Case: 202504254
NHS organisation: Shetland NHS Board
Subject: Patient safety
Outcome: Fully upheld
Date: August 2026
Summary
C complained to the board about a number of patient safety issues within a dental service, which included incidents of patient harm, a lack of waiting list management and poor governance and record keeping. C was dissatisfied with the response from the board and complained to this office that the board’s investigation had not been thorough or impartial and had not adequately addressed their concerns about patient safety.
We reviewed the evidence provided by C and the board and sought independent clinical advice from an experienced consultant dentist. We found that where the board made recommendations to improve governance and joint working, those recommendations were reasonable and effective. However, we also found that the board’s investigation had not addressed all of C’s concerns, that a number of findings were based on incomplete evidence and that the investigation at times lacked impartiality. Therefore, we upheld C's complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C for not adequately responding to their concerns about patient safety. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
What we said should change to put things right in future:
- All staff within the service are aware of best practice guidance in relation to irrigation, infection prevention and control and are aware of the requirements of Duty of Candour.
In relation to compliance with the Standards, we recommended:
- The board is aware of its responsibilities under the Standards when investigating whistleblowing concerns. Staff investigating whistleblowing concerns are aware of the requirements under the Standards. In particular:
- Sufficient time is provided to allow for a thorough investigation.
- All concerns are understood and responded to.
- Information and evidence relating to a whistleblowing investigation is not held by one individual.
- Appropriate cover and shared access to the investigation file is in place for periods of absence.
- The investigation is impartial and those involved in the investigative process are not involved in the complaint.
- Staff feel confident that their concerns are being taken seriously.