Give Us Answers!

Ombudsman report highlights the devastating impact of service failures and poor complaints handling across the public sector.

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A new report reveals that too many people who complain to the NHS are not getting the answers they deserve when things go wrong.

This latest shapshot of investigations by the Parliamentary and Health Service Ombudsman shows the devastating consequences families suffer when complaints are not resolved locally.

The Parliamentary and Health Service Ombudsman investigates approximately 4,000 complaints a year and upholds around 37%. When it upholds complaints it makes recommendations for the organisation to put things right if they have not done so already. Most of the summaries published are of complaints upheld or partly upheld.

The 133 cases in the report were investigated between July and September 2015 and include 93 complaints about the NHS. Incidents of avoidable death, delayed cancer diagnosis, mistreatment of patients with mental health problems and poor end of life care are among the upheld NHS complaints in the report.

These are the cases which provide clear and valuable lessons for public services by showing what needs to change to help avoid the same mistake happening again

Parliamentary and Health Service Ombudsman Julie Mellor said:

“The NHS provides excellent care for patients every day, which is why it is so important that when mistakes are made they are dealt with well.

“These cases bring home all the suffering patients and their families experience when things go wrong, particularly when complaints are not handled effectively at a local level. Families have been left without an explanation as to why their loved ones died, mistakes have not been admitted, which means that much needed service improvements are being delayed.

“We are sharing these cases to help the NHS and other public sector organisations recognise and value the importance of complaints in helping to improve services.”

In one case, the organisation found that an NHS trust had missed opportunities to prevent a woman committing suicide after she was discharged from hospital despite a history of depression and previous attempts to take her own life. The trust also failed to apologise properly or learn from its mistakes when the woman’s family complained.

The report also details the case of a pregnant woman who lost her baby in the latter stages of pregnancy after a trust had failed to carry out a scan that could have diagnosed the problem and probably saving the baby’s its life. She was treated with a lack of care and compassion during the subsequent delivery of her stillborn child, according to the report.

Another investigation found that a woman had died an avoidable death after two GPs failed to diagnose and treat her correctly after she had developed deep vein thrombosis. She was admitted to hospital nine days later then died. The trust delayed in responding to her husband’s complaint. Following the Parliamentary and Health Service Ombudsman investigation the GP practice apologised and paid her husband.

The report includes 40 complaints about other public bodies such as the Home Office’s border law enforcement, Border Force; the organisation that represents children in court cases, Cafcass; the Job Centre and Her Majesty’s Courts and Tribunal Service (HMCTS). Delays, poor decisions and complaint handling were common findings in all the cases in the report.

Selected cases from the report:

Missed opportunity to treat two year old child who died.

A two year old child with Down’s syndrome and leukaemia was admitted to hospital for chemotherapy but was then given anaesthetic for a follow up operation even though he had an infection. The child subsequently died. We found that the doctor should have known it was a risk to operate on the child in his condition.

Cancer patient dies after being mis-prescribed laxative for 38 days.

A man being treated for prostate cancer was mis-prescribed a laxative for 38 days and died shortly afterwards. We found this to be a serious clinical failing that left the man’s wife distressed.

Surgeon removes part of woman’s breast unnecessarily then retires and moves abroad.

A woman went to hospital with painful cysts on her breasts but the doctor operated on a different part of the breast leaving a scar. She had to have another operation to remove the cysts three weeks later. The woman said the mistake left her physically and emotionally damaged. The doctor retired and moved abroad shortly afterwards.

Man dies after discharge failures and funeral director charges family for removing nails from body after hospital errors.

A man went to hospital and was treated for a pain in his leg. He was mistakenly told he could walk on the leg after failures in the discharge process. He then had an operation and died in hospital four days later. The Trust then made a mistake filling in the cremation form which led to his family being charged to have dangerous nails removed from his body. There were no nails.

Doctors did not treat heart attack patient appropriately and he died.

We found that an opportunity was missed to save a man’s life after he was taken to hospital by ambulance. Doctors diagnosed that he had had a heart attack but he was left for several hours before doctors identified that his health was worsening and arranged to transfer him to the local cardiac centre. This should have happened immediately. He died at the cardiac centre shortly after he arrived.

Hospital misses opportunity to save a man’s sight.

A man had eye surgery and reported suffering from pain and sickness afterwards but he was given treatment then discharged. We found that he should not have been discharged and that his condition needed observation and care. He lost the sight in his eye.

Cafcass gave poor service to father who did not have direct contact with his children.

Cafcass had been ordered to pass on letters from a father who did not have direct contact with his children, but they failed to do so.

A man damaged his car travelling to work driving over a pothole.

The man could not continue his journey and had to pay to have his car repaired. Highways England eventually agreed to pay 80% of the cost. We recommended that he receive 100% of the cost and an additional payment and eventually Highways England agreed.

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