Case ref: 202505555
NHS Organisation: Lothian NHS Board
Subject: Patient safety
Outcome: Fully upheld
Date: August 2026
This is the report of the Independent National Whistleblowing Officer (INWO) on a complaint about the handling of a whistleblowing concern. It is published in terms of section 15(1) of the Scottish Public Services Ombudsman Act 2002 which sets out the INWO’s role and powers. There is more information about this here: https://inwo.spso.org.uk/
Supported by four confidential appendices, it is a full and fair summary of the investigation.
Executive summary
C raised several concerns about the care of patients with Hepatocellular carcinoma (HCC), which is the most common type of liver cancer. C described a number of issues that they believed contributed to delays or variability in the care of patients.
The Board handled C’s concerns at stage 2 of the procedure in the National Whistleblowing Standards. The investigators met with C and spoke with several other staff involved in the care of patients with HCC.
At the conclusion of the investigation, the Board shared a stage 2 response to inform C about the outcome of the investigation. The stage 2 response advised that some of C’s concerns had been upheld. The response also included details of recommendations made because of the findings.
Following the stage 2 response, the Investigation Commissioner met with C several times to keep them informed and involved in the development of an action plan.
C was dissatisfied with time taken to develop the action plan and was unhappy with how their concerns had been handled. C asked the INWO to independently review the Board’s handling and investigation of their concerns.
Following discussion with C, my office notified the Board of C’s complaints and requested evidence from the Board. The complaints I have investigated are:
- The Board’s investigation did not fully address C’s concerns (upheld)
- The Board have not taken timely action to address the risks (upheld)
- The Board did not handle the concern in line with the National Whistleblowing Standards (upheld)
- The Board did not take reasonable steps to provide C with support and protection (upheld)
To support my investigation, a complaints reviewer carried out several interviews, including with one of the investigators and staff involved in the care of patients with HCC. I also obtained independent advice from a suitably qualified professional to inform my assessment of the Board’s investigation and recommendations.
As a result of my findings, I am asking NHS Lothian to implement a number of recommendations that aim to support learning in concern handling and build on the improvements that the Board have already made in relation to the care pathway for HCC.
My investigation also identified a number of areas of good practice by the Board. I have included this feedback at the end of this document.