Standards.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
In relation to compliance with the Standards, we recommended:
- Compliance with the National Whistleblowing Standards.