PHSO - People not given answers when they complain to NHS, latest ombudsman report reveals

2 Mar 2016 12:53 PM

Some people who complain to the NHS are not getting the answers they desperately need meaning they are forced to bring their complaints to the Ombudsman service to get answers.

The Parliamentary and Health Service Ombudsman's latest snapshot of cases it has investigated includes cases about grieving parents and partners not being given answers as to why their loved ones died and mistakes not being admitted, which means that much needed service improvements are being delayed.

The latest snapshot of cases published today details how one family was forced to bring their complaint to the Ombudsman service, after their nine-year-old son died of sepsis after he was wrongly discharged from hospital.

Our investigation found that his death could have been avoided if he received the right care and treatment. Following our investigation, the trust provided the parents with an open and honest acknowledgement of the failings, apologised and paid them £15,000 recognising that the death of their son was avoidable. 

The hospital trust also took action to learn from the failings and to ensure that they did not happen to someone else.

Parliamentary and Health Service Ombudsman Julie Mellor said: 

'The NHS provides an excellent  service for thousands of people every day, which is why when mistakes are made it is so important that they are dealt with well.

'When people complain to public services they deserve answers. If mistakes are made, an open and frank apology should be given and action should be taken to stop it from happening again.

Unfortunately we are seeing far too many cases where grieving families are not being given answers when they complaint to the NHS, forcing them to endure more anguish and distress.'

The report contains a snapshot of unresolved complaints brought to the Ombudsman service for investigation. They cover the NHS in England and UK government departments and other public bodies, such as the Crown Prosecution Service.

Most of the summaries published are of complaints upheld or partly upheld. These are the cases which provide clear and valuable lessons for public services by showing what needs to changed to help avoid the same mistake happening again, including complaints about failures to spot serious illnesses and mistakes by government departments which caused people financial hardship. 

Cases include: 

• The death of a nine-year-old boy from sepsis could have been avoided if he received the right care and treatment. Following our investigation the hospital trust provided the parents with an open and honest acknowledgement of the failings we identified, apologised and paid them £15,000. It also prepared an action plan ensuring it had learnt lessons from the failings. (Merseyside) Case summary 966 on page 42.
• A man who became paraplegic after a road traffic accident was wrongly refused IVF treatment by the NHS. Following our investigation, the request was reconsidered under the exceptional circumstances criteria and evidence was provided when the second application was declined. (South East). Case summary 959 on page 35.
• The next of kin were not informed by a hospital that a patient had died, denying them the chance to go to the funeral, due to a series of errors by the hospital trust and a council. Following our investigation the trust and council apologised to his sister, who complained, paid her £650 in recognition of the distress caused and for the loss of opportunity to attend her brother's funeral and a further £374 to cover the two months when bills were unnecessarily paid by his estate. They also took action to prevent it from happening again. (London) Case summary 950 on page 22.
• The trial of a man accused of threatening a mother and her teenage daughter with sexual violence collapsed, because the Crown Prosecution Service failed to inform the mother of the date of the court hearing. This meant that she did not attend the court hearing and the CPS prosecutor offered no evidence which resulted in the alleged offender being acquitted. Following our investigation the CPS apologised and paid the mother £2,000 in recognition of the injustice she suffered. Summary 940 on page 8.
• Hospital took 72 weeks to arrange hip surgery on straightforward case, leaving patient in unnecessary pain, 17 months after she was first referred by her GP. Following our investigation, the trust apologised, paid her £2,500 and took action to stop it from happening again. (North Staffordshire) Case summary 952 on page 25.
• A hospital trust communicated with a grieving family via its solicitors when they complained about the end of life care their father received when he had terminal cancer. Following our investigation, the trust apologised for the distress caused. (Lincolnshire, East Midlands) Summary 962 on page 38.
• A failure to x-ray a child's teeth led to root canal treatment. Following our investigation, the practice acknowledged and apologised for the failings. It paid £2,600 for the cost for of the private root canal treatment he had and paid him £750 in recognition of the impact of the failings. (London) Summary 957 on page 33.
• A GP practice failed to urgently refer patient to a neurologist leading to a long delay in diagnosing his Motor Neurone Disease. Following our investigation, the practice apologised, took action to stop it from happening again and paid his daughter £4,000 in recognition of the impact the failings had on the daughter. (Greater Manchester) Summary 965 on page 41.
• A war pensioner had to wait 18 months for travel expenses to be paid by the NHS for trips to have an artificial limb fitted. Following our investigation, the NHS Business Services Authority apologised, took action to help prevent it from happening again and paid him £600 in recognition of the frustration and inconvenience caused.Summary 945 on page 15.
• Hospital trust incorrectly diagnosed a woman with schizophrenia. Following our investigation the trust acknowledged and apologised for the misdiagnosis and paid her £7,500 in recognition of the injustice she suffered. (Hertfordshire). Summary 947 on page 18.
• A dental practice's failure to diagnose decay in a child's teeth over a three-year period, resulted in her having four teeth extracted and a crown inserted. Following our investigation the practice apologised and paid the family £5,150 in recognition of the pain and discomfort the extractions and the crown caused, and to enable her to have implants fitted to replace the lost teeth. (Cornwall) Case summary 960 on page 36.

The report contains a snapshot of 40 case summaries of the 544 investigations of unresolved complaints the Parliamentary and Health Service Ombudsman completed investigating in April and May 2015.

Approximately 80% of the cases investigated by the Parliamentary and Health Service Ombudsman are about the NHS and the rest are about UK government departments and other organisations.

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.

Case summaries are published on the Parliamentary and Health Service Ombudsman'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 seventh report of case summaries published. The first batch was published in August 2014. The Parliamentary and Health Service Ombudsman makes final decisions on complaints that have not been resolved by the NHS in England and UK government departments and other UK public organisations.

If someone is unhappy about the service they have received from the NHS in England they should first make their complaint to the organisation in question and give them the chance to respond. If they're not happy with how their complaint is dealt with, they can contact the Parliamentary and Health Service Ombudsman by calling 0345 015 4033 or submitting their enquiry online here.

For more information contact Steven Mather on 0300 061 4324 or email steven.mather@ombudsman.org.uk or Marina Soteriou on 0300 061 4996 or email marina.soteriou@ombudsman.org.uk