An ex-drinker with irreversible liver damage feared he was given a "death sentence" when told he would not get a transplant, according to a new report.
Edinburgh Royal's liver transplant unit was criticised
The Scottish Public Services Ombudsman revealed the case to highlight a need for better communication in the NHS.
The news about the 43-year-old's suitability for a liver transplant was broken to him in the absence of any family members.
His family sought to challenge the decision, but he died months later.
The watchdog found that the complaint by the man's relatives, and other complaints involving the NHS, all showed common themes.
- poor communications between nursing and medical staff
- poor record-keeping
- poor communications with relatives
- and poor complaint handling
Another of the complaints against the health service involved the treatment of a 74-year-old man who fell after he was left sitting unattended in a chair at Glasgow's Southern General Hospital.
He had cancer and Parkinson's Disease and after his death his widow lodged four complaints which were upheld by the ombudsman.
Of the 23 ombudsman reports published, 13 relate to the health service, seven to local government, two to housing, and two to other public bodies.
The ombudsman, Professor Alice Brown, said: "Deficiencies in communication with relatives is a feature of several reports, including the complaints about the fall of an elderly man, the death of a patient after cardiac surgery, assessment of suitability for a liver transplant, and the inappropriate delivery of a cancer diagnosis."
Nine of the complaints involving the health service were upheld in whole or in part.
The case of the former drinker denied a liver transplant prompted recommendations by the ombudsman for procedural reforms at the Scottish Liver Transplant Unit, based at Edinburgh Royal Infirmary.
John Forsythe, clinical director in the transplant unit, said steps had been taken to amend their procedures.
He said: "We already verbally inform patients about their right to a second opinion and we are amending our literature to make this more explicit.
"We are assiduous in getting relatives involved but this patient was reticent about involving his family.
"We have amended our paperwork to show what family members are involved in any assessment discussions and where no relative is present, we will also document the reasons why."
The ombudsman also called on NHS Greater Glasgow to provide the dead man's family with a written apology for the delay in responding to his complaint.
She partly upheld a complaint from the uncle of the dead man that the SLTU did not properly assess him for a transplant.
A complaint that Glasgow's Gartnavel General Hospital failed to provide proper care for the patient, or arrange a timely review of his eligibility for a transplant after the unsuccessful assessment, was also partly upheld.