Ombudsman’s report highlights poor complaint handling and service failures across the NHS in England and UK government departments
The Parliamentary and Health Service Ombudsman has published a report containing a snapshot of summaries of the complaints it has investigated over a two month period, during which it upheld 41% of the complaints it investigated.
The report contains summaries of 163 investigations, showcasing the wide range of cases the Ombudsman service investigates about the NHS in England and UK government departments and their agencies such as the UK Border Force, the Driver and Vehicle Licencing Authority and HM Courts &Tribunals Service.
Included in the report are cases about breaches of cancer waiting times, families resorting to putting their family in private care following unsafe discharges from A&E on Christmas Day, people wrongly losing their permanent status to reside in the UK because of poor advice and people going into debt due to incorrect benefit advice.
The report published yesterday by the Ombudsman service contains summaries of 163 complaints it completed investigating in October and November 2014. During this period it made final decisions on a total of 618 complaints and upheld 41% of these complaints. In cases where the Ombudsman service doesn't uphold complaints, it is often because no failings were identified by the Ombudsman service or because the Ombudsman service found that the public service did the right thing to resolve the complaint, which the Ombudsman service then explains to the complainant.
Approximately 80% of its investigations are about the NHS in England as opposed to UK government departments and their agencies. During this two month period, most of its NHS investigations were about hospital trusts, followed by GP practices and then mental health trusts.
Parliamentary and Health Service Ombudsman Julie Mellor said:
'These cases show the impact that service failure can have on individuals and their loved ones.
'These case studies - which are a snapshot of our work - show the wide range of unresolved complaints we look at, many of which should be resolved by the organisations locally, without people having to refer the complaint to us.
'Good complaint handling has to start from the top, and leaders will recognise the valuable opportunities complaints provide to really improve the service they are delivering.
'Many people complain about public services to enable lessons to be learnt because they don't want the same thing to happen to somebody else.'
Yesterday's report includes the following case summaries:
- A patient with dementia was left on a trolley in A&E for more than 33 hours and then left in an assessment unit for 42 hours. The Ombudsman service's investigation found that the patient had to wait in both departments far too long and nurses did not provide an appropriate care plan for him and that University Hospital of North Staffordshire NHS Trust's response to the complaint gave no reassurance that the failings would not happen again. Following the Ombudsman service's investigation, the trust acknowledged and apologised for its failings and agreed to explain what action it has taken or proposes to take to ensure that there is learning from what happened. (Full case summary on page 141 of the report).
- A family could not be with their mother in her final hours although she was just the other side of a curtain, on a hospital bed at University Hospitals Birmingham NHS Foundation Trust. Her family were only allowed to see her 45 minutes after she had died. The Ombudsman service's investigation found that there were failings in how staff communicated with the patient's children and how they treated them and that the trust's complaint handling fell short of the expected standards. (Full case summary on page 81 of the report).
- Paramedics left frail woman in her 80s home alone with inadequate support although she was suffering with sickness and diarrhoea and had soiled herself. The Ombudsman service's investigation found that the patient should have been taken to hospital by East of England Ambulance Service NHS Trust. She was not able to use a commode without help so it was inappropriate to leave her alone. The failure to take her to hospital sooner caused her avoidable distress, discomfort and loss of dignity. (Full case summary on page 144 of the report).
- A hospital trust did not follow cancer waiting times and kept a patient waiting far too long with possible prostate cancer symptoms. When he was eventually diagnosed with cancer, he faced a further wait and paid to receive private treatment. The Ombudsman service's investigation found the cancer waiting time targets were breached by a significant margin and that the patient suffered great distress and worry for several months as a result of the delay which led him to seek prompt private treatment. University Hospital Southampton NHS Foundation Trust paid him £5,000 in recognition of the money he spent on private treatment because of its delays. It also prepared an action plan to address the shortfalls in the service. (Full case summary on page 152 of the report).
- A family had no choice but to place a vulnerable man with dementia in private care over Christmas, after he was unsafely discharged from A&E on Christmas Day. (Full case summary on page 65 of the report).
- A man received £1,000 following a delay by the DVLA in reinstating his driving licence, after he was diagnosed with early-onset dementia. The DVLA revoked his licence as soon as it found out his diagnosis, however once it received more information from a consultant stating that he was fit to drive, it took seven months longer than it should have done to reinstate the licence. The Ombudsman service's investigation found that the explanations and advice the DVLA gave about the revocation were very poor. (Full case summary on page 9 of the report).
- A failure by Jobcentre Plus to tell a man about benefit rules led him into debt.The complainant wanted to separate from his wife and move into a council property. He told Jobcentre Plus he was doing this but it failed to tell him that unless he sold his previous property, he would lose entitlement to income support when it was due to be reviewed after 26 weeks of the change. When it was discovered some months later, his income support was stopped and he had to move back into his marital home. He could not afford to rent the council property without his benefit payments and he was unable to get his wife to sell the marital home, and so had to move back into his marital home. The Ombudsman service's investigation found that he suffered significant stress and inconvenience. (Full case summary on page 12 of the report).
- UK Visas and Immigration's incorrect advice led to a woman from New Zealand wrongly losing her permanent status to reside in the UK. Following the Ombudsman service's investigation, her permanent status to reside in the UK was reinstated. This was after she was advised by the UKVI to apply for the wrong type of visa when returning to the UK from New Zealand. (Full case summary on page 27 of the report).
- The UK Border Force paid a company more than £12,000 after it damaged several sacks of bran during a routine inspection of a lorry in Dover. The company supplies cereals to manufacturers in the UK and Europe. The lorry from Poland was stopped at Dover and UK Border Force officials carried out a search. They used sticks to probe the contents of the sacks which damaged the packaging to the extent that the contents could no longer be used and had to be destroyed. (Full case summary on page 29 of the report).
Most of the summaries published are cases the Ombudsman service has upheld or partly upheld. These are the cases which provide clear and valuable lesson for public services by showing what needs changing so it can be avoided in the future. They include complaints about failures to spot serious illnesses and mistakes by government departments that caused financial hardship.
The Parliamentary and Health Service Ombudsman makes formal decisions on complaints which haven't been resolved locally by the NHS in England or by UK government departments and their agencies, such as the Department for Work and Pensions, the DVLA, the Passport Office and the Highways Agency.
The Ombudsman service investigates approximately 4,000 complaints a year and upholds around 37%.
Notes to editors
- For more information please contact press office Steven Mather on 0300 061 4324 or email email@example.com or contact senior press officer Marina Soteriou on 0300 061 4996 or email firstname.lastname@example.org
- In 2014-15 approximately 79% of the Parliamentary and Health Service Ombudsman investigations were about the NHS in England and 21% were about UK government departments and their agencies.
- In October 2014, the Ombudsman service completed 327 investigations. Of these 252 were about the NHS in England and 75 were about UK government departments and its agencies.
- In November 2014, it completed 291 investigations. Of these 233 were about the NHS in England and 58 were about UK government departments and their agencies.
- During this two month period, the Ombudsman service upheld 60 cases, partly upheld 193 and did not uphold 321. The remaining investigations were either resolved before the formal investigation ended or closed because for example the complainant did not wish to pursue it further or because the organisation complained about, offered to do further work to resolve the complaint locally.
- Case summaries are published on the Ombudsman service's website, and can be searched by entering key words such as cancer, diagnosis and death, as well as by organisation, for example the name of a hospital trust and by location.
- This is the fourth report of case summaries the Ombudsman service has published. The first batch was published in August 2014.
Contact: Marina Soteriou
Phone: 0300 061 4996
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